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Section 2

2 Family Health Nursing

"The workforce has to be prepared in order to have the skills and knowledge to take on new roles and responsibilities. Social and cultural understandings need to be reshaped to accept and support the introduction of new practices."

( WHO Europe (2006) Report on the Evaluation of the WHO Multi-country Family Health Nurse Pilot Study. Copenhagen: WHO Europe.)

The Family Health Nursing project in Scotland is part of a wider WHO Europe initiative.

Changing demography and disease patterns have challenged WHO Europe member states to review the ways in which they deliver health care services. New health problems such as HIV/ AIDS have emerged. Non-communicable diseases have reached epidemic proportions in developed and developing countries. Ageing populations and declining birth rates prevail in some member states. And chronic conditions and environmental risks present challenges for most health care systems ( WHO, 2003).

Nursing and midwifery education and practice have reformed in many ways in response to this changing health map. An example of this can be found in the multinational pilot of the Family Health Nurse role.

The Family Health Nurse initiative was developed following a recommendation from HEALTH21 ( WHO, 1998). WHO Europe described the role of the Family Health Nurse as one that contains elements of existing roles of several nursing disciplines working in primary care settings across the European region. The particular combination of elements - the focus on families and on the home as the setting in which family members can jointly address their health problems and create a 'healthy family' concept ( WHO, 2000; Scottish Executive Health Department 2003a) (Box 2.1) - is what gives Family Health Nursing its unique characteristics.

The global meeting of Chief Nursing Officers held in May 2006 agreed to review the European model of the Family Health Nurse and share experiences of other generic community nursing roles through a 'community of practice models approach', which includes exploring further the role of the Family Health Nurse in pilot countries.

Box 2.1 The family unit
The Family Health Nursing concept is based on the idea of the 'family unit'.
A family unit may include:

• individuals with geographically distant relatives
• friends who provide a supportive role in a similar way to a family member
• a traditional nuclear family, with different generations being geographically close.

This broad definition of 'family' is consistent with current international thinking on relationship units within contemporary society. The focus on this type of kinship unity is increasingly being recognised as central to targeting and addressing health challenges. The World Bank (2004), for instance, states:
"Households matter in the health sector - more than most policymakers acknowledge. Improving the health of households is what the health sector is all about. People rely on their health in their everyday lives, and for poor households, health is one of their major assets. Households are also key actors in the production of health. Indeed they play a dual role - as users of health services delivered by professional providers and as producers of health through the delivery of home-based interventions and in their everyday health behaviours."

Role, model and framework

Role

The vision of Family Health Nursing in Scotland is closely aligned to WHO Europe and the World Bank's emphasis on developing family-focused care as a vehicle for strengthening and developing community-orientated health services.

The role has a strong focus on the family and takes into account wider family, social and environmental influences on health. The overall aim is to maximise health and well-being, enabling empowerment of individuals, families and communities by motivating them to take responsibility for their own health.

The role in Scotland has been underpinned by three principles:

• a 'generalist' approach to practice that encompasses a broad range of duties, with the Family Health Nurse acting as the first point of contact for individuals and families and referring on to specialists when greater expertise is required
• a model based on health as well as illness - the Family Health Nurse is expected to take a lead role in preventing illness and promoting health in addition to caring for members of the community who are ill and require nursing care
• a role founded on the principle of caring for families as well as the individual.

Fundamental to the role is the unique approach to family assessment and care, which is highly valued by service users (Parfitt et al, 2006). Working in a family-focused way is key to developing trust and building the confidence of families to take greater responsibility for their own health. The following quotation from a Family Health Nurse provides insight into what can be achieved through this way of working.

"Often there are many issues affecting a family from environmental, financial, educational, health related and social, therefore it is important to identify any barriers that might affect the family's ability to achieve their goals. A lot of my time is spent helping families to work through these issues and helping them to identify possible solutions e.g. a family suffering from social isolation and stress as they have just moved into a new community and have no family or friends. We would look at developing a support network and encouraging them to get involved in community events. Once a support network is in place the family's stress would reduce and they would feel more of a part of the community and this would impact their health and well-being."

Working from the premise of a family-focused health care system that sees the community as the client, rather than defining a range of separated and non-linking specialist caseloads, could avoid fragmentation of service provision (Parfitt et al, 2006).

Model for the role

The Family Health Nursing model for the role described by WHO Europe (2000) is one of 'a skilled generalist with a support network of community nurse specialists who may be geographically distant' (Figure 2.1). This model provided the conceptual framework for the education curriculum and development of the role within the Scottish pilot.

Using a generalist approach in the Family Health Nursing model requires advanced clinical skills acquired through experiential and formal learning combined with public health knowledge.

Figure 2.2 presents a conceptual model summarising the key features of a family-focused health care system located within a generalist model of care delivery. The model was developed from evidence gathered from the final piece of research on the Family Health Nursing role in remote, rural and urban sites (Parfitt et al, 2006).

The community is at the centre of the model, with the Family Health Nursing role adopting a dual health improvement and disease management function delivered through an integrated team network.

Figure 2.1 The Family Health Nurse under the 'umbrella' of public health and primary health.

This model is built on a systems approach that is dependent upon three inputs:

• an education culture that takes account of formalised programmes of education and a team ethos of shared learning that embraces the family health approach to care
• integrated team working involving specialist and generalist roles from within nursing and across other professional groups and agencies
• professional expertise underpinned by a portfolio of skills and knowledge on family health approaches that include assessment and health planning.

These interlocking inputs interact with the community setting where health care is delivered to individuals and families to enable the output of family-centred care. If any of the inputs are not present or there are barriers to their implementation, family-centred health care cannot evolve.

The key shift to take place in this model is from an emphasis on single clients to a focus on communities and the individuals and families who live and work within them.

The process described in this model would enable the Family Health Nurse to function as described by WHO Europe in Figure 2.1.

Figure 2.2 Conceptual model for Family Centred Health Care ¹ (Parfitt et al, 2006)

Role framework

As Family Health Nursing was a new role, it was necessary to create a framework for practice. The framework built on work carried out by WHO Europe (2000) and NHS Education for Scotland (2004) ² and helped to demonstrate similarities and differences between the Family Health Nursing role and other roles in primary care.

A nominal group voting technique ³ was used by Family Health Nurses to identify the four most important indicators within each of the WHO Europe Family Health Nursing principles:

• ways of working
• health improvement
• family focus
• generalist model (Figure 2.3).

This approach ensured that Family Health Nurses had 'ownership' of the indicators and also drew on the expertise they had developed within their practice.

Figure 2.3 National Family Health Nurse ( FHN) Practice Indicators

Pilot phases 1 and 2

Scotland joined the WHO Europe Family Health Nursing multinational study in 1999 as the lead pilot country (Scottish Executive Health Department 2003a). A National Implementation Group ( Appendix 1) was appointed to oversee the pilot, involving representation from interested parties such as nursing and medical professional groups, practitioners, educators, researchers and members of the public.

The pilot was introduced in two phases:

• Phase 1 (2001-2003): the evaluation of the Family Health Nursing role in remote and rural settings and the education preparation, involving 31 Family Health Nurses
• Phase 2 (2003-2006): the evaluation of the Family Health Nursing role in remote, rural and urban locations, involving 18 Family Health Nurses.

Four NHS Board areas participated in Phase 1 - NHS Highland, NHS Argyll and Clyde, NHS Western Isles and NHS Orkney. Thirty-one Family Health Nurses completed their education programme and 29 returned to work with clients from their previous caseloads ⁴ on completion of their education programme at Stirling University. Two Family Health Nurses moved into other roles outwith the area. Students and mentors were supported by clinical teaching fellows based at Stirling University during Phase 1.

Researchers from The Robert Gordon University conducted an independent evaluation of the education programme and the practice of Family Health Nursing following Phase 1 (Scottish Executive Health Department 2003b). The research suggested three ways in which the role could be further developed:

• enable the Family Health Nurse role to
  merge with current service provision in a meaningful way
• develop the core Primary Health Care Team ( PHCT) to incorporate a more systematic focus on family and health within existing services and care practices
• involve individuals and get the wider community to expect, accept and value a different approach to nursing care in particular and health in general.

These findings, combined with the views of the National Implementation Group, influenced Phase 2. This was designed to consolidate the learning of Family Health Nurses in existing sites and to establish an urban pilot.

Family Health Nurses in the urban setting became additional members of nursing teams and established new client caseloads. As part of the preparation for Phase 2, a situational analysis (recommended by the evaluation of Phase 1 (Scottish Executive Health Department 2003b) informed the selection of practice sites. The analysis included:

• role analysis, outlining what work would be carried out by the post holder
• cultural analysis, detailing how the role
  would fit with existing services and consideration of the perceptions of others affected by the change
• business analysis, identifying requirements to support and sustain the role
• situational analysis, considering gaps in service provision and changes required to accommodate new role.

Practice facilitators (Box 2.2) were also introduced in Phase 2 to support Family Health Nurses and their teams in all areas in implementing their role.

Research evaluations

Multinational

WHO Europe researchers conducted a multi-country evaluation across all pilot countries to explore inputs, processes and outcomes ( WHO Europe, 2006).

The results demonstrated a strong commitment from policy makers, stakeholders and service providers to the Family Health Nursing role. The role was found to be similarly implemented within countries, but was capable of adaptation to meet the needs of national health and education systems. It was perceived as creating a greater focus on public health and improving communications within teams as they worked towards a common family-focused goal.

Most countries experienced challenges in relation to change management, which tended to manifest in misconceptions about the role. 'Receiver' resistance was a recognised change management issue; this has implications for the future integration of new roles into existing service provision.

National

As part of the ongoing evaluation of the project within Scotland, a piece of research was conducted by Glasgow Caledonian University (Parfitt et al, 2006). This complemented previous research conducted during the initial phase of the project. The aims of the study were to:

• evaluate the role of the Family Health Nurse in the urban pilot area by identifying the impact of the role from the perspectives of Family Health Nurses, their colleagues and service users
• assess the impact of the Family Health Nurse role after 3-4 years of practice in the remote and rural settings
• identify factors that have helped or hindered the implementation process across all settings.

The evidence from this study highlighted the following key issues:

• care enhancement was shown through service users valuing the role's ability to offer a first point of contact and provide a professional who understood their health needs and those of their family
• in addition to clinical and public health, the knowledge and skills found to be of most value in the role included: counselling, negotiation, facilitation, family development, dynamics and interaction, and change management.
  These were all included as topics in the education programme
• although challenges were identified in the integration of a generalist approach into a system of specialist nurses, there was agreement that Family Health Nurses were able to identify people who do not fall under the remit of other services
• building relationships with families required significant time, which was not always easy in a context of large client caseloads
• the role was able to provide inter-generational care within families to help them address and cope with existing health issues and look towards reducing risk factors
• change management was an important aspect of the practice development process and was essential in supporting people involved both directly and indirectly in the project.

Specific findings from the study are integrated within the remainder of this report. An executive summary is provided in Appendix 3.

Box 2.2 Practice facilitator development
Practice facilitators, introduced in Phase 2 of the project, provided a diverse resource of experience and expertise to the development programme. A key function was to raise awareness and understanding of the Family Health Nurse role through activities such as road shows, newsletters and team development work.
The practice facilitators participated in three-monthly workshops to develop their thinking in relation to the role of the Family Health Nurse. The workshops created a learning environment in which the facilitators could develop new skills and knowledge in practice development, change management and project leadership. Together, they shared experiences and challenges, explored solutions and grew professionally and personally.
To support implementation of the Family Health Nurse role, the practice facilitators prepared learning tools and organised two workshops on 'Family Health Nursing Practice Indicators' and 'The Continuous Improvement Model'. These enabled practitioners to explore the role of the Family Health Nurse and to develop the role and their practice through the use of a change management process.

Education programme

The Family Health Nurse education programme was developed by Stirling University from a competency-based, multinational curriculum for Family Health Nursing ( WHO Europe, 2000). The programme was subject to internal and external evaluation over the course of the two phases of the project ⁵.

On completion of the programme, the Family Health Nurse was expected to be competent as a:

• care provider
• decision maker
• communicator
• community leader
• manager.

NHS Education for Scotland assisted in the evolution of the programme through the development of a revised set of competencies for Family Health Nursing ( NES, 2004) ⁶. This piece of work also underpinned the practice role.

The education programme was based on a systems framework incorporating the following elements (University of Stirling, 2006):

• socio-economic, demographic, epidemiological and service networks
• family dynamics and theoretical and
  ethical constraints
• development, life events, normality and crisis
• evaluation of interventions in the family system using case study and single-case experimental design.

The programme was delivered full-time over 45 weeks using mixed-mode learning techniques, including computer-based learning (Web CT) and other distance-learning approaches integrated with campus-based study. Clinical practice constituted 50% of the programme.

Eighteen students from urban and remote and rural settings undertook the final education programme of the project. Accreditation of prior learning ( APL) was developed to enable recognition of students' previous education and clinical experience, particularly those who had already completed a district nursing or health visiting programme, who were able to take a shortened programme.

Table 2.1 outlines the format of the programme, and further information on the modules is given in Appendix 4.

Mentorship preparation was essential to ensure students were supported during periods of clinical placement. A preparation and support programme was created which included study days, the appointment of a clinical teaching fellow and a dedicated discussion area on Web CT.

Evaluation of the programme was conducted as part of higher education quality processes. Key points of learning from this were:

• students, particularly those in remote and rural areas, found Web CT crucial from both learning and peer-support perspectives
• students felt the programme had changed their thinking and had enabled them to develop professionally
• some students felt challenged during practice because of lack of support and perceived negativity from colleagues
• students identified limitations with the shortened programme in relation to material having to be repeated or delayed until Semester 2
• some mentors found their role challenging, which impacted on the support they provided to students
• few mentors used the Web CT site, but they found the support of the clinical teaching fellow important
• where mentorship was successful, the role provided an important champion and support for students (University of Stirling, 2006).

Practice development

Practice development work for Phase 2 of the project, which focused on further developing graduates from Phase 1 who were now practising as Family Health Nurses in their own areas, was based on agreed national and local practice objectives, which were to:

• clarify perceptions about and understanding of the Family Health Nursing role
• identify barriers and enablers for the development of Family Health Nursing
• implement and evaluate a development programme to enhance family health practice
• support and enable changes within local teams to develop the full potential of the role
• develop Family Health Nursing in each of the sites.

Practice development work was led by the practice facilitators and was built on the ethos of developing local ownership of the project through creating implementation groups in each NHS Board, encouraging stakeholder involvement and providing an active facilitation process.

An action learning approach was followed in all pilot sites (Box 2.3), with a locally focused practice development programme tailored to meet individual team needs.

Table 2.1 Education programme

Box 2.3 Action learning
An action learning approach was used to underpin the development programme. Through action learning, individuals learn with and from each other by working on real problems and reflecting on their own experiences.
The approach used by practice facilitators was one of joint learning with the Family Health Nurses, perceiving them as reservoirs of knowledge and skills on which to build and encouraging them to take control of their own learning. The role of the facilitator was to support and guide them through this process.

Langley's Continuous Improvement Model

Langley's Continuous Improvement Model (1994) was selected for the practice development work because of its flexibility, simplicity and focus on achieving change through small-scale actions. It is based on the principles of action research and has been used successfully in different clinical settings, providing practitioners with a tool to enable them to develop, test and implement change focused on creating improvements (Figure 2.4).

One of the real strengths of this approach is that it enables the practitioner to take ownership of changes in his or her practice and develop leadership skills. Each of the actions in the model is essentially one cycle that is planned, implemented and evaluated before moving on to the next one. Each change cycle is small, reducing associated risk. Every idea consequently progresses through successive cycles until the practitioner has achieved his or her desired outcome.

A guidance pack developed by the practice facilitators was provided on an individual and team basis. This enabled Family Health Nurses to work with their teams on shared and individual practice development activities linked to clinical and health improvement work.

Calgary Family Assessment Model

Family Health Nurse assessment and documentation is based on the Calgary Family Assessment Model, adapted to meet statutory and NHS Board requirements. The assessment of families involves six broad categories (Friedman, 2000; Wright and Leahey, 2000) which provide a framework for Family Health Nurse documentation:

• identifying data
• developmental stage and health history (including a genogram - a family health history)
• environmental data
• family structure
• family functions
• family stress and coping (including an ecomap - a map of the family social history and their network of support).

The assessment process is underpinned by advanced communication and interviewing skills which enable relevant areas to be explored in more depth, including family needs and risk factors. Interventions are directed towards goals collaboratively generated by the Family Health Nurse and the family. Family health plans may include clinical care, screening and health improvement strategies.

An example of how the genogram and ecomap are used with families is illustrated in the following quotation from a Family Health Nurse.

"I use the genogram and ecomap at the second or third visit. Both are powerful tools which have great impact on the individual and their families. Each individual member of the family reacted differently to the information provided and required (at times) intense interaction with the Family Health Nurse. I also help them to look at strengths and weaknesses within the family and try and encourage them to be aware of their strengths which can help improve their problems."

The principles of Family Health Nurse assessment have been shared with teams and other colleagues to provide a better understanding of this approach and some members have integrated them into their own practice.

Change management

The multinational evaluation of all countries taking part in the pilot carried out by WHO Europe ( WHO Europe, 2006) emphasised the importance of change management in the implementation of the Family Health Nurse role. Bainbridge (1996) outlines the progressive stages for effective change management:

• design stage, to identify requirements for change
• definition stage, to outline the design of proposed change
• development stage, which incorporates preparation, education and restructuring
• dismantling stage, where reform is carried out to remove or convert redundant parts of the system
• deployment stage, where new parts are integrated into the organisation.

The multinational evaluation suggested that many countries are in the development stage of Family Health Nurse implementation.

Figure 2.4 Langley's Continuous Improvement Model (Langley, 1994)

The model has two parts:

• three fundamental questions that enable practitioners to focus on an area of their practice that they wish to develop
• the 'Plan-Do-Study-Act' ( PDSA) cycle to implement and test changes in real work settings.

Change management was key to role implementation. The project in Scotland was conducted at a time of major organisational change, particularly within the urban site. It was important to recognise the different ways in which resistance to change could be expressed. Some colleagues felt vulnerable and anxious about the impact of the role on their practice, and others chose not to engage in the process of implementation. Similar experiences emerged from the multinational study.

Change was necessary at different levels within the organisation. Box 2.4 offers a reflection from an observer on how a Family Health Nurse worked through the process of role integration and acceptance in her practice. It provides a good example of how the team addressed the challenging issue of ensuring a balance between clinical care and public health issues.

More information on the development work can be found in the local reports of implementation of the Family Health Nursing model. ⁷

Box 2.4 Reflections on time spent with a Family Health Nurse
In 2004, I was in the fortunate position to spend a day with a Family Health Nurse. The purpose was to 'shadow' her to identify how she, working as a generalist nurse, managed the caseload and ensured that the needs of the practice population were met.
A large proportion of her time was initially spent in assessing, care planning and agreeing with other members of staff who was the most appropriate nurse within the team to deliver on the care plan. A development plan for the team was agreed with the Family Health Nurse attending short courses to further develop her skills in dealing with children within the practice. This included a breastfeeding course, a parenting skills course and some further 'in-house' training in child protection.
Once the post was established and the Family Health Nurse had completed her analysis work, the practice met as a team to agree what, if any, gaps in service had emerged. They decided not to employ a health visitor for the practice, but would call on one from another area when the Family Health Nurse felt the care required was outwith her bounds of her skills and competencies (a GP practice in another area agreed to this plan). They team agreed that they might need to employ another part-time staff nurse for support.
The team met as a group to discuss who should take referrals. It was agreed that the Family Health Nurse would take over the care of all children aged under five years and their families after the health visitor had carried out her first visit. The health visitor would attend the surgery as required to assist the GP with developmental checks. If the Family Health Nurse felt a family had needs she could not meet, she would discuss these with the health visitor. The health visitor would either offer advice or carry out a visit to further assess the situation.
The Family Health Nurse and district nurse would agree who should take any particular referral, depending on whether a short intervention was required or the family needed more intensive support.
Although the post was still being established at the time I visited, I was impressed with the team approach and how they had shared the workload equitably, taking cognisance of the skills of each member of the team. The general consensus was that the Family Health Nurse model was beneficial to patients and worked well within the area. As a result of adopting a different way of working, time had been freed up to allow the nursing team to engage more meaningfully in community development and other health promoting activities.

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