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

6 CONCLUSIONS

Summary of research findings

6.1 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 Furthermore it was strongly associated with the extended family which was thought to be outdated and no longer fitted modern family structures.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 the 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.

6.2 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 teams that already worked across health disciplines.

6.3 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 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 Community Nurse 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 are introduced.

Making sense of the findings

6.4 These findings represent an account of those closest to the proposed reforms. The report provides insight into the structural and other issues which affected the uptake and implementation of the Community Health Nurse role. These focus on the following areas:

Education

6.5 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 required diversity of the role. Any gains were confined to an improvement in knowledge. Some also linked this problem to their initial nurse training which prepared them to work in specialist subjects rather than broad areas of health.

6.6 The resulting tension between specialisation and breadth is not easily reconciled, although it should be noted that education was viewed as instrumental in developing community and public health nursing in Ireland (Poulton 2009; Markham and Carney 2008) the USA (Hill et al 2010) and the Family Nurse Role in Scotland (Scottish Executive 2003).

6.7 More specifically, Markham and Carney (2008) and Hill et al (2010) indicate that improvement in knowledge and also competence was 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). The Family Health Nurse Role education was longer (delivered over one year) compared with that for the Community Nurse Role which was delivered over several weeks. However it should be noted that majority of nurses who were trained in the Family Nurse Role also struggled to incorporate their ideas into practice.

Managing change

6.8 Changing existing roles is difficult and there were three areas which we think proved extremely problematic in doing so: the level of support required to bring about change, the strategic vision of the new role and ownership of the new role.

6.9 Critical to the success of such development is the level of support from their nursing colleagues and those from other disciplines. For example resistance by other health care professionals acted to limit the role of district nurses in England (King et al 2010), practice nurses in Australia (Halcomb et al 2008; Mills and Fitzgerald 2008; Jasiak and Passmore 2009); school nurses in the USA (Krause-Parello and Samms 2009); and advanced practitioners in England, the USA, Canada and Australia (Aranda and Jones 2008; Bonsal and Cheater 2008). We also 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. 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).

6.10 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. There are examples in the literature where the development of such diverse roles in practice has been successful but it requires great flexibility on behalf of the individual nurse (Yarwood 2008; Fagerstrom 2009) and their nursing colleagues (MacDuff 2006) to make these work. We think success depends on a shared vision of the new role and an understanding of how it fits within the health care setting. As our findings suggest there was a shared vision which was viewed as highly problematic by nurses.

6.11 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. Nurses are viewed as being actively involved in the process of 're-constructing boundaries, identities and social relations in healthcare'. Our findings have provided insight into the boundaries which were created by community nurses in the three pilot sites and ultimately where they positioned themselves in relation to those boundaries, particularly in terms of ownership of the new role.

Leadership and organisational support

6.12 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 the health boards who volunteered to participate and pilot the new community nurse role. Some local managers and the nurses who took part in the programme were also supportive of it.

6.13 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. Community nurses are extremely capable of building these relationships with service users and it forms an important part of their professional identity (McIntosh and Runciman 2008). Indeed it is likely that nurses see this as critical part of their professional development.

6.14 Key to this development, 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

6.15 There are methodological limitations to the research which concern sampling and representation. 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.

6.16 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. 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

6.17 The theoretical development of nurse roles as described by Aranda and Jones (2008) provides a useful perspective from which to view the implementation of the CHN role. The model of nursing and the related attributes were viewed as highly problematic by nurses and became important territory upon which the implementation of the new role rested. It could be argued that these constructions became major stumbling blocks for the new role and should be addressed when designing future policy. An essential part of the design process is the consultation which recognises the importance of co-constructing new 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.

6.18 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. Specific attention could be paid to why the particular role is needed; what work will be done; how it will fit with current practice; what resources will be available to support it (including managerial support); and how the new role will be incorporated as part of a wider review of service provision. We would add that this requires a strong strategic vision of any new role.

6.19 Nurses valued the transition education which was designed to prepare them for the new role, although any gains were confined to an improvement in knowledge. Markham and Carney (2008) and Hill et al (2010) indicate that improvement in knowledge and also competency was necessary to help change nursing roles in the community. Interestingly the educational programme which was designed for the Family Nurse Role in Scotland was valued by students for its emphasis on communication, assessment and health promotion skills (Scottish Executive 2003). It should be noted that education is one of many facilitators commonly cited in the literature. Nevertheless designers of courses could consider how both skills and knowledge are best promoted in their training programme.

6.20 As we noted in the literature review which accompanied this report (Annex C) the 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 which may lead to more effective care. The first is the co-construction of therapeutic nurse patient relationships. The second is the co-construction of nursing roles. The third is partnership working with other nurses and other health professions. If taken together and implemented well then these may make for more effective forms of practice and ultimately improved health of service users. This takes us to our final recommendation that 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.