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Evaluating Family Health Nursing Through Education and Practice

ANNEX FOUR: TWO CASE STUDIES OF FAMILY HEALTH NURSE PRACTICE

INTRODUCTION

These in-depth case studies have been constructed in order to offer the reader greater insights into the world of family health nursing through the words of the Family Health Nurses themselves, family members, professional colleagues and researchers. Sites exemplifying the Slow/No go and Bold build patterns have been selected as they represent different ends of the spectrum of family health nursing practice that we studied. Within this contrast lies a great deal of useful knowledge about how the FHN role may or may not work. The case studies have been constructed to illustrate particular themes that are characteristic of these patterns. They also aim to offer some insights into the interview methods used by the researchers. It is important to note that these case studies are based on data from the first year of FHN practice and only reflect the evolution of the role up until autumn/winter 2002.

Each site case study starts by "going in through the eye" of a family case study done at the site. The working of the FHN model with this particular family is then considered in relation to FHN practice with other local families, district nursing practice at the site, and the practice and perceptions of the wider Primary Health Care Team and local community.

Extracts of dialogue from interviews have been selected for analytical purposes but at times also fulfil a narrative function. These extracts are used verbatim except for the very occasional editing out of any excessively personal material. Different names have been used to help protect the identities of those family members who kindly took part in interviews. FHNs are referred to as "FHN" except for in the body of dialogue where they are referred to as Una (as Cohort 1 were pioneering this role). Other health professionals who had knowledge and close involvement in the case are all referred to as " Colleague". Finally, somewhat predictably, the researcher is referred to as " Researcher".

SLOW/NO GO

The context for this case study is a large geographic district (Site G) with a sparsely distributed population of around 1700 people. The district has one predominant settlement where almost all the Primary Health Care team members are based. The FHN has been allocated a distinct geographic "patch" within the district. Cardiovascular disease, cancers and diabetes are all prominent health problems within the community.

The focal case involves the following family who are native to the area:

Grace, a 77 year old lady who for many years has required district nursing input for recurrent problems with varicose leg ulcers. She lives with her daughter Heather (42) and son Calum (44).

Researcher: .... generally, what have you been trying to achieve with this particular family?

FHN: What I set out to achieve I haven't because of other pressures within the caseload. With terminal care I've had quite a few ill people. I haven't been able to cause I had to prioritise. When I originally spoke to them the mother had got varicose ulcers, Calum had been diagnosed diabetic and Heather has been under investigation just now, but she's been having this skin problem......

This extract exemplifies the theme of thwarted case development that frequently emerged for those trying to implement family health nursing on top of busy district nursing caseloads. The FHN was typically going in once or twice a week to attend to Grace's ulcer, and other members of the community nursing team provided back up:

Colleague: ... our input now with Grace is purely on a relief basis for Una (FHN). You know if Grace is pencilled in for a visit on Una's days off or she is on holiday, then we go in and do that visit and record it on Una's notes.

Researcher: Can I ask you about Una's notes, do they stay in the house or do they stay in here (site base)?

Colleague: Here.

Researcher: Is that them you've got there?

Colleague: Yes, it's the same notes, the same but different. They are the same as our own notes, except Una's got extra bits for the genogram and ecomap.

This customisation also incorporated completed assessment sheets pertaining to family dynamics (such as power structure, roles, strengths, stresses and coping) and culminated in a family plan: To discuss dietary habits with family in view of Calum's hypertension and diabetes, and Heather's anaemia. A family "progress sheet" recording sheet had two entries by the FHN, one of which was Unable to have family discussion due to visitors being present. This family assessment material supplemented sections with individual traditional nursing notes for all three family members, with comprehensive information relating to the range of medical problems that were existing and emergent. As such the notes provided comprehensive evidence of care and represented a sustained, if rather unwieldy, attempt to reconcile family health nursing and district nursing documentation.

The FHN had made a start to the plan by giving the family a number of leaflets on healthy eating, but had not had a chance to follow this through. The other community nursing staff did not have any specific input with the family in this regard.

Researcher: So has there been any need to change your diet, to use these booklets?

Grace: No.

Heather: We were going to look them up to do with losing weight.

Researcher: Is that something you've made any progress with?

Heather: Haven't started. You haven't tried to lose weight yet, have you?

Grace: I don't take sweet things or anything. Maybe I could do more walking and that. That would help.

However the family members interviewed were very appreciative of all nursing input received, and made special mention of the FHN's listening skills. Indeed the FHN herself felt that some progress had been made

Researcher: Is the contact you've been having with the family similar to your previous way of working before you came on the course? Are you doing anything different?

FHN: Probably not. I've arranged more with them. Probably as a DN you'd go in twice a week on the same days. It's a bit more flexible and has their agreement that the days get changed. The times are more flexible.

Researcher: Is that more flexible to suit you or to suit them?

FHN: Well, if it suits us both. I discuss it with them. What suits them.

Researcher: And previously would it have mattered if you'd seen Heather? I mean you were going in anyway to do the dressing. But do you think in the past if Grace had said to you 2 or 3 years ago when you were doing the dressing that she had some worries about Heather or Calum, what would you have done?

FHN: Spoken to them and spoken to the GP. And would have been involved then if there was anything nursing wise. I feel Grace is more communicative with me, talking more, certainly, and she's coming across with more of her feelings.

Researcher: Do you think that's been influenced by your attempt to sort of formally assess them by spending time with them?

FHN: I think maybe it is. Just getting to know her better and building up trust.

Researcher: Would that have been legitimate activity before in terms of your DN work? If you had said to your colleagues or decided that it seems as if Heather has got some needs here, I'm going to spend some time trying to get to the bottom of this, would that have been a reasonable thing to do in terms of your normal work?

FHN: Yes.

At the time of interview Heather was receiving input from the local GP and Calum saw the diabetic specialist nurse periodically.

Researcher: I suppose I'm hunting for what extra dimension, if any, you feel that the FHN brings to a family like this?

FHN: I think had I more time it could have been more. More meetings with them. More discussion. More in-depth. Which is what I planned to do, but then there were other priorities on the caseload and really in the past two months they've had to come further down my list. I haven't been able to spend time with them or do what I initially set out to do.

Confirmation was provided by the family that a new approach to care hadn't yet been established:

Researcher: Who would you contact first if you had a problem with your health; that is yourself? Would it be the doctor, the family health nurse or the District Nurse?

Heather: Probably the District Nurse.

Researcher: For yourself?

Heather: Probably. I only go to the doctor when I have to. Eventually.

Researcher: And for your mum, would it be……..?

Heather: Probably get in touch with the nurse, like going to the District Nurse in Maintown. Either phone the doc, or to the hospital.

Researcher: So the district nursing service you'd contact rather than Una (FHN) herself?

Heather: Yes. Yes.

Researcher: Do you think what Una is doing is, as far as you can tell, any different from what happened before with the family?

Heather: Well there wasn't really a before so I can't tell you.

Researcher: Yes, there was just the District Nurse coming in. As far as you are aware, is there any sort of plan for the family's health, or anything like that?

Heather: No.

The above extract also confirms the FHN's assessment that there is a need and opportunity for some integrated secondary prevention work with this family as a whole. However the challenge of delivering sustained work of this sort (eg. working on attitude change) within the present local working arrangements had so far proved insuperable. Moreover there was still the question of how much individual members, and the family as a whole, might want to engage in any more pro-active, health focused model of service delivery. There was no suggestion of any dissatisfaction with pre-existing health care services.

This affords good opportunity to broaden discussion towards analysis of working practices at the site as a whole.

Overall the core PHCT comprises the FHN (G grade 30 hours per week); one full-time District Nurse who is team leader; two full time community nurses (one F grade, one E grade); one community nurse who does "bank, relief" work; a full time auxiliary nurse; two Practice Nurses, and 3 GPs. The nursing caseload for the whole geographic district numbers around 200 patients and is dominated by chronic health problems of over 75s. Many supervisory visits take place. Bathing is mostly done by the auxiliary nurse, but nurses do some. The FHN's distinct "patch" within this site typically has 40-50 community nursing patients. A team midwifery system operates locally from a different base. Although many of the core primary care team listed above are midwives, none now are practising.

The Health Visitor covers an even wider geographic area . Within the part of her patch that is coterminus with this primary care team, she carries out a range of work. Much of this work is with children and mothers (around 30 children who receive developmental screening and related interventions if necessary). She also does health checks and health teaching in the local primary school; sees a limited number of adults individually to help them with smoking cessation and/or cardiac rehabilitation; and runs a variety of evening groups in the area (eg. womens' "look after yourself" group).

Within this team context the FHN has been trying to make the role work:

FHN: I feel that I'm not really working on my own, yet I'm not really part of the team as I was either.

Researcher: So, in between?

FHN: I feel I'm missing out. I haven't been able to do anything sort of community based.

In fact there was evidence that the FHN had been active in some health promotion and screening work with the local primary school. Some of this was in collaboration with the Health Visitor, but there had not been sustained development of this activity. Work with specific families was slow and it had been possible to engage in sustained, in-depth family health work with less than five families since starting the post.

Researcher: I'm interested in what makes someone a family health nurse case, or what makes a family a family health nurse case, and the example you are giving here is where there's quite a lot going on in terms of health needs.

FHN: Probably for education.

Researcher: Yes and you are also saying that it's possibly easier for you to take on people or families who haven't had previous DN involvement. But from what I understand the vast majority of your work so far has actually been with the traditional DN caseload in your area. In a few cases like this family, you've tried to branch out from that caseload to other family members. Would…

FHN: What I'm finding is hard. There's another family as well that I've done an assessment on and it's the daughter in that family that's diabetic and the mothers diabetic, but when I go in primarily as a DN I've been going in to visit the mother. And because they're all so polite they get out the room to let me speak to mother, and I find it very difficult to get them to come back in to the room as a family committee. Because of what traditionally happened. But I find it easier if there's been no involvement, then from the beginning I can get the family together and have discussion.

From the beginning of the project the rest of the primary care team were very supportive of the FHN's personal professional development and of her aspiration to make the role work. There was already a good pre-existing culture of regular, open team meetings and the team set up an open diary for ongoing team reflection on the process of introducing family health nursing. Negative comments tended to predominate. One particular issue for the rest of the team was that the routine data returned monthly on patient contacts and activities did not properly reflect their input in covering the FHN's patch. By the end of the year there was general consensus that the role wasn't working:

Researcher: So there's a question about where it fits in. Is it providing a similar or a different service?

Colleague: At the moment Una (FHN) is doing DN under a different title. But then that's not Una's fault. Cause Una was brought back into the community as a member of the team. And she was given a caseload, so she had to carry that caseload and she had to continue doing the work that was done before. And we all felt that it would have been better if Una had been brought back supernumerary, and if they had come out as new nurses and developed their caseload, rather than taking on what was already there and having to continue doing what was already being done.

The above extract exemplifies a strong theme that emerged at this site and indeed the vast majority of other sites. That is the embedded need for the community nursing service to continue as normal. At this site a specific geographical sub-patch had been hived off for the FHN but it was not seen as an opportunity for any substantive review of nursing caseloads and working practices. Given that the family health nurse initiative was presented as a time-limited experiment this is not surprising, but it does suggest that the team at the site saw it more as an experiment on them, rather than by them. The professional stakeholders' comments about consultation on the introduction of the role support this interpretation:

"I don't think the concept and where the FHN fits in vis a vis community nursing and health visiting was explained to us at all"

"Consultations have been mainly with evaluators. Nothing prior to project start"

At a more fundamental level team members struggled to see the need for a new role

Researcher: How do you feel that the role of the FHN fits in with local services in general?

Colleague: Well it was felt, we all felt, that it's a difficult one because there's already a framework in place for the delivery of service. You know there's already the DN service, the HVs, there's health promotion.....

At the end of the year only one of the ten professional stakeholders who replied (10%) said there was a positive need for a distinct FHN role. Three (30%) felt there wasn't, and the remainder didn't know. Explanatory comments revealed a range of perceptions:

"I think it should be decided whether we have DN or FHN. There is so much duplication of remit that it is otherwise confusing to the public"

"I feel the role is that of the present Health Visitor. Duplication not needed"

"Good community nursing care is already given and it would be better to extend the district nursing role. Health visiting service is very good also"

"Existing team networks well and has staff who are motivated and continuously professionally develop. We should concentrate on development of existing team"

Amongst the team there was little recognition of any substantive gap in current service provision

Researcher: I don't know if you would have a chance to discuss this as a team but in that event, which is now hypothetical, but if she'd been brought back as a supernumerary person, do you think you could see the need for that?

Colleague: No, I don't really know. I think we would be doubtful about that. Again because, and you can correct me if you've got information that I don't have, but you know things are pretty well covered.

Researcher: Yes and you mentioned that health promotion are covering a number of areas, District Nurses ... But I suppose if we take the elements of this new title, family health nurse, emphasising health, do you think there is anything missing in terms of the care of families?

Colleague: In respect of the DN service?

Researcher: In respect of the whole team: the net effect?

Colleague: Maybe because we are rural and nearly everyone knows everyone else, I think it's pretty much covered because the HV, the DNs, the Practice Nurses, we do pick up things with families. We do pick them up and you find out, you know word of mouth, you pick up what's happening.

Researcher: Maybe not in the way that's in these notes (FHN) where, if you like, there's a systematic…

Colleague: Yes. I don't know, Una (FHN), whether she's had any problems, but especially the Highland and Island personality is quite reluctant to change. And I don't know how well people will take to these forms which are quite probing. And I think there might be some…

Researcher: Do you think that some of that's a bit too intrusive?

Colleague: Well I think that people might find that.

Most of the lay stakeholders who responded felt unable to give an opinion on the implementation of family health nursing so far, but one respondent saw possibilities:

"I believe that this would be a valuable service and prevent illness if individuals and family unit were assessed as a whole, not mainly when medical assistance is required for specific illness"

While a few of the professional stakeholders indicated that the development had caused disruption to the team (especially when the FHN was away on the course), many also commented positively on the FHN's professional development and saw her recent training and experience as a useful resource for the team. However referral activity continued to be almost exclusively for traditional district nursing input with individual patients. During the year there were less than five referrals of families to the FHN. When asked to comment on any change for professionals in the way they worked together, one stakeholder commented:

"It should have but hasn't - needed more facilitation and support"

The FHN provides summation

Researcher: If you could change one thing about your current role, what would that be?

FHN: What I'm doing just now? I would change it totally.

Researcher: Totally? Right, let's hear about it!

FHN: I don't think the FHN is working and will work in this area based on a DN caseload as there is too many other things going on. The area I'm working in has a lot of elderly and initially when I started there was a lot of general nursing care which I had never minded doing. But when there's auxiliaries and carers that can do the role, I think I should have been doing things that I'd been trained to do.

During the year some extra auxiliary nursing hours were allocated to assist the development of the role, but these came from within existing resources and there was no net increase in nursing resource at the site during the first year of implementation.

In summary, the FHN development in this Category 2 site (see Table 3.5) can be characterised as:

• sporadic, and seldom developed or sustained, despite much effort
• not really seen as needed by professional colleagues, but the team tried to support the FHN

The characteristic pattern can be summarised as:

Context: FHN role super-imposed on "heavy" district nursing caseload within established and functional medium sized PHCT

Process: Sporadic and limited introduction by FHN only, with little/no change in other professionals' activities

Outcome: No substantive change in practice. "Normal" district nursing services maintained, but remains stressful for FHN and colleagues.

Two other sites (F and H) shared this characteristic pattern (see Table 3.6). Like Site G, each of these sites had some difficulties with staff shortages and sickness during 2002.

BOLD BUILD

The context for this case study is a large geographic district (Site I) with a population of around 2200 people. This population is sparsely distributed apart from one relatively isolated large village with a distinctive post-industrial heritage. The majority of the core Primary Health Care team members are based in this village. The FHN does not have a distinct geographic "patch" within the district, but much of her work is focused on the needs of people in the village. The village has a particularly high proportion of vulnerable groups (the elderly, unemployed, single parent families, cultural minorities and socially deprived families). Cardiovascular disease, cancers and mental health problems are all prominent health issues within the community.

The focal case involves the following person who had raised her family in the area:

Jean, a 74 year old widowed lady who lives alone and has a large number of chronic health problems. Jean has four grown up children who live outwith the immediate district but keep in regular contact.

Researcher: What was your first contact with Jean?

FHN :Well she approached me. I met her in the surgery waiting room when she was waiting to go in to the doctor, and she said "Oh I hear you've been away on a course" and she asked me if I could come in and speak to her. She'd recently been diagnosed with diabetes and was unsure about her diet and different things, and she was wondering if I could help her with that. So I said "Yes, that would be fine, I'll come and see you". And then I cleared it with my colleague and saw her, and from then on I've been seeing her on a weekly basis most of the time. I think probably now we'll be tailoring it down a bit, but it has been weekly so far.

Researcher: What is the main thing you've been trying to achieve?

FHN :Really trying to improve her basic knowledge of diabetes. How it affects her, how it affects her life, and also the other medical problems she's got, cause she's got a whole host of medical problems on her list. But diabetes was the first thing and through that we've just been discussing her and realised that she was wanting more information on angina, her chronic obstructive airways disease and things like that. She wasn't sure about what they were, or how they affected her, and what she could do to help, so its really been a lot of health education we've been doing together, and also looking at building up her independence and trying to reduce stress as she finds coping on her own quite hard.

This input from the FHN had been sustained over the past 8 months.

FHN: ... so I think, as far as the diabetes management, I know from asking her myself how she feels she's getting on, as its her targets that we stick to, and she feels that she has quite good knowledge of the diabetes, how it affects her and what her diet should be and what the complications are and how to reduce the chances of developing any more. So I think the progress from that part has been good.

... Cause if I was a community nurse I would come in, give the info, do what I have to do and then that would be it finished, whereas with this I've been going over it over a month and building up slowly. Going back over things cause quite often you can tell someone something and they say "Oh yea I understand that" and then a few months down the line they think "I didn't really quite understand that, can we go back over that again" So its been quite a back and forth programme.

Researcher: And while we're on that pre-FHN, why would you not have spent so much time on health education? Was it because you lacked the knowledge yourself or did you have other things to do?

FHN: Usually because I had other things to do. Cause that was always what frustrated me about being a community nurse, being stuck in that situation where you didn't have the time to give properly to your patients, and you would give ad hoc kind of info that you knew that the patient couldn't actually use very well. But you felt you were doing your job right if you did it anyway.

This perception of a more in-depth service was confirmed by colleagues within the core PHCT, but the view of community nurse information giving expressed above was by no means universally held within the core PHCT. There were also differing perceptions as to how much this service was needed and whether any extra quality/benefit was actually being delivered.

Colleague 2: ... also you have problems trying to cope with people who are needing a lot of support and input, and Una (FHN) filled the gap.

Colleague 1: I'm not entirely sure the benefit an FHN can give to Jean that would not already be addressed by the GP, the Practice Nurse and the District Nurse.

In the context of diabetes care a number of services were already available within the site. These included the practice nurse, a dietician who visited the site weekly and a Nurse Specialist in Diabetes Care based outwith the site. Jean had some contact with these services prior to the FHN becoming involved and occasional contact with the practice nurse and Nurse Specialist thereafter.

Jean also continued to have fairly regular contact with other members of the core PHCT, particularly the district nursing service which continued to visit weekly in order to co-ordinate Jean's complex oral medication arrangements. These visits were typically brief (around 10-15 minutes) and occurred at the other end of the week from the FHN visits. This arrangement was initially seen as beneficial by all parties in that it gave more regular support to Jean, but in recent months the district nurse and the FHN had recognised that the arrangement involved some unnecessary duplication. Despite mutual recognition that the FHN alone could cover all home input for Jean, however, both services continued to visit and record brief details on continuation sheets within a summary nursing care plan kept in Jean's home.

FHN notes were kept at the nursing base. These were comprehensive and incorporated two main sections. Firstly there was a full FHN documentation including a genogram, an ecomap, and assessment of family roles, functions, values, activities and strengths. Secondly there was a section comprising individual health history sheet, medication record sheet, a variety of diabetic monitoring sheets, and finally need-goal-intervention plans for six different health needs. The latter plans were very detailed, had been evaluated on each FHN visit and included Jean's own perceptions of progress.

The genogram highlighted a family history of cardiovascular problems.

Researcher: Even though ostensibly you're dealing with one individual, do you feel its been worthwhile doing the genogram?

FHN: Definitely because Jean herself found it very interesting. Just looking at the family members and looking at the links, because not many people realise, until its down in black and white, you can be talking about past family history and they know that things travel in families, but until they see something like this they cant actually get that into their head and see how important it is to encourage a healthy lifestyle throughout the generations.

Although the FHN did not have professional contact with Jean's children, she indicated that Jean herself had raised the topic of lifestyle issues with her sons and daughters. Jean derived a great deal of psychosocial support from the FHN's visits.

Jean:She's got a good listening ear.

Researcher :Is that one of the important things?

Jean: Yes very much so.

Researcher: What sort of things do you tell her?

Jean: Sometimes the way I feel and things like that. It's hard to say really. I'd be lost without her, she makes my day.

Researcher: So it gives you a support?

Jean :Definitely, If I need any help or aid she'll try and get it for me.

Researcher :Financial?

Jean :Yes. She's supposed to try the internet for it, but she hasn't got access yet.

Researcher :So that's a bit different from the district nursing?

Jean: Oh aye, different entirely.

The FHN highlighted one of the major differences.

Researcher: I found it very useful that latterly in your notes you'd actually write down how long some of your visits had been taking. It's very helpful and gave me an idea that you were often there for an hour or so, and that's quite intensive work?

FHN :That's right it's a long time. And I do find on average most of my visits are about an hour to everyone that I see really, and I was clocking up so I thought I would write it down in the notes as it does reflect that it is very different from community nursing where you average visit is 15-20 minutes in and out, whereas mine last year has been on average one hour to one and a half hours.

The FHN was working towards reducing her input with Jean and recognised that dependency was a potential problem. Colleagues shared this concern.

Colleague 2:Its difficult for Una (FHN) as well, if she's going to restrict herself down to X number of families and they've all got problems that are not going to go away today. She's going to have them on her books for months & months, that's a problem. I mean I don't know how many families she's supposed to have in all, but I think she's pretty near full, if not full. What can you do in that situation?

Indeed the FHN's colleagues had a number of broader concerns about the development of the role and how it fitted in with core PHCT activities. As such this is a good point at which to broaden discussion towards analysis of working practices at the site as a whole.

The core primary health care team based in the main village comprises one full time G grade District Nurse; one F grade community staff nurse (15 hours per week); one auxiliary nurse (10 hours per week); one Practice Nurse (10.5 hours per week) and two GPs. Prior to undertaking the course, the FHN had been working locally as an E grade community nurse for 7.5 hours per week in this village and 7.5 hours per week in a smaller village. Since completing the course the FHN was now working full time at G grade (Monday to Friday). Although based in the main village the FHN provided family health nursing services across the district.

The rest of the core PHCT for the district are based in a smaller village and comprise one full time G grade District Nurse; one F grade community staff nurse (15 hours per week); one auxiliary nurse (13.5 hours per week); one full time Health Visitor. The Health Visitor's work within the district was predominantly with children and mothers, and involved work in a number of local schools. Her remit also involved working in schools outwith the district.

The district nursing caseload for the district as a whole numbers around 120 and is dominated by elderly people with chronic health problems. Many supervisory visits take place and these are seen within the district nursing team as part of the family dimension of their care. Bathing is mostly done by the auxiliary nurse, but nurses do some. A team midwifery system operates locally from a base just outwith the district.

The mode of FHN role development at this site was found to be unique in our study of practice:

Researcher: If there's a whole lot of people with needs, how do you choose who you prioritise?

FHN :Very difficult.

Researcher :Is that,…. it sounds like its been an issue, or has it?

FHN: Not for me personally, because I haven't been choosing my patients. I've had all my patients have been referred to me directly, either by self or by DN, GP other community professionals, (midwives, practice nurses), so I haven't in a sense been choosing them because of their need; they haven't been getting priority over other people. I take anyone or anything it doesn't matter.

Researcher :Right, cause that's an interesting way. You've developed the caseload pretty much from scratch, haven't you?

FHN :Yes.

Researcher :And you're telling me that you've developed it from referrals from other professionals. So the need has been recognised by them?

FHN: Yes.

Researcher: And would you ever say "no" to some of the people?

FHN :Yes. And I have done. If I feel that the caseload is too heavy, or I'm too busy and I feel that I cannot give that fairly equal time and proper input, then I would say could you either defer this, or I have a waiting list of a month, and I'll get round to seeing them in a months time. And that's worked OK so far.....

Assessment of referrals often proved interesting

FHN: ... if there is somebody that they send me that I think will probably, may not be suitable, I'll see them and try and work out things. But often actually sometimes from what the referring person perceives as that persons problem, when that person comes to me and I assess them, sometimes its quite different. What the patient sees their problem is and why they think they've been sent to me. And then it can actually turn out that they are an ideal candidate for an FHN, but I wouldn't have known that sometimes from the assessment. So every patient that I'm referred I do see, if only once to ascertain that they are not falling within my jurisdiction...

The client led aspect of the service was highlighted by the FHN:

Researcher: ... from what you're saying its different?

FHN: It is different, definitely. I think it meets the clients needs more because I ask the client what they need. Often as a DN you go in, because the doctors told you that you've got a diabetic patient that's on heaps of medication, can you sort it out? You're not going in under any other terms, that's your task go and do it. But with this its much more open, it's often at patient's request, or at other reasons to go in. So it's much more client-led and so it's quite different.

Researcher: Sticking on that client-led nature, and Jean, how many more cases like her could you have on your caseload where you are going in quite frequently (eg. weekly)?

FHN :I am not sure. I've got about 24 caseload at the moment. I've lost a few in the past few weeks. I manage that just, but I do a lot of other stuff.

However the client-led aspect did not necessarily fit easily into the overall system of service provision locally:

Colleague 1:So I'm not sure how productive it is for Una (FHN) to be spending time with a patient selected out of all the other ones, with no particular reason why its this patient as opposed to other patients with chronic heart, lung, diabetes.

... There are lots of people, so how do you select, I mean which ones get the sort of intensive care (as in one is worthy of more attention than the other) and my criticism is that we are not making best use of the PHCT.

The way that family health nursing was developed at this particular site raised issues about the equity of the new service amongst several members of the core PHCT, and in turn engendered reflections about the equity of pre-existing services at this site. These included the service coverage for particular client groups.

Colleague 2:I think we're very well provided for here really. But if Una (FHN) wasn't here, excluding her, the PHCT team would work but there would be various things like the clinics she's doing down there wouldn't be getting done and again these problem families wouldn't be getting covered because you'd be running in and running out. Whereas Una can sit and say "right just exactly what is it you want?". Right, I'll refer you to OT whatever and go through the assessment. We do the assessment but it's not in as much depth.

Researcher :Last time we spoke you raised the question of a possible 2 tier service.

Colleague 2 :It is actually still a worry. I feel that it's a service that probably everyone should have, but that's an ideal situation. But everyone should have that sort of assessment to start with...

During the first year of FHN practice though, this single FHN had necessarily only been able to provide the service to a limited number of individuals and families. Moreover from the FHN perspective this new service was based entirely on expressed need (ie. referrals from other health professionals and by local people self-referring) and everyone who was referred was assessed.

The possibility of widening FHN service coverage through delegation was explored:

Researcher:Thinking of your own work with Jean, as an FHN, are there any aspects of your own work that you would think about delegating, or that could be done by someone else feasibly?

FHN :Yes, I suppose a lot of it…well not a lot of it, but part of it could be delegated. Maybe the weekly, day-to-day visiting of families could be done once a case plan is put in motion and the assessment done. Some of the support could be done by somebody else. And the health education part of it as well, there is no reason why a community nurse who has a special interest or knowledge in that area couldn't do that too. And a lot of the documentation and planning and organising of groups could also be done by somebody else. And lots of kind of letters you write, that could be delegated, I don't know, its difficult to answer that in this context at the moment because it's just me and there's no-one I can kind of delegate to.

This highlights that integration with mainstream community nursing had not been achieved during the first year of FHN practice. The reasons underlying this were contested within the site. During the educational course the FHN and colleagues from the project team initiated meetings to try to explain the new role to professional colleagues and the local public. The FHN's colleagues generally felt, however, that they had been poorly consulted prior to the introduction of the role and many were unclear about what the role involved and did not involve:

"We were told that this was going ahead. We had no choice"

"Initial information patchy. Caused upset and confusion with health care professionals"

The process of introducing and establishing the role entailed considerable stress for the FHN and a number of colleagues within the core PHCT. From the FHN perspective there was the very difficult challenge of trying to grow this distinctive new role while simultaneously trying to fit into the established core team approach. From the perspective of some, but not all, colleagues within the core PHCT there was an ongoing feeling that:

• the role was being imposed from outwith the site
• there was no clear need for the role
• its introduction reflected badly on pre-existing services

Unsurprisingly this gave rise to some sustained working difficulties. During the first nine months in particular there had been some conflict between roles:

Colleague 1: ... she's got some resentment from people she works with as to taking over their patients.

In a more general sense some colleagues within the core team did not see the FHN role as being part of an open, on-call primary care service that would necessarily have to respond to the full range of community nursing and/or medical priorities.

Colleague 1: ... the FHN has a far smaller number of cases. The other thing with the DN is that she's got an open model - she can't turn down any work. If someone gets discharged from hospital tomorrow she's got to take on the case. The distinction is that you have an open workload for the DN which is whatever work that happens to be needed for the day , and a closed workload which is controllable - I can see that it's far better - I mean I would like it if you could start the day and you knew exactly what you were going to do and nothing else - it takes all the stress out of it, no worries.

This point is important as, unlike the other FHN practice that we studied, this FHN did not necessarily have to be generalist in the sense of concurrently addressing all the role expectations traditionally associated with the district nursing caseload. This enabled the FHN to have more autonomy to determine and act on FHN priority:

Researcher:Well that's a useful explanation of priority within an FHN caseload, because I'm thinking of, when I talk to triple duty nurses for instance, they will often give you the hierarchy of work which usually goes along the lines of, midwifery or acute DN care first, going through to less acute DN work, to health promotion, to notionally community development work if that's even on the agenda, that's what I hear.

FHN :Cause health promotion and education to me is my top priority.

Researcher :Is it?

FHN :Yes, Cause what we are trying to do. We're trying for the long run, for the future. We're trying to educate these families to live with their chronic conditions and to empower them, and for them to be able to be independent, and not need so much from health service in the future. So its vitally important, and yes if they have an acute problem I would deal with that (obviously I'd have to) but if it was just a well individual that I was going to see my first priority would be the health promotion/education, lifestyle issues that they had, that I was going to see them with. That's really what we are doing ,or what I'm doing anyway.

What this model of family health nursing implementation also did not necessarily do, within the present system, was make the FHN the first point of contact:

Colleague 1: You see it mentions in this Scottish Executive thing about the nurse as the first point of contact for patients. I think that's daft, as I don't see how she can be - she hasn't got a role that makes her the first point.

... So the first contact concept seems a bit hopeful to me, totally impractical in fact. If you've only got one. If you're thinking of this person as a nurse practitioner, that nurse is the first contact with patients so it makes sense to have her as a prescriber and as someone who is going to consult, make a diagnosis and management plan. That I could see as person who is going to have first contact, but not your FHN.

By the end of the first year of practice the FHN had actually become an extended nurse prescriber, but she remained the only provider of family health nursing services and this limited her capacity to necessarily be the first point of contact for nursing and/or other primary care services.

In some ways the FHN's model of consultation at this site had more in common with the ideals of health visiting than district nursing (eg. overt prioritisation of health work). In addition to addressing the needs of individuals and families, the FHN had considered need at the general community level in her community portrait (completed during the educational course) and was using this to underpin the development of more broad based community work. By the end of the year the following activities had been developed which together comprise roughly 30% of the FHN workload:

• a fortnightly general health clinic in the main village which is open to anyone who wants to discuss a health issue or concern. This has been advertised in local media. Appointments are encouraged but people can drop-in and still be seen. Typical consultations have involved short-term input for smoking cessation; weight checks and healthy eating advice; immunisations; and mental health problems
• working as the health link person for the local community centre. This has involved a key role within a local Social Inclusion Project which has been offering teenage girls the chance to discuss contraception and other health and lifestyle issues. It has also involved joint facilitation of an exercise and music group for over 65s in the village, with health checks are incorporated into the programme
• weekly visits to the local Day Care Centre offering ad-hoc health checks and information/advice
• setting up a community reference group to enable the local community to pass on their views on local health needs. So far this has proved more difficult to establish and sustain
• consulting with others regarding setting up a Carers Group, having found that there are many young carers in the village with unmet needs
• consulting with others (eg. community OT for mental health) regarding setting up a Stress and Anxiety management group

Within the activities outlined above there are many that appear to be addressing gaps in wider health and social care provision locally. Professional stakeholders from the wider health and social care community (eg. community workers) viewed the FHN role as a very positive development indeed:

"In area my local FHN works there are many medical/social interlinked problems which don't fit neatly into any "box". She has been aware of "bigger picture" and improved care/support"

"Huge impact on my ability to address health issues in an informal setting but with professional knowledge and back up"

"Our FHN has been very supportive of our project, she is always available if we need to talk. She gives talks on health issues and does checks whenever she can"

"Highlights the appropriateness and positive impact of bringing health issues into the "community" sphere of work"

Some of these community based activities (e.g. immunisation; sex education for teenagers; assessment of the elderly) clearly overlap with the role boundaries of other core service providers within the PHCT (eg. GP; Health Visitor; Practice Nurse). Again there were concerns among some of the core team that these FHN services were being developed in isolation from overall PHCT services and that, from their perspective, further fragmentation rather than integration would ensue. Anxieties over infringement of role boundaries were a persistent feature during the first year of FHN practice at this site. Given the very broad range of activities being undertaken by the FHN, and their relatively vigorous development, this is not surprising.

Colleague 1:... it (FHN) seems to be such a big job, it seems to be everything. I mean this specialist/generalist thing is anything you can think of.

Indeed a key feature of this FHN's health work was that it could cover a very large range of subject matter and client groups. There was a particular focus on secondary and tertiary prevention work for elderly patients with chronic conditions. This is a client group that some people locally saw as "falling through gaps in the net". Some work with families with young children was undertaken but there was very little joint working with the Health Visitor.

The breadth of the health work undertaken brought with it some features of "generalism", in the sense of having to have a broad knowledge base about a large number of topics. However the FHN also emphasised the distinct, specialist nature of the role:

Researcher:Thinking of future development, how would you like to see the FHN go, would you like to see it fit in alongside other existing specialist community nursing roles such as HV, DN FHN in one team like this, or do you think it could replace these roles?

FHN: In this situation I don' think it could replace any of these roles because of the population and the kind of area. But maybe a smaller area and where you have a set population or a very tight geographical area where influx was not going to be a huge amount, you could, have just an FHN I suppose. But I think the real strength of the FHN role lies in it being a speciality. In it being separate from DN & HV. Because I do think it's a completely different role. It complements DN & HV, because it takes it that step further.

Four out of thirteen professional stakeholders locally (31%) did see it as providing a substantively different service by the end of the first year, while two (15%) actively took an opposite view. This contrasts markedly with all the other sites and tends to confirm the distinctiveness of this FHN role development. A key feature within this site was that the FHN was seen as providing a much more in-depth, intensive and sustained service to a small/medium caseload of families. Professional stakeholders generally felt poorly consulted in the early stages of the development, but by the end of the year seven respondents (54%) felt the development to be well suited to the area. Eight (62%) thought it likely to lead to an improvement in local health service and none characterised it as a failure. Five respondents (39%) felt the development had involved substantial change for professionals in the way they work together.

The majority (54%) felt that the development had added to, rather than taken away from, pre-existing local services. This perception was not universally shared, however, and amongst the district nursing team there was still a feeling that they had lost 15 hours of service provision from their team (prior to undertaking the course, the FHN had been working locally as an E grade community nurse for a total of 15 hours per week). This highlights that family health nursing is being seen within the core PHCT as a different kind of service that should be supplementary to the maintenance of normal service, rather than supplanting it. Indeed district nursing activities continued very much as normal during the year. While the introduction of the FHN was not seen as a catalyst for substantive review of community nursing caseloads, a number of families were referred to the FHN. Sometimes the FHN subsequently delivered all their care, but often there was concurrent input from both services.

Looking at the net change in site staffing over the first year of implementation, there has been:

• loss of 15 hours of E grade community staff nurse
• gain of 37 hours of G grade FHN
• one F grade community staff nurse (15 hours) has been replaced by an E grade community staff nurse (15 hours)

Accordingly there has been a small increase in the nursing budget during the period that FHN practice was introduced.

By the end of the first year six of the thirteen professional stakeholders who replied (46%) felt there was definitely a need for an FHN locally. Four did not know (31%) and two felt that there wasn't (15%). The fact that most of the core PHCT had actively referred families to the FHN in sufficient quantities to form a new caseload tends to confirm the need for an additional service of some kind. There were still doubts, however, about what the format of that service should be:

"I am not sure if its about creating a further role to DN and HV or about ensuring that the FHN role is accepted as being the way DNs should work, and their role changed accordingly"

"The FHN is really a "licensing" or permission for time and space to work in the way many of our health professionals already do on their own initiative"

Colleague 1: I think it's a bad idea to have yet another category of nurse full stop. It doesn't matter what she is doing or the quality. There is too many categories of nurses already....

The characteristic pattern of FHN development at this site can be summarised as:

Context: "Heavy" district nursing caseload within established medium sized PHCT, but FHN not super-imposed

Process: New FHN caseload built vigorously through referrals from professionals and public. Autonomous workload management with high community outreach element. Some friction at the boundaries of other professionals' roles. Tensions within the core PHCT

Outcome: Positively viewed by the families who received the service and by a range of groups in the wider community. Some change in referral practices for a number of professionals. "Normal" district nursing services maintained, but persistent core PHCT concerns about perceived lack of integration of the FHN role and the resultant equity of the overall service. More satisfying for the FHN, but much more demanding

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