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Section 2
What works, what doesn't work, and what we need now
The international picture
Nurses in the community across the globe face similar challenges as the focus of care is shifted from hospital to community. The challenges are compounded by nursing personnel shortages and the need to increase the scope of practice by moving beyond 'technical' care to a health-maintenance, health-improvement orientation in partnership with individuals, carers, families and communities.
Models of community nursing delivery vary from country to country, with great variety in role titles, educational preparation and breadth of practice. Models of 'family medicine', however, have been developed and can be broadly described under six categories (Meads, 2006):
- extended general practice
- managed care enterprise
- reformed polyclinic
- district health system
- community development agency
- franchised outreach.
Each of these different categories, or 'types', typically has a distinguishing focus, location and end point. The community matron model in England, for instance, with its focus on at-risk target groups, would fit most comfortably within the 'managed care enterprise' type. The 'community development agency' type is commonly associated with South American countries such as Colombia, Bolivia, Peru and Brazil. It could be argued, however, that its focus on local ownership and management of primary care, with health being seen as an issue for citizens and not just for professionals, aligns it closely to models of care emerging within Community Health Partnerships ( CHPs) in Scotland, typified in the Family Health Nursing role operating in some areas. Initiatives such as these reflect a shifting away from the traditional 'extended general practice' model towards one embedded in a community development approach.
In Slovenia, the Republic of Ireland, Finland, Iceland and Latvia, community nurses work as generalists and provide services across the spectrum of care - from illness prevention to cure, and from the cradle to the grave. Many of the newly independent states of the former Soviet Union are developing generic roles for emerging community nursing services. Health promotion and illness prevention roles in Hungary, Denmark and Norway are undertaken by one nursing discipline, with home care nursing taken on by another. The United States has a variety of different models of community nursing both between and within States, with care being provided by private, state and church providers.
National Chief Nursing Officers agreed at their global meeting in May 2006 to review the European model of the Family Health Nurse ( WHO Europe, 2006) and share experiences of other generic community nursing roles through 'a community of practice models approach'.
The picture in Scotland
The Review process of consultation among individuals and carers, nurses, fellow health and social care professionals, managers and educators ( see Appendix 3 for a description of the Review processes and methods) revealed clear indications of what people in Scotland look for from nursing services in the community. These elements of service are being provided in some areas of Scotland, but to varying degrees of consistency and effectiveness.
Overall, the consultation presented a strong message that people believe nursing in the community should be all about delivering safe and effective nursing services within a multi-disciplinary, multi-agency 1 context, and:
- delivering what individuals, carers, families and communities have identified as being most important to them
- improving health and well-being
- supporting social and health care services in protecting the public from harm
- maximising individuals' and communities' self-care potential
- reducing inequalities.
What works
The Review found much to celebrate in nursing in the community in Scotland.
Workshop participants described nurses' breadth of knowledge and skills, a rich blend that enables them to undertake holistic assessments and to creatively problem-solve with individuals, carers, families and communities.
Individuals and their families value the relationships formed with nurses in the community, which are based on mutual respect, trust and rapport. It is through these relationships that nurses are able to make accurate holistic assessments and negotiate strategies for promoting health improvement and enabling self care, helping people to achieve maximum health and well-being outcomes.
The fact that nurses are viewed as being accessible and approachable and often work with people over extended periods, taking time to build relationships and address lifestyle changes to enhance health and well-being, was highly valued. The final report of the Family Health Nursing Pilot in Scotland ( SEHD, 2006b) confirms how important individuals and families believe building relationships over time with an identified nurse to be.
It was clear that nurses' approachability and the respect in which they are held was leading some people to view them as an important access point to health services, and their skills in organising and co-ordinating care provided by other professions and organisations were well recognised.
Nurses' strengths as identified by the Review can be summarised as:
- approaching health assessments from a broad knowledge base
- providing a wide range of health-promoting, health-enhancing and direct-care interventions
- problem-solving with people, taking into consideration the choices available to them and their potential impacts
- building relationships with individuals and communities over time
- supporting people to access and co-ordinate health and social care services when necessary.
What doesn't work
The Review was also able to identify areas that must be strengthened if nursing is to play its full part in delivering the services people in Scotland need.
An extensive range of role titles is currently used in nursing to describe the many different functions performed, educational standards attained and qualifications achieved by nurses. Some titles are well established and were founded prior to the birth of the NHS, while others (most) have developed more recently. The development of titles and roles reflects local health services' desire to address gaps in service provision and support individual nurses and teams to practice to optimum effect. Consequently, some roles have been superimposed onto other nursing services rather than being integrated with them. These tend to have been developed within a very particular local context with an apparent lack of awareness of the way services are evolving elsewhere.
The Review presented an opportunity to stand back and look at nursing services in the community as a whole across the entire country. It found that not only are individuals, carers, families and communities unsure of which nursing service to access to meet their particular needs, but also that health and social care professionals are frustrated by the plethora of nursing roles and titles existing in community services, which can lead to unnecessary delays in accessing appropriate nursing support and advice.
Individuals, carers and health and social care professionals want a single point of contact with nursing services. They find having to deal with a number of different nurses who appear not to be part of an integrated team confusing and frustrating. Sometimes they perceive that care is unco-ordinated and receive conflicting advice from nurses; at other times, they can't access any advice at all.
The impact of nursing in the community is often 'hidden' or 'buried' behind the work of other health care professionals, the Review found. There is a need to demonstrate clearly how nurses contribute to community services as members of multi-disciplinary, multi-agency teams. Understanding the added value nurses bring to community services will enable a more appropriate positioning of nursing services to maximise the benefits of their contributions.
This is particularly the case in relation to public health. Promoting health is central to nursing practice, and must be approached from a public health perspective. The Review found, however, that nursing's contribution to public health is often indistinct and insufficient. Nursing for Health ( SEHD, 2001a) set in place the changes necessary to give nursing a distinct public health focus, but implementation of its recommendations has been sporadic and inconsistent throughout the country.
Nursing needs to reclaim public health as a core function, with public health awareness and approaches being adopted as a kind of 'default position' by each nurse working in the community. Nurses should have the knowledge and skills to practise within a public health framework, drawing on specialist skills within and outwith their discipline as and when required.
Much of what nurses in the community do is already focused on the elements of care that Delivering for Health has identified as being vital in meeting the needs of the people of Scotland now and in the future. The Review found, however, that other elements of their role are less effective, can be done equally well by other practitioners, and are not well understood by individuals, carers, colleagues in the multi-disciplinary, multi-agency team and even fellow nurses. The match between nursing activity, knowledge and skills and the defined needs of individuals, carers, families and communities is now far from exact, and the configuration of the nursing workforce is no longer appropriate to meet the demands of community care - indeed, it sometimes imposes barriers and rigidity where flexibility is required.
What we need now
A new service model for nursing in the community is needed to deliver modern, appropriate, safe and effective services for the people of Scotland.
Services must now build on nursing strengths and appropriately address identified weaknesses, using the new model to create nursing services in the community that help to:
- promote individuals', families' and communities' health and self-care abilities
- support people to live healthier lives in their homes for as long as possible
- reduce health inequalities
- develop career options that reflect the importance and value of nursing in the community to the people of Scotland.
The Review identified seven core elements of nursing in the community that need to be promoted as the foundations for practice. The model sets in place conditions that will help nurses to deliver consistently on these elements in providing high-quality, safe and effective services.
The shape the model should take and the seven core elements are presented in the next section.
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