Family Health Nursing in Scotland – Lessons for New Zealand ?

Judy Yarwood, RN, MA (Hons) (Nursing), DipTchg (Tertiary), MCNA(NZ),
Lecturer, School of Nursing, Christchurch Polytechnic Institute of Technology ,
Christchurch

Thinking innovative family nursing models doesn't automatically turn the mind to Glasgow , Scotland , and yet that is where it is happening. I recently had the opportunity, as part of study leave, to visit Glasgow with the aim of exploring the pros and cons of a family health nursing role in community settings. It had been through reading and attending international forums that I had learned of how colleagues at Glasgow Caledonian University had progressed this family nursing role over recent years. During this time the concept of a family nurse, or family health nurse depending on your point of view, has remerged after decades of a somewhat individualistic approach in nursing practice. Both the International Council of Nurses (ICN, 2001) and the World Health Organisation (WHO, 2000) have been deeply involved in constructing this nursing role, driven mostly by increasingly significant health care delivery challenges confronting many nations including our own. For all that, a family nursing role remains unclear, and it was in search of clarity that took me to Glasgow .

Unlike my first foray into the international world of family nursing at the Calgary Family Nursing Unit, Canada , my trip to Glasgow was redolent of times past. Memories from the late 1960s, while somewhat blurred, recalled a Dickensian landscape, grey, gloomy tenement buildings, grinding poverty and a city half hidden under a pall of smoke. Thirty something years on and I could hardly recognise the city - clean(ish), vibrant and seen as one of the cultural capitals of the UK ! I loved it – sure, poverty was still apparent, drugs remain a problem, not unlike many cities world wide, but for all that it was exciting, diverse and provocative on many levels.

I was warmly welcomed to the School of Nursing where I met and talked with staff teaching in undergraduate and postgraduate family nursing programmes. I spent time with Lesley Whyte, the Family Health Nurse Project Officer for the Scottish Executive Health Department (our equivalent of Ministry of Health) and the WHO. An afternoon spent discussing family and community nursing with project managers in the Scottish Executive in Edinburgh highlighted not only the difficulties integrating new nursing roles into established practice locations, but also the political nature of such an endeavour. The Director of Family Health Nursing Programme at Stirling University , where we discussed curriculum and practice issues for students and new graduates, also raised these sentiments. One of many highlights was an evening with the Family Nursing network, a group of like minded nurses who support each other in their family nursing endeavours in practice, research and education. My focus in all discussions was possibilities inherent in a family nursing role. Having started, before my visit to Glasgow , analysing data from a research project aimed at looking at how registered nurses integrate family into their practice, similarities and points of difference were of interest.

It was in 2001, under the auspices of the WHO, that the first of two pilot studies exploring the feasibility of family health nurse role was launched. Defining the role of a family health nurse in this context may be helpful here to counter the marked blurriness of this role. In this particular project the WHO Europe description is seen to “ contain elements which are already part of the role of several different types of nurses working in primary care across the European region. What is new is the particular combination of the various elements, the focus on families and on the home as the setting where family members should jointly take up their own health problems and create a ‘healthy family' concept (WHO Europe, 2000, p.2). Assisting families with healthy lifestyles, health matters and problems incorporating health assessment, treatment, health promotion, public health issues and social issues are all part of this multifaceted role. The most distinctive element is seen to be a family rather than individual focus, which differs considerably from other community nurses' practice (Scottish Executive, 2003).

Thus the role tends to follow a generalist model, and one located within communities. With strong encouragement and support from the WHO and the ICN, Scotland and eight other European countries participated in the first pilot study with varying degrees of success (WHO, 2006). Although evaluations from all participant countries are worth a read I shall concentrate here on Scotland's participation, as these two projects were the focus of my visit and the ones I enjoyed discussing with key stakeholders.

The first pilot study took place in rural and remote areas of Scotland as far afield as the Western Isles. One of the driving forces for this nursing role development in rural areas was similar to New Zealand - a lack of general practitioner's service provision in remote areas. I wonder why deficits in medical care are often the catalyst for increasing nurses' autonomy? That aside, registered nurses chosen to participate in the pilot study completed a 40 week theoretical and practical post graduate educational programme. Once completed, many consolidated their learning and cultivated their family health practice by returning to former practice areas. For some this was a relatively easy transition, whereas for others it proved both challenging and exhilarating, as their own and others' expectations were questioned and shifted. Consequently progress in developing this new nursing role was site specific and dependant upon quite varied contextual influences (Scottish Executive, 2003).

Only recently completed and evaluated, the second study was situated in urban locations. It was in one central city clinic for homeless people that I was privileged to visit with a newly graduated family health nurse. I was immediately struck by the commitment and compassion this nurse manifest for the people and families she worked with. This new practice role was far from easy; nonetheless it was one this nurse saw as having huge potential. She repeatedly spoke of the importance of developing responsive relationships with people whose experiences with bureaucracy and health care providers had been less than positive or convivial. Her humanity was humbling as were her endeavours to work and live with uncertainty and complexity, so much a part of being with families for whom poor health concerns were frequently generational.

Evaluations of family health nursing in both rural and urban studies have met with mixed achievements (McDuff & West, 2004). Ongoing challenges include addressing tensions between a health promoting, family, and an individualistic, illness approach continuing to rage in a system favouring the latter. Nevertheless family health nurses were able to appreciate changes in their practice approaches. For example, family capabilities and resources were recognised and called upon as were extended family members. Working in this way nurses found people previously reluctant to participate in their health care now becoming involved (Scottish Executive, 2003).

What newly fledged family health nurses found on returning to practice was a certain amount of gate keeping, by nursing colleagues as well as other health professionals, suggesting there is a wee way to go before acceptance of new roles occurs. Challenging the status quo is never easy, and one of the key findings that emerged was the extent to which change management had been underestimated. In future studies investing time and energy in active change management were identified as critical for success in facilitating and supporting the inevitable upheaval, be it positive or negative. Finding that a radical shift in health care systems was required for a family health nurse model to thrive came as no surprise to many (Parfitt, Cornich, Whyte & Van Hooran, 2006). Nevertheless strong support for further role development is obvious, if for no other reason than to enable families to move from dependence on health professionals towards independence within supportive communities (WHO, 2006). And the latter is exactly what I saw across the English Channel .

Visiting France and Italy , all in the name of family nursing research you understand, I was struck by just how valued family and community appeared to be in both countries. I realise this is somewhat of a generalisation however we immediately noticed families of all shapes and sizes strolling out together on balmy evenings, young teenagers meandering arm in arm and chatting with elderly people, while the older generation were seen sitting in piazzas very much a part of extended families and community life. Romantic vision this may be but this was apparent everywhere. In Paris Sunday is family day, with only a few shops open - mostly patisseries and florists, the latter to purchase a floral offering for family visiting, the former open until lunchtime to obtain the staple. Strolling through a suburb of Paris one evening we were drawn to dulcet tones singing French folk songs. This was a regular community get together where people came together to sing and connect. All of these activities gave rise to considerable reflection on my part – especially about the place of family in nursing practice. And it's not necessarily as Doane and Varcoe (2005) suggest about the literal family either – it's about how we relate to all those we work with, be it families, people and colleagues. This though is another side of family nursing…

Did I get the clarity I was seeking about a family health nursing role? To be honest, no. Nonetheless I did encounter a real commitment to understanding, progressing and articulating the many dimensions inherent in this work. Implementing such a role into existing health care systems may be fraught and yet knowing this can be helpful in highlighting just how constraining certain structures can be when introducing new and innovative nursing roles. A radical change in the way health care is delivered is necessary - a detail recognised by many, including more recently Pete Hodgson, the Minister of Health (Hodgson, 2007). Interestingly, two remedies he singled out to counteract what he sees as the unreliability of our health system, primacy of the patient and good communication, also underpin family nursing. Developing and building relationships are crucial in any responsive, open and accessible health care system.

In some ways family health nursing roles are underway here in NZ, especially in rural and community locations. Jackie Cooper, a neighbourhood nurse working with families in a low socio-economic area of Christchurch, is doing exactly that in providing health care people want, not necessarily the health care health ‘experts' believe families need. Many questions remain about the nature of nurses' work with families. Direction and guidance can be found in other countries, however my recent overseas experience has lead me to believe we have both the capabilities and expertise right here to develop innovative nursing roles well suited to the unique health needs of New Zealand families.

References

Doane, G.H. & Varcoe, C. (2005). Family nursing as relational inquiry: Developing health-promoting practice. Philadelphia : Lippincott Williams & Wilkins.

Hodgson, P. (2007). Building quality into our health system . Retrieved 30 March. http://www.beehive.govt.nz?PrintDocument.aspx?DocumentID=28773 .

International Council of Nurses. (2001). The family nurse: Frameworks for practice . Geneva , Switzerland : Author.

Mc Duff, C., & West, B. (2004). An evaluation of the first year of family health nursing practice in Scotland . International Journal of Nursing Studies, 42, 47-59.

Parfitt, B., Cornish, F., Whyte, L., & Van Hooran, M. (2006). Family-centred health care: The contribution of family health nurses. Glasgow , Scotland : Glasgow Caledonian University .

Scottish Executive. (2003). Family health nursing in Scotland : A report on the WHO Europe pilot . Edinburgh , Scotland : Author.

World Health Organisation (2006). Report on the evaluation of the WHO multi-country family health nurse pilot study. Copenhagen , Denmark : Author.

World Health Organisation. (2000). The family health nurse: Context, conceptual framework and curriculum. Copenhagen : World Health Organization Regional Office for Europe .

My thanks to CPIT for the many opportunities this visit provided. I also want to thank Dorothee Burchard O'Sullivan from Glasgow Caledonian University for an instructive and fascinating programme, her collegiality and for wonderfully stimulating and enlightening conversations. My conviction that family health nursing is the way ahead for responsive and progressive nursing practice was well and truly affirmed on this trip.