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

5 FINDINGS

5.1 Nurses and managers who participated in this evaluation reported that the new CHN role had not been implemented as originally envisaged in the policy. There were a number of reasons given by respondents. These appear under the headings in the present chapter and will be discussed in more depth in the final chapter. As noted in the methods chapter these headings represent the dominant themes which emerged from our analysis. The quotes presented in this chapter are typical in that they represent the views and experiences of nurses across the three pilot sites.

Strategic vision

5.2 There were a number of prominent concepts which underpinned respondents' strategic vision of the Community Health Nurse Role. The issue is not whether these are factually correct. Rather it is how these concepts were used by nurses to construct a narrative of how the policy was implemented and their subsequent response to it. Three concepts emerged: Double and Triple Role Nurses; Extended Families; and Single Point of Contact.

Double and Triple Role Nurses

5.3 There was a strong sense that the new Community Nurse Role represented a return to an older model of community nursing that had 'failed'. A number of participants thought that the previous roles of triple and double duty nurses were abandoned due to concerns over the depth and range of knowledge and skills required to satisfy each.

'I had a lot of district nurses who were also midwives. The roles were separated and the reasons given at that time were that they [post holders] could not keep the expertise that was required. The disciplines become more complex and more evidence based, and we become more accountable and working at a higher level, and that they couldn't do that so they were deliberately separating those posts. And suddenly we were saying, to often the same staff, hey we've got an idea - you're not allowed to do midwifery because that's too complex but why don't you do a bit of school nursing and health visiting as well. And I think that caused quite a lot of problems because we were actually asking them to go back to a model that was not seen as being ultimately successful in the past'.

(Manager).

'I felt as if we were going back in time having had dual roles that didn't work and I think district nurses were more scared with all the child protection issues in health visiting whereas the health nurses we had all been staff nurses and with some training could probably do it.' (Transitioned Health Visitor).

On the other hand, there were some nurses who felt comfortable with the new role but did not feel comfortable sharing this with their colleagues. This tension is explored in depth in a later section (5.10 Structure and Organisation).

'…..there was a huge outcry that nurses are going to go back to dual roles…I was one of the only ones in the team that didn't freak because before I went into being a public health nurse I had worked as a community and nurse and midwife so I had had a dual role and I didn't know if I was going to be that bothered really… but I didn't tell any of my colleagues that because there was such an outcry'. (Transitioned Health Visitor).

Extended Families

5.4 Respondents also raised concerns about the demographic information which appeared to underpin the Community Health Nurse role, or to be more precise the model of a typical family which they thought was used to promote the new role i.e., the traditional extended family.

'Gone are the days that you're actually having the family with all the extended family, the grandfathers, the baby, everybody in the same house, we don't see that nowadays so if we're going in to see a patient very seldom is there a child or a health visitor need there, it's purely district nursing. Whereas years ago you went out and all the family was in the one house so you could potentially have had the health visitor going in but also a district nurse going in but that doesn't happen.' (District Nurse)

Single Point of Contact

5.5 There was also some dispute as to whether service users would welcome the notion of one nurse looking after their family needs, particularly if this resulted in a conflict of interest.

'Quite often if you speak to families they see their needs independently and they don't necessarily want to be represented by the same professional. So quite often in family situations like social work you'll have a parent with a social worker and a child with a separate one because the needs of family members sometimes have to be represented by different people because they conflict.' (Manager)

'And families may worry you know. Do I tell this nurse something very personal about the child or father of the child or whatever, and will she ... whether there's any chance that granny might find out. It shouldn't under confidentiality but I can see why families would feel nervous about that situation.' (Manager)

Changing professional boundaries

5.6 Much of the discussion in the focus groups and interviews focused on professional boundaries. These shaped nurses' professional identity and many raised questions about the impact of change on such identities. They also raised issues about the role of education in bringing about change and being able to sustain a multiple role nurse in the future.

Professional boundaries

5.7 Professional boundaries were valued and often thought difficult to change.

'I think what you're looking at is people who have made a definite choice to be a health visitor or to be a district nurse or school nurse and they chose that because of the knowledge and skills and their personality a lot of the time. (Other nurse profession)

'From a personal point of view, I thoroughly enjoy my role as a community nurse and that's where my knowledge base is, where I'm most comfortable with. I think people choose to do a health role because that's what they want to do. I think they try to merge both roles, which might not necessarily be what they've chosen to do... I think there's a bit of conflict there'. (Staff Nurse).

Education

5.8 Whilst the transition education was valued by participants they thought it may be inadequate in preparing them to undertake the CHN role. Incidentally traditional nurse training was also criticized in that it was designed around specialist rather than general care.

'We couldn't possibly fulfill what they were expecting. The roles are too different. The expertise, they don't provide the training in general nurse training to get these nurses that when we all retire were going to be able to come out as Community Health Nurses. A 12, 15 week module does not equip you with the skills to look after children and adults, I'm afraid'. (District Nurse).

'I think the education for nurses needs to be more flexible. And I feel, yes, what's being offered at the moment is completely inadequate to prepare you for going to look after children and to learn parenting skills. It's just completely inadequate, just reflecting on my own training and the type of conditions children have. With heart conditions they're congenital conditions. It's totally different from the type of heart conditions that we've seen in our patients and I think just to know about the two and to be practising and working with these patients everyday is just incredibly difficult.' (District Nurse)

Sustaining multiple roles: Jack of all trades

5.9 The majority of respondents reported that it would be difficult to keep up to date with developments in all nursing disciplines and they were concerned about maintaining the specialist knowledge and skills needed for each area. Concerns were also raised around a potential dilution of skills and competencies which could compromise patient care.

'Our community health profile tells us the age and population within the area and the new housing that is expected may cause there to be a rise in the younger children in the area which then affects schools, which then affects work, which then affects transport, so all these public health issues are contained within that profile. But it doesn't state that one person should be able do that, it does state that we should be able to provide for all these people but not that one person should be able to do it'. (Transitioned Public Health Nurse).

'The only impact it would have, it would reduce the quality of care because I'm having to then stretch myself over two disciplines and also I'd be seeing the district nursing patients less because I'm then also going up to the health visiting patients as well.' (Transitioned District Nurse)

Structure and organisation

5.10 Another dominant theme concerned the structure and organisation. The main issues here were critical mass and the level of support for the proposed change, including managerial support.

Post-education

5.11 Following the transition education most nurses went back to their original teams and posts and there were few examples of significant change. There was also evidence that the new job titles appeared confusing and as a result old job titles were reinstated by those who had transitioned as illustrated in the second quote.

'…most people they went back in to the team……the majority of people had gone back into the (original) post. (Transitioned Public Health Nurse).

'…the term community health nurse and public health nurse sound very similar yet they're very different roles. And so at one point I was a health visitor then I was a public health nurse then I was told to call myself a community health nurse but people didn't know who I was... so I didn't know what I was either, it was all of these things. So now I've gone back to the term health visitor because that's what everyone always understands'. (Transitioned Health Visitor).

Work environment

5.12 Embedding the CHN role in practice was seen as challenging due to the persistent and overwhelming opposition to it. A lack of critical mass was viewed as problematic by transitioning and non transitioning nurses. Additionally, those who had undertaken the transition education and were highly motivated to carry out this role often returned to practice and experienced much resistance.

'I was actually called a traitor which was a bit...' (Transitioned Public Health Nurse).

'I think that more people had negative views of the transition role, maybe because it's dilution of skills, to have so many skills and be a specialist in all of these skills. The feedback that I got was very negative'. (Transitioned District Nurse).

'I think logistically as well if you did the training and thought I could do this generic role, and if you come back and there's two separate teams and there's not a pool of you working together you end up not really fitting in to what's there, so if everybody in an area ... which is what we tried to do; if everybody had bought into it, and done it, then it would have been easier to come back to because everybody's sharing it and you're working together. But what I found was that there were individuals who were keen and wanted to change who came back into a team where half of the team were very resistant. And there was a lot of anxiety and some of the team felt quite threatened by the fact that some of these other people had done this magic training and thought there was something different. So there was quite a lot of ... locally ... quite a bit of animosity. And that didn't make it easy for those who had done things and come back and end doing something different'. (Manager).

5.13 There was a however the suggestion that support for the new role could be more easily achieved in nursing teams that already worked across health disciplines. As the following illustrates, the dynamics of the multidisciplinary team are perhaps more suited to the adoption of a new role which is more diverse and thus more supportive of it. Nurses saw multidisciplinary working as an important way to address the issues which were raised by the Review of Nursing in the Community and this is outlined in more depth in Section 4.7.3 Changing the System.

'The teams started off with a very different point, so we were already a long established integrated team not just within nursing but within... with the allied health professions as well. So we had already recognised that the team approach in providing care to the community is really the way to go and I think for us the review of nursing really embedded that even more into our practice and just felt that we were on the right track and that within the team itself we would have the competencies across the board.' (Manager)

Managerial support

5.14 There were some who thought their managers were supportive and tried to put things in place to support the nurses who had transitioned.

'Yes, she encouraged all her staff to go and she gave all her staff the entitled study time and was very keen to know your plans. She came and she wanted updates…' (Transitioned Health Visitor).

5.15 Nevertheless, many spoke about the lack of managerial support and resources in some areas, which made implementing and embedding the new role extremely difficult.

'I think there was a lot asked of us and we were all happy to take on new roles and new skills but my personal opinion in our area is that there's been a massive lack of resources and lack of time as always there is. But there has been no support from managers I would say to allow us to carry out the job holistically within the time frame. So you're forced to pass it on (to district nurse, health visitor or school nurse colleagues) when you really don't want to because you don't have the time'. (Transitioned Health Visitor).

'I feel that management probably hasn't given us the support and pushed us to embrace our transitional education. I don't think that even my manager will know what I studied on… she's never asked me about it. And I think she should be pushing me to implement my plan but she's never once asked me. When I think about it that's really bad. There's been no encouragement to change your way of working and they've invested all this money and no body's pushing from the top'. (Transitioned Health Visitor).

Staff nurses working as generalists

5.16 Many participants, nurses and managers, thought the CHN role and transition education should have been aimed at staff nurses who generally work at band 5 rather than band 6 nurses (Health Visitors, District Nurses) and band 7 (Team Leaders). The rationale for this appeared to be that band 5 Nurses would be able to offer generic care across the disciplines but still have specialist nurses to provide support and advice. One idea was that staff nurses could rotate around the nursing team.

'It was in the pilot team the community staff nurses who were working across health visiting school nursing and district nursing and probably out of every member of the team they rose to the challenge and enjoyed that. I personally felt towards the end when it focused the review on nursing community that it was really at the wrong level and should have been looking at the community staff nurse role'. (Staff Nurse)

'We've got Band 5s that do rotate, or there's possibility for them to rotate within that one year but they weren't subject of the training and you felt that if perhaps they had been it might have been more beneficial'? (Manager)

5.17 Although supportive, the views and experiences of staff nurses and some managers gave rise to a number of concerns, some of which reflected those already given about the new community health nurse role.

'I find that there's probably an easier transition at staff nurse band 5 level because they are not so involved with the really complex things on the assessments so there's a bit more flexibility at band 5 - in public health not across district nursing though I do have some people who do some shifts in district, some in health and some in school. But that's odd shifts and odd people, it's not an amalgamated service, it's just some people are able to move.' (Manager)

'We had a trial in (local) area, a staff nurse have been given the opportunity to double duty as it were, she found it useful, she did find it hard to... she felt she couldn't give either her full capacity, she was too tied up on her health visiting days and not see things through on her district nursing days so she's back in her original post'. (Transitioned District Nurse).

Impact on knowledge, awareness and working practice

5.18 It could easily be concluded from the findings presented thus far that there was no positive impact on nurses as a result of the new role. However some of the nurses who had completed the transition education felt that it helped heighten their awareness and re-engagement in the wider aspects of health and social care. It helped them to consider these within their own role and in some instances it led to a change in practice.

Knowledge and awareness

'It's the way that your thinking's kind of changed a wee bit… see a broader [perspective]. You would go into [a consultation with] an anemic patient and say "Oh I'll just take the bloods" or if a woman's had a section…. saying "Oh I'll just change the dressing" and support them in that way, whereas historically it would have been the district nurses' [role].' (Transitioned Health Visitor)

5.19 One area where there was evidence of stronger influence was in public health including community health profiling and health promotion.

'The health needs analysis…..will also have an impact on patients because of everybody really understanding the population more and then services are being planned accordingly. Now that wouldn't have been met before and so that's a result of the project'. (Manager).

'…I think that's really important, a really positive thing that came out of the new nursing community, that the district nurses were able to start to get back to thinking about health promotion, health improvement and also the need to identify the needs of the community is positive too, and to think about the skills that the teams would develop according to the needs of the community as opposed to what the needs were in the past'. (Staff Nurse).

Working practice

5.20 There were examples cited where the education had resulted in opportunistic changes in practice rather than a systematic change in the way in which care was organized or delivered.

'Swine flu obviously was something that was identified and we would all work together as a team whereas previously that would have just been down to district nurses so we were going out in multi-disciplinary teams immunising patients in the community. So from that point patients would probably have noticed a difference because there was someone with the district nurse who they weren't used to seeing. They asked who you were and you said 'well I'm a public health nurse' or 'health visitor' and they seemed a bit surprised but they were very accepting of the change as long as you were a trained nurse giving the jag.' (Transitioned Public Health Nurse)

'... I was previously just doing health visiting and just about the time of doing the transitional education I was doing a little bit of schools, working in some schools and I've taken on a dual role now. And part of the transitional education was about improving my knowledge in schools which I didn't have previously'. (Transitioned Public Health Nurse).

'Mine has been fairly positive change as well in respect to similar to [name of nurse] but I was public health trained but mainly in a health visiting role and now I have a day a week in schools in (local area) at the moment'. (Transitioned Public Health Nurse).

5.21 However when asked whether these changes had an impact on patients, most transitioned nurses thought there was no discernible impact.

'When you look at the patients as a whole I don't think they really know how much difference has been made. They... at the end of the day most patients show that from patient satisfaction... as long as it gets done and whoever they see is pleasant, they're not bothering who does it. But I think given the choice and they were asked would you rather it was someone else who came and then someone else two hours later, then they would say 'no I would rather have the same person'. But they're very unaware particularly the older generation... they seem to be just happy to go get someone to go in and have a look at whatever is bothering them.' (Transitioned Health Visitor)

'Whatever way it went I don't think there would be any difference to patients at the moment.' (Transitioned District Nurse)

'Quite honestly I don't think they'll have noticed any difference because a nurse is a nurse.' (Transitioned Public Health Nurse)

The future

5.22 There was little doubt that the Review of Nursing in the Community in Scotland and the subsequent pilots had given rise to debate within the nursing professions and from this debate reflection on how community nursing should develop. For example some of the core elements which were advocated in the Review were viewed as extremely relevant to the future of community nursing.

'I'm not meaning it failed but we've not been able to proceed with it the way that it [the concept] was created. I think the core principles were really good and I think some of these will be kept in place, principles like self care... you know there are some really good principles that the model is based around and I think we've had a lot of eagerness because everybody has to be really eager... and in a way it's a shame that was lost..' (Health Visitor)

Strengthen existing practices and developing new practices

5.23 There was a strong sense that community nursing should involve more public health, anticipatory planning and encourage self-care.

'That's about having a public health role focussed on the younger population and how you determine how that younger population may be could ... change. I mean that's just my thoughts but if you think in terms of the role of nursing within promotion of health there could be something you could develop there. But in terms of district nursing, what they're looking at, they're very much with the older population and yes health promotion comes into that and is all about keeping people well but isn't as closely align to the younger population.' (Manager)

'I think it's definitely the way forward, and I would love to see it as the normal that we give more and more nursing care in the home and people only... they stayed at home for the nursing care as the normal. Whereas in the past, folk have maybe been taken into hospital for things. Maybe just extend the role even more to do more things at home maybe.' (Transitioned Public Health Nurse)

'I think also we have to encourage nurses to be more enablers because they tend to do things for patients and this has allowed people to be more enabling and get people to look after their own health. And to start that young, I'm thinking of young diabetic children so we can carry on that self management but also encourage older people to be in charge of their own health. And also use this to look at public health and involve all the disciplines to look at public health and improve that.' (Transitioned Public Health Nurse)

Changing the system

5.24 Most of the respondents thought that the system of care needed to change to allow better ways of providing care, including the development of interdisciplinary relationships. The responsibility of care was not seen as confined solely to the nursing professions. There were a range of health and social care partners involved. Thus there was a perceived need to introduce system change which focused on multi-agency working and better communication including greater centralization of General Practitioners.

'There would be a key worker, it might not necessarily be a nurse depending on the situation because in that particular initiative there's the police, there's social work, health visiting, school nursing, you know there's quite a number of agencies, and housing, you know a number of agencies involved. The likelihood is that it would be either social work or health who would take the lead but it would be dependent on the needs of that situation.' (Manager)

'I think the communication between services at the point of transition [in care] is something that needs to be further developed and possibly, was highlighted, with the community nurses' role there's possibly work ongoing there and that's something we'd need to continue and further develop.' (Manager)

'I think [local area] having five different practices is just ridiculous….. but if it was one big practice and we worked geographically, you would probably work around your schools you're attached to. You did the housing areas within them areas you would be far more beneficial… you as the public health nurse for that area and certainly take on some of the school work as well.' (Transitioned Health Visitor).

5.25 Inter-agency team work resulted in improved confidence among nurses both in terms of their practice and in the ability to call on others as required.

'It is a multi-agency approach. So everything is fed back to the multi-agency team because obviously this is all done with consent from parents. So all of it is discussed with the multi-agency team and if it was felt that there were conflicting interests then that would be addressed with that multi-agency team and they would then look at how best to address that.' (Manager)

'One thing that happens here at [local area] and that should happen everywhere, is that we have a weekly primary healthcare team meetings with the GP's, when district nurses, health visitors, school nurses and other allied health professionals are in the room and then of course there will be discussions about families where for example where people, the doctor would say that the fact that this granny is going into hospital will have an impact on this family because it's the granddaughters main carer and so on and so forth, so we'll talk about the wider families in the primary healthcare team meetings which the girls here said they did anyway, prior to [the review], so it's a good practice that was already existing.' (Health Visitor)

Team working and communication amongst nurses

5.26 Better team working and communication was also seen as important across the nursing disciplines including community staff nurses. It is notable that this view was often expressed in the context of preserving the existing nursing disciplines as illustrated in the third quote below.

'I think it's probably... you really need to involve the whole team. I think the focus on the... what's been perceived as the senior staff maybe wasn't the best way to go about things. You know people feel alienated. Everyone needs to be involved in such a huge changed role. I think a lot of health professionals feel that it's been a very much top down approach.' (Staff Nurse)

'We don't have good communication with our district nurses if I'm totally honest. We work very closely with our school nurses… as health visitors we are very closely linked with our schools and nursery. (Transitioned Health Visitor)

'My own personal opinion is that I would like to see the disciplines continue as they are. I like to see District Nursing continuing with their own specialism, treatment room as they do and maybe working more closely with DN which I think is probably evolving a little bit anyway. But I think public health nursing should continue but perhaps be more working across age bands and nought to nineteen. I know they have a very big focus on the early years at the moment and the drive that if young people, if they get it right in the very early years...for both parents and young people, then everything else comes right in the future. I'm not sure that... obviously it's going to be 10, 15 years longer before we see any benefits of that. So still got quite a scope of the younger generation to go through. But I do think that there's scope for public health nurses to work more closely together... and deliver more targeted interventions to look at that locality needs, looking at what other areas in the community work with and being able to profile a little bit more. I wouldn't like to see a joined up CHN... much prefer it to be in the disciplines. (Other nurse profession)

5.27 There were some examples cited where team working was already being developed with a view to minimizing unnecessary contact with multiple care providers, improving communication and developing new posts.

'I think one of the potential impacts is around the fact that we've set up the single point of access so actually people should find that access to the teams is much easier now than they did previously.' (Manager)

'I think that's how I would want things to move forward. And I also think that if the teams have been allowed more time for their own team building and better facilitation team building and came up with local solutions because the teams here know their area, they know the patients then that would have been more successful. And I think we're using that actually as the springboard to look at how things were working. Here we've had a couple of days looking at how to carry forward things like the health agenda right across the community team.' (Transitioned Public Health Nurse)

'I think in the future what you have to look at is whether that's the most appropriate person for that team and for that family and I think that's something we would all invest. Just thinking of an example, I had a situation where I had a child in school who had a parent who was terminally ill. Now in that situation I contacted the district nurse and at that point they weren't involved but were able to give me information about the family which helped me to approach them. But had that they had been involved then they would have been the best people to approach the mother... so it's helped us look at who is the best person to deal with certain issues.' (Transitioned Public Health Nurse)

Listening to nurses

5.28 There were a large number of comments on the way the Review had been introduced and an appeal for greater consultation with nurses before further policies are designed and implemented.

'I think we have to be really careful about any other model that comes out whatever it may look like... be or could this person look like or... we damaged our health visiting service by going down this way and we caused a lot of anxiety, a lot of pain, and a lot of cases... and the health visitors that I know... a lot of them were trying to get to what they were so many of them forgot what it was like to be a health visitor. I think we don't want to put them down that road again so I think how the government actually plans to pilot anything that's new has to be really carefully thought about... coz we don't want that again.' (Other nurse profession)

'Well, obviously we think it's a waste of money and I think if the people who had the ideas and wanted to go ahead with this project, I think if they had really spent quite a bit of time listening to what the staff thought about what would be the benefits and advantages and disadvantages and how things were really working then I think they could have saved a lot of time and money here because this is what we all said at the beginning. We're not against change of course, we always want to change, and all want the service to go forward and the quality to improve, but none of us saw this as being something that would benefit patients, we actually did see it as something that would potentially take nursing time away from the patients, which it did, and we couldn't really see what the benefits were going to be and so unfortunately it's one of those horrible moments when you think that all that money's been spent and we've all been proved right.' (Health Visitor)

5.29 A contrasting view of the Review of Nursing in the Community suggested that it actually raised the profile of community nursing however further consultation should seek the views of those who undertook the transition education.

'One of the benefits is that it is has actually raised profile of nursing and community... they're still very specific disciplines... but it has got people talking about it and I think the community nursing the... I think it needs to be... it definitely raised the profile so that's going to really positive outcome so I think people that went through the module... I think they have been able to look at how to do things differently. And we're the ones that tried to do things differently, so I suppose we're the experts in that... not the people who have set the module but who went through it. So I suppose this kind of thing, this feedback is essential... as even things progress in the modernising nursing community does continue we need to be asking the right people because we're the ones who shape the future.' (Health Visitor)