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

4 DESIGN AND METHODS

4.1 The Research was conducted in two phases:

• A literature review which updated that presented in the baseline line study and helped to inform the design of the evaluation. The review appears in Annex C and includes a detailed description of the searches used to identify the relevant papers.
• The evaluation which comprised focus groups and interviews with nurses who transitioned (those completing the transition education) and nurses who did not transition in each of the three pilot areas. The nurses' managers were also included. The transitioned nurse sample comprised mainly Health Visitors, District Nurses and Public Health Nurses (Figure 2). NHS Boards were given flexibility to determine how to test the model to meet the needs of their local populations and, as a result, a small number of other nursing professions were included (Table 3). The non-transitioned sample also comprised mainly of Health Visitors, District Nurses and Public Health Nurses. Staff nurses were included 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. Please refer to Annex B for definitions of nursing disciplines.

Figure 4.1 Evaluation Design

Methods

The fieldwork

4.2 The total number of nurse and manager focus groups and interviews appears in Table 2 and the professional disciplines appear in Table 3. Annex A provides the number of nurses taking part in the evaluation in each area, but to protect their identity, does not give their profession.

Table 4.1 Focus groups and interviews

*Staff nurses were also included in other focus groups

Table 4.2 Professional Disciplines

* Not listed to protect identify

How nurses and managers were chosen and recruited for the study

4.3 We liaised with the lead nurse in each pilot site to identify the nurses and managers. This was a highly iterative process which involved the lead nurse approaching managers and asking whether they would like to take part in the study. All managers agreed to take part. Managers were then asked to approach all of the transitioned nurses in their area and ask if they were interested in joining the study. The number of nurses who took up the transition education across all three areas was 48 (Table 1) and we recruited 20 (Table 2) which gave a 42% response rate. Reasons given for not taking part were: general reluctance to participate, not turning up for focus group or interview or moving post. We also thought that the delay in gaining ethics permission for the study could have led to a loss of interest early in the field work phase.

4.4 Research indicated that new roles need time to become established (Bonsall and Cheater 2008). We recognised this and recruited those who transitioned early and those who did so more recently. We also recruited from different teams. Together this helped us gain a range of views and experiences of the new role.

4.5 Research indicated that new nursing roles were dependent on the reaction of others in their immediate team (Senior 2008). Therefore, the focus groups offered transitioned nurses the chance to discuss issues with their transitioning peers. In doing so we aimed to form a shared understanding of the central influences which shaped practice including the delivery of health care. Members from their teams were offered the opportunity in a separate focus group to discuss their views of the new roles. Those in non-transitioned teams, including staff nurses, were also offered the opportunity to take part in separate focus groups and in doing so given a space to provide their views of the role as well as their own methods of working. Staff nurses were also offered the opportunity to provide their views in a separate focus group. Individual interviews were conducted when respondents felt uncomfortable about taking part in a focus group or when a focus group was difficult to arrange e.g., geographical constraints. The topic guide used for focus groups and interviews appears in Annex D.

Data Collection and Analysis

4.6 All focus groups and interviews were audio recorded and transcribed verbatim. An initial analysis of the data was conducted by all members of the research team and this resulted in a number of initial themes. These themes were discussed at a series of team meetings and refined to give four main categories:

• What nurses know of the Review of Nurses in the Community and how it was implemented
• The extent to which it has impacted on their role
• The benefits and barriers to its influence in two key areas: i) nursing practice ii) patients and carers
• Staff nurses being the focal point for the future development of such roles

4.7 Members of the team then checked these against their more detailed interpretation of the data and further team meetings were held to discuss and refine the analysis. The following themes emerged from this more detailed and iterative approach. These themes underpinned respondents' perspectives of the new community nurse role and provide a deeper understanding of its implementation. The themes were used to structure the findings chapter.

Refined themes

• Strategic vision
• Changing professional boundaries
• Structure and organisation
• Staff nurses working as generalists
• Impact on knowledge, awareness and working practices
• The future

Ethics

4.8 Ethics approval for the study was granted by the East of Scotland Research Ethics Service REC 2: Fife and Forth Valley Committee on Medical Ethics