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Listen
Section 4
4 Learning and key messages
"I find I have increased awareness of family function and dysfunction and the part it plays in family health. Underlying tensions can be very destructive and being instrumental in helping to resolve these can be rewarding."
Family Health Nurse
Learning
WHO Europe and the World Bank recognise the importance of the 'family unit' in identifying risk factors and targeting interventions to avoid health problems now and for the future. With its family and health improvement focus, the Family Health Nursing role can make a significant contribution to achieving health benefits for individuals, families and communities.
Box 4.1 A day in the life of a Family Health Nurse in Scotland
The Family Health Nurse role is based on a generalist model. This means my role is very flexible and can change according to the needs of my caseload and the community. I try to target my services to meet those changing needs. Most of my families are visited at home but I will go wherever is appropriate for that individual or family. Care is planned in collaboration with the family or individual to meet their needs or referred on to more specialist services where appropriate.
First two visits of the day are to see individuals who recently had orthopaedic surgery. An assessment is made of the families coping mechanisms as a result of the reduced mobility. Exercises given by the Physiotherapist are reinforced and dietary advice is provided.
10.45 and it's off to do a joint visit with the GP to see an elderly person who had recent surgery and has a possible wound infection. This individual had a family health assessment carried out 2 months prior to their hospital admission. Issues that were concerning them and the family were discussed which had promoted the individual's independence since discharge from hospital. The use of the ecomap (map of family social network) had been a successful tool for this family.
Back to the Health Centre for 11.30am to meet with the care manager, home care co-ordinator and GP for a complex case review of a family with chronic illness and ever changing health and social care needs.
After attending the funeral of a long-standing patient it's back to the office. Telephone call to the specialist team to discuss a teenager who I am seeing regularly.
Healthy lifestyle group 3.30-4.30. This group meets fortnightly at the Health Centre where each individual has a planned programme of lifestyle modification. Just about to go off duty when we receive a phone call from a resident who has had an injury that requires suturing.
Family Heath Nurse
The Family Health Nursing role responds to the needs of the community, as determined by community and GP practice profiles. Family Health Nurses have a clinical remit and an individual, family and community health improvement focus, a multifunctional approach that has been highlighted positively in all research evaluations associated with the pilot ( SEHD 2003b; WHO Europe, 2006; Parfitt et al, 2006). The combination of clinical care and public health has been most successfully achieved where team members have worked collectively on presenting health needs. Box 4.1 describes a typical day in the life of a Family Health Nurse, demonstrating this blending of care and health improvement.
An integrated approach which involved input from researchers, policy makers, educationalists, practitioners and nurse leaders contributed greatly to the success and sense of collective ownership of the project.
Each of the NHS Boards involved in the two phases of the pilot has distinct cultures linked to geography, language and health priorities. Remote and rural areas are faced with the challenge of providing accessible services to sparsely spread populations, while Family Health Nurses in the urban site work in a densely populated area providing services to an increasingly culturally diverse population. As such, the role needs to be flexible to adapt to different demands across remote, rural and urban sites.
For a number of reasons, the 'skilled generalist' model underpinning the Family Health Nurse role has been a difficult one for practitioners to pursue. Creating a generalist role within the context of existing specialist nursing roles has been challenging, and changing attitudes has been difficult to achieve. Strong leadership is necessary to support staff, individuals and families to understand the role Family Health Nurses play and the benefits they bring, and to make the sometimes difficult decisions required to progress thinking within organisations.
The Glasgow Caledonian University research (Parfitt et al, 2006) shows that care enhancement has been achieved by the Family Health Nursing role. The research indicates that this was particularly the case with Family Health Nurses working with families with complex needs, often linked to long-term conditions (Parfitt et al, 2006). For some of these families, the Family Health Nurse played a key 'lynchpin' role in co-ordinating the inputs from several specialists; for others, she provided a valuable lifeline to people who did not fall within the remit of any single specialist service.
The extent of care enhancement delivered by the role, however, depends upon a range of factors, including the effectiveness of the change management process put in place to introduce the role and the system of referral of individuals and families to Family Health Nurses by other professionals and services. Care enhancement was greatest when:
- change management was recognised as being central to the successful introduction and ongoing development of the role, and where all parts of the system understood the need for change to reflect new perceptions of the way members of the primary care team should function
- the Family Health Nurse was seen not to have a defined and limited client caseload, but considered the entire community as her caseload ( see Appendix 2 for further discussion of the concept of 'community as caseload').
Change management is therefore crucial to the process of introducing Family Health Nurses into the service, with the development of the practice facilitator role being seen as key to moving forward recommendations from Phase 1 of the project. Because of the challenges associated with 'real life' change management, support is needed for staff at all levels of organisations, from educators, to practitioners, to practice facilitators, to managers. Systems change requires education and continuing professional development ( CPD) activity at different levels to facilitate behaviour change by all members of the team.
There is a need to ensure whole-systems approaches to change are adopted within organisations, which should include the redesign of processes (many of which are based in historical precedent rather than defined benefits for service users) that may hinder individuals' and families' access to services. A clear system of referral protocols at NHS Board level is essential in ensuring that individuals and families are cared for and supported by the most appropriate member of the team, with integrated teamwork ensuring effective use of both generalist and specialist team members. Community Health Partnerships ( CHPs) offer an opportunity to lead and develop innovative approaches to multidisciplinary team working which maximise professional roles to ensure prompt and smooth service 'journeys' for individuals and families.
Effective Family Health Nursing depends on the development of positive ongoing relationships with families. This calls for the investment of time in the early part of relationships to build understandings and dialogue. The benefits of this investment will be seen over time as families, supported by the Family Health Nurse practising to the principles underpinning the role, move away from being dependent on professional services towards developing coping strategies that enable them to manage their own health, particularly in relation to
long-term conditions. Investing time in the early stages of the relationship is therefore time well spent in the long term.
Traditional caseload models which focus on numbers of patients seen and tasks performed do not enable the role to achieve its full potential, nor does it provide sufficient qualitative measures of effectiveness of the Family Health Nursing model, the research found. More appropriate models designed to measure benefits to families' health over the long term are required, as this is the central focus of the Family Health Nursing role and the ultimate arbiter of its success.
Raising awareness of Family Health Nursing with stakeholders and communities was a key part of practice facilitators' roles. They were involved in activities such as road shows, newsletters, team-building activities and media coverage. The challenge is not only in providing such opportunities, but also in encouraging people who feel most anxious about the piloting of the role to attend and engage in dialogue. Despite a wide programme of awareness raising, some stakeholders felt they did not receive sufficient information on the project, and findings from all evaluation research studies showed that while there was a clear understanding of the Family Health Nurse role among those directly involved in the pilot, some of those outside the pilot carried misconceptions.
Key messages
Findings from the project offer potential solutions to developing a modernised health care system, as described in Delivering for Health. Key areas where the findings can inform thinking are set out below:
- the Family Health Nursing model has offered benefits to families in remote, rural and urban communities
- service users showed an enthusiasm for the Family Health Nursing model. Although many were also positive about other nursing services, they valued the added contribution of the Family Health Nursing role, which was focused on having someone who understood and responded to the clinical care and health needs of all family members. They welcomed a single point of contact into the health care system, especially those who did not fall within the remit of specialist services
- the creation of a multi-skilled advanced-level generalist who can respond flexibility to the intergenerational needs within a family unit, providing clinical care alongside health improvement activities, offers a positive response to needs in the changing demographic landscape of Scotland
- Family Health Nursing can contribute to managing the problems of an ageing workforce through supporting existing practitioners to develop a new portfolio of skills and knowledge to ensure fitness for purpose in responding to future health care demands
- there may be benefits in combining the family care elements of the Family Health Nursing education curriculum with the strengths of existing programmes of education at pre- and post-registration level to ensure fitness for purpose as stated in Delivering Health, Enabling Care. The Family Health Nursing curriculum can make a significant contribution to achieving this aim
- the recommendation from previous research carried out by the Robert Gordon University (Scottish Executive Health Department 2003b) that a situational analysis should be carried out as part of the feasibility phase for the introduction of new roles is strongly supported.
Conclusion
The project has highlighted the Scottish Executive's commitment to investing in infrastructures within small communities, particularly within remote and rural areas, and to addressing the complex and fast-changing health needs of people living in large urban communities.
The Family Health Nurse model underpins the development of family-centred care in a way that reflects the Scottish health policy focus on delivering care that is based on health improvement and disease management. Findings from the project will inform the future policy development for nursing in the community and will contribute to the wider debate being taken forward within WHO Europe on the exploration of different models of generalist practice in member states.
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