Study of the Implementation of a New Community Health Nurse Role in Scotland

1 EXECUTIVE SUMMARY

Introduction

1.1 In 2006 the Scottish Executive, as part of the modernisation of the National Health Service (NHS), began a radical and far reaching review of nursing in the community. The Review of Nursing in the Community (RONIC) proposed the absorption of district nursing, health visiting, school nursing and family health nursing into a single community health nurse (CHN) role (Scottish Executive 2006). The new role was piloted in three Health Boards across Scotland namely Highland, Borders and Tayside. The following seven core elements identified by the Review of Nursing in the Community formed the basis of the new role:

• Working directly with individuals and their carers
• Adopting public health approaches
• Co-ordinating services
• Supporting self-care
• Multi-disciplinary and multi-agency team working
• Meeting health needs of communities
• Supporting anticipatory care

1.2 In 2010, the Scottish Government commissioned the research team to conduct an evaluation of the new role and an updated literature review (published as an annex to this report). This was the third study commissioned by the Scottish Government on this particular topic. The first was a literature review conducted by Kennedy et al (2008) which identified the contribution made by nurses in the community. The second was a baseline study and literature review which was conducted by Kennedy et al (2009).

Aims

1.3 The original aims of the study were to:

• Evaluate the impact of the new model of practice on both staff and patients (including carers),
• Provide evidence to inform a future decision on the use of the CHN in Scotland.

1.4 Early indications from our field work suggested a strong sense of inertia around the new model of practice. There was a strongly held view among nurses that in many instances it was not implemented and in the few places where it had been implemented the effect had dissipated. A decision was made by the commissioners to focus on the implementation of the new role and this resulted in a change to the first aim.

Revised aims:

• Provide insight into the structural and other issues which affect the uptake and implementation of the Community Health Nurse role
• Provide evidence to inform a future decision on the use of the CHN in Scotland.

Method

1.5 The evaluation comprised focus groups and interviews in the three pilot areas with nurses who completed the transition education for the new role (known as transitioned nurses) and nurses who did not transition. The nurses' managers were also included. Those transitioned were mainly Health Visitors, District Nurses and Public Health Nurses. Staff nurses were included in the study because indications from data collected early in the evaluation suggested that nurses thought staff nurses would have been more suited to the new CHN role. A total of 75 respondents took part in the research: 20 nurse managers and 55 nurses.

Findings

1.6 Nurses and their managers participating in the study questioned the strategic vision of the new Community Health Nurse role or to be more precise the model of nursing upon which the role was based. For many it represented a return to a previous model which in their view had 'failed' i.e., double and triple duty nurses. Furthermore it was strongly associated with the extended family which was thought to be outdated and no longer fitted modern family structures. The CHN role challenged more traditional nurse boundaries which formed strong professional identities and were highly valued. Some concerns were raised regarding the effectiveness of transition education in helping nurses change their identity and sustain their new role. Another important issue was that of critical mass. Many nurses returned to their original teams after the transition education and experienced opposition to the new role. In some instances they also lacked managerial support.

1.7 There were, however, some favourable reports. The transition education helped heighten nurses' awareness and re-engagement in the wider aspects of health and social care. This was particularly so in public health, including community health profiling and health promotion. It also helped them to reflect upon their role and led some to change their practice. Notable examples included district nurses, public health nurses and health visitors conducting immunisation programmes; health visitors taking on district nurse duties such as taking bloods and changing dressings; and health visitors and public health nurses visiting schools. However these were often viewed as opportunistic rather than systemic changes and there was little discernible impact on patient experience. There was support for the notion that the new role could be more easily accommodated in nursing teams that already worked with a range of health professions and other disciplines.

1.8 There was little doubt that the introduction of the CHN gave rise to extensive debate within the nursing professions in Scotland. There was broad support for the core elements such as promoting self-care, adopting a public health approach to nursing, developing community profiles, and preventing unnecessary hospital admissions. However nurses thought that, rather than focussing on changing nurse roles, more should be done to improve interagency working and foster better collaboration among the existing nursing disciplines. Some examples were offered including identifying a single point of access to health and social care, greater liaison with nursing colleagues to improve patient management, and multidisciplinary team meetings to improve communication. There was a strong sense that the new role was introduced from the top and had not fully considered the views of nurses to which it was directed. Thus, many felt the need for greater consultation before new policies were introduced.

Key conclusions

Education

1.9 Whist nurses in the current study valued the education they received there were some concerns about its effectiveness in helping them change and sustain their new role. The main issue was around the depth and scope of education required to meet the diversity of the role. The resulting tension between specialisation and breadth is not easily reconciled. Recent research indicates that improvement in knowledge and also competence is necessary to help change nursing roles in the community. The issue of competence links well to the educational programme which was designed for the Family Nurse Role in Scotland where students highly valued the skills based parts of the course specifically those which focussed on communication, assessment and health promotion (Scottish Executive 2003).

Managing change

1.10 Changing existing roles is difficult and there were three areas which we think proved extremely problematic in doing so: critical mass, the strategic vision of the new role and ownership of the new role.

Critical mass

1.11 We noted in the baseline study that approximately one-third of nurses supported the new community nurse role (Kennedy et al 2009). It is probably reasonable to conclude that the lack of widespread support for the new role continued after the baseline. For instance, many nurses returned to their original teams after the transition education and experienced opposition to the new role. In some instances they also lacked managerial support. Therefore support did not reach a level necessary for its implementation. Building critical mass was also recognised as important for the future development of the Family Health Nurse role in Scotland (Scottish Executive 2003).

Strategic vision

1.12 There was uncertainty around the strategic vision of the new role which, as we have demonstrated, was framed in terms of an older approach to community nursing that was thought to have 'failed' i.e. double and triple duty nursing. This failure was linked to the breadth and depth of knowledge and skills required to carry it out. Critically, the diverse nature of the new model also represented a challenge to the existing professional boundaries. We think success depends on a shared vision of the new role and an understanding of how it works within the health care setting.

Ownership

1.13 We think our findings fit very well with a more macro theory of role development as described by Aranda and Jones (2008). They explain how new nursing roles are essentially socially and politically constructed. Critical to this theory of development is the mechanism by which new roles are adopted (or rejected) by nurses. Here, nurses are viewed as being actively involved in the process of 're-constructing boundaries, identities and social relations in healthcare'.

Leadership and organisational support

1.14 It would be misleading to suggest that there was a total lack of support for the new role. There was clearly a strategic commitment to the policy by the Scottish Government and from the health boards which piloted the new community nurse role. Some local managers and the nurses who took part in the programme were also supportive of it.

1.15 Nurses also thought they should take a stronger lead in developing their public health role, encouraging anticipatory care and self care. They envisaged adopting extremely proactive roles in working alongside services users to help them improve their health, avoid unnecessary use of more intensive healthcare and live independent lives. Key to these developments however is the working dynamic of the nursing team (including managers) and other health professionals. It was noted that nurses who undertook the transition education were better supported by teams with a history of multidisciplinary working across nursing professions and other health professions. This connects well with the notion of critical mass which needs to be developed before a new role can be successfully embedded into a team (Scottish Executive 2003).

Research

1.16 There are methodological limitations to the research which appears in this report. First, the views outlined in this report represent nurses and their direct managers and not strategic managers and policy makers. Second, it represents the views of those who volunteered to take part in the transition education and those who did not undertake the education from the three pilot areas, which means the views of those from the remaining Health Boards in Scotland are not considered. Third, there were nurses who declined to participate in the research and it is possible that the voices of those who held contrasting views were missed.

1.17 There are also strengths of the research. Every effort was made to include nurses from a range of disciplines which were affected by the Review of Nursing in the Community in Scotland. We also, after a preliminary analysis of our data, included nurses thought to be indirectly affected by the role i.e., community staff nurses. We included nurses who had undergone the transition education, members of their immediate nursing team and those from non-transitioning teams. Thus, the data presented in this report represent the views of those most directly affected by the new policy, those who work along-side them and those who were given the opportunity to adopt the new role and declined.

Recommendations

• The model of nursing and the related attributes were viewed as highly problematic by nurses participating in the study and became important territory upon which the implementation of the new role rested. Thus, future consultations could focus on co-constructing new nursing roles particularly in developing critical mass which will secure support for a new policy. A crucial part of this is how the roles fit with existing teams particularly within the multidisciplinary team setting.
• We would also agree with the recommendations which appeared in the evaluation report of the Family Health Nurse in Scotland (Scottish Executive 2003) which suggested that before introducing new roles developers devise a detailed plan which facilitates and sustains such roles.
• Nurses valued the education which was designed to prepare them for the new role although any gains were confined to an improvement in knowledge. However competency is also necessary to help change nursing roles and thus designers should consider how both skills and knowledge are best promoted in their training programme.
• Tension surrounding the introduction of new nursing roles tends to dominate the scientific literature, however there are studies which point to new developments within nursing which merit closer scrutiny and may lead to more effective care. This includes the co-construction of therapeutic nurse patient relationships; the co-construction of nursing roles (as highlighted above); and partnership working with other nurses and other health professions. Future research could focus on evaluating the impact of the new nursing practices on the end users as well as providing insight into how new roles work.