Transitional Education Progress Report

This Visible, Accessible and Integrated Care report focuses on the transitional education programme put in place to support the Review of Nursing in the Community in Scotland.

There is wide acknowledgement and agreement that to meet the changing needs of Scotland's communities now and for the future, nursing services in the community need to change. And as a recent scoping exercise has shown, things are changing, with health boards in Scotland at different stages in reviewing their community nursing services.

Nurses in the community take their place within multidisciplinary, multi-sectoral teams. Nursing in the community is part of a much wider modernisation agenda that is changing the way the public accesses services, enhancing the quality of the services they receive, and strengthening partnerships between communities and professionals to ensure that the services delivered are what people need and want.

That last point - about providing the services people need and want - is the central driver behind the ongoing modernisation of the nursing service in the community.

Starting with the WHO Europe family health nursing pilot in Scotland, which reported in November 2006, to the national review's report, Visible, Accessible and Integrated Care (also November 2006), moving through the launch of pilots of a new service delivery model in four NHS board areas in Scotland in 2008 and their ongoing evaluation, to the creation of the Modernisation Community Nursing Board in June 2009, the key issue of meeting communities' health care needs has underpinned thinking and guided actions.

So how can communities' health needs best be met? Strategic and policy-level action, such as the actions set out in Scotland's health care policy Better Health, Better Care, the Visible, Accessible and Integrated Care report and the work the new Modernisation Board will be taking forward, provides the framework through which services can be refocused to truly meet needs. But the actual differences individuals and communities see - the personalised, responsive and compassionate services they seek - are delivered by teams and individual practitioners, including nurses, in community settings.

And that's why the focus of this report is so important. It recounts the development, delivery and experience of the transitional education programme designed to complement the various initiatives under way to modernise the nursing workforce in the community. This programme is creating sensitive, skilled, patient-focused practitioners who are now championing better care for the individuals and communities they serve. They are delivering the differences that make a difference.

It's also a story about joint working involving the Scottish Government, NHS Education for Scotland (NES), Scotland's higher education institutions, NHS boards and the Partnership Forum. Guided by the common aim of delivering what is best for the people of Scotland, these partners have worked together to facilitate the educational development of several cohorts of community-based nurses. This willingness to work together, even though different (and strongly held) views on the best model for nursing services in the community exist among the partners, offers grounds for optimism about the prospects for success of the Modernisation Board's work.

The report has a less-formal feel than other reports that have emerged from the Review of Nursing in the Community project. In developing it, we wanted to capture, in their own words, the views and experiences of the people who have developed the transitional education programme and the practitioners who have worked through it. It also contains some powerful testimony from a service user on how the new model has supported him and his family through some very trying challenges.

Scotland has a strong tradition of developing caring, capable and enabling community-based nurses who are focused on meeting health needs. The "graduates" from the transitional education programme will now play a very significant role in the development of the professions for the good of Scotland's population.

Jane Walker

Nursing Officer

Chief Nursing Officer Directorate

Modernising nursing in the community in Scotland - the story so far

Nursing services in the community in Scotland are changing, and education is changing with them. This section briefly recounts the major initiatives that have shaped, and are shaping, the structure of the transitional education programme..

The Review of Nursing in the Community in Scotland was launched in 2006. It set out to put in place a service model that would offset the dual challenges of an ageing population with increasing service needs and an ageing community workforce.

The review signalled a recognition that change in nursing services in the community is both necessary and desirable. The aim now is to ensure that the nursing service is appropriately prepared and supported to meet local needs for a changing population.

Through its consultations, workshops, consensus conferences and online survey activity, the national review identified seven core elements of practice that need to underpin the activity of nurses in the community:

· working directly with individuals and their carers

· adopting public health approaches to protecting the public

· co-ordinating services

· supporting self-care

· working in multi-disciplinary and multi-agency teams

· meeting health needs of communities

· supporting anticipatory care.

These seven core elements provide the central underpinning for the service model proposed by the review report, Visible, Accessible and Integrated Care. The service model is now being piloted in four NHS board areas:

· NHS Borders

· NHS Highland

· NHS Lothian

· NHS Tayside.

Pilot-site NHS boards also have the option of introducing community health nursing roles as part of the service delivery model.

The service delivery model is not prescriptive - it has inbuilt flexibility to reflect local needs and should be considered as a framework to facilitate service redesign. No hard decisions have yet been made on the future shape of nursing services in the community, but undoubtedly the outcomes of the formal evaluation of the pilot sites that is now under way will contribute significantly to the learning and evidence which will help shape the future.

A Modernising Community Nursing Board with the broad remit of modernising community nursing services throughout Scotland has now be established, under the chairmanship of Professor Margaret Smith of the University of Dundee. The board will support community nursing services' development for the future, consider career development options for registered nurses within existing community nursing professions and undertake a governance role with the pilot sites.

A central component of the new service delivery model is the provision of transitional education to enable current practitioners to deliver maximum benefits from the service model to the communities they serve. The first cohorts of practitioners to have completed the transitional education programme have now emerged. Their stories, and the story of how the programme came into being, are the focus of this report.

A flexible approach to creating consistency

The transitional education programme offers a tailored, individual approach to developing consistently high-quality education for practitioners.

The transitional education process for the project has been designed by NHS Education for Scotland (NES) and is being implemented by higher education institutions (HEIs) in partnership with NHS boards.

Transitional education focuses on the knowledge, skills and capabilities the current workforce needs to practice within the service delivery model. It is therefore very focused on the seven core elements of nursing in the community (see Figure 1) and is grounded in a work-based learning approach that enables the application of theory to practice.

Figure 1. Seven core elements of nursing in the community

Nurses working in the community

Working directly with people

Coordinating services

Meeting health needs of communities

Supporting

anticipatory care

Multi-disciplinary, multi-agency team working

Supporting self care

Adopting public health approaches to protecting the public

From Visible, Accessible and Integrated Care

Those taking transitional education are registered nurses working in community settings. They have access to an educational supervisor from their host HEI and a local work-based facilitator throughout their programme.

The programme very much aims to build on the strengths the practitioners bring with them. It reflects and reinforces the common underpinning elements of nursing in the community, but is also tailored to meet service and individual needs.

The programme length can vary. HEIs can either set a prescribed time for achievement of learning objectives and assessment of portfolios of evidence, or adopt a flexible approach that reflects individual learning needs and the particular circumstances within the practitioner's employing NHS board.

Five-stage process

A five-stage process was designed to support the transitional education.

Stage 1 involves the practitioner completing a personal development plan with his or her manager, using the national capability framework (see Box 1) to identify where his or her strengths lie and where there are gaps.

Box 1. The capability framework

The Capability Framework for Community Health Nursing was finalised in November 2007. It is linked to an outline in the Knowledge and Skills Framework and is presented under four areas:

· practising ethically

· knowledge for practice

· leadership for practice

· co-ordinating and delivering care and interventions.

To access the framework, go to: www.nes.scot.nhs.uk/nursing/review/framework/

Practitioners are then linked in stage 2 to HEIs and are supported to develop a learning development plan (LDP) which provides a guide to their achievement of the capabilities and identifies:

· outcomes specific to their individual learning needs

· the activities they will undertake to meet the objectives

· how they can show evidence of achievement.

While the LDP is highly individualised to reflect the practitioner's learning needs, it is very much service-driven. The learning will enable him or her to plug perceived gaps in service delivery and enhance services offered to patients/clients and communities.

Stage 3 is about personalised programmes being developed to meet learning needs. Different approaches can be taken to this stage.

At Queen Margaret University (QMU), for example, where practitioners from NHS Borders have been accessing their transitional education programmes, participants are offered four study days that focus on the work-based learning process, public health approaches, anticipatory care and person-centred approaches. Participants are also supported through the QMU website.

The University of Dundee and University of Abertay joint programme offers two modules, one at undergraduate and one at postgraduate level. In addition to ongoing practice-based and educational supervision and support, participants also have four university study days to facilitate learning designed to positively influence their practice and enable them to meet their own defined learning needs.

For practitioners undertaking the programme from sites in the Highlands, the University of Stirling will take responsibility for assessing their final portfolios of evidence (see stage 5 below), but they can access their modules from another university. The university also has in place a very strong website that practitioners are able to access and use and which is particularly useful for those in remote and rural areas.

Stage 4 is about putting the whole programme into action through undertaking the work-based activities defined in the previous stages. Among other activities, practitioners are expected to organise "shadowing" opportunities with experienced practitioners in areas where they have a specific learning need.

And stage 5 is the creation of a portfolio of evidence of achievement. The portfolio of evidence demonstrates the linking of theory to practice and records personal and professional growth over time. The portfolios are assessed rigorously by the host HEI and are verified by an external examiner.

Things are a bit different in NHS Lothian, where a five-day in-house programme is being offered by the health board for staff nurses in the community. The aim of the programme is to educate the nurses and raise their awareness of issues important to driving public health approaches to services. Subject experts have been identified to deliver sessions to the nurses over the five days, with "shadowing" opportunities also available.

Ensuring consistency

While there is flexibility locally within the programmes to meet service and individual needs, the need for consistency nationally is also emphasised.

NES has developed a model that defines those areas within the transitional education programme where consistency is necessary and those in which flexibility is permissible. As Figure 2 shows, areas of consistency include following the five-stage approach and ensuring support from a supervisor based in an HEI, but there is flexibility around personal development planning documentation, implementation of LDPs, choice of practice-based facilitators and the structure of portfolios of evidence.

Figure 2. Areas of flexibility and consistency

Areas of consistency

Areas of flexibility

Areas of consistency

Capability Framework for Community Health Nursing

Five-stage work-based approach

- personal development planning

- learning development planning

and documentation

- portfolio outline document

Personal development documentation

Transitional education programmes

Implementation of LDP

Practice-based facilitators

Portfolio development as learning approach

- supported by education supervisor (HEI based)

Portfolio assessment

- quality assured by HEI

(assessed and moderated)

Portfolio structure

Evidence within portfolio

"The whole process is about fitting with the needs of each practitioner while maintaining a consistent standard throughout the country," says Ishbel Rutherford, a community nursing lecturer at QMU who is also national project lead for transitional education within NES.

Ishbel believes that the trend towards work-based learning in Scotland puts HEIs in a strong position to pursue this kind of consistent yet flexible approach. "At QMU, for example, we already have a range of work-based modules in place and a culture in which we encourage practitioners to identify their own learning needs," she explains. "We are also well-versed in portfolio assessment."

The transitional education programme has created opportunities for HEIs in Scotland to strengthen their links and work together in a common cause. When NES held its first meeting on the transitional education programme, it was attended by representatives from every HEI in Scotland that ran a nursing programme -not just those who ran community nursing programmes. This has created an extraordinary sense of interest and partnership, perhaps best illustrated in Tayside, where the University of Abertay and the University of Dundee have come together to design the modules, support and assess the practitioners and deliver the programme jointly.

"This has been a fantastic partnership," says Jane Harris, programme leader at the University of Dundee. "Combining the experience and expertise in community nursing education from both universities in one programme has been very beneficial for both staff and students. We've also seen great partnership working with NHS Tayside, practice facilitators and many others. It was a new experience for all of us, but one that has been very positive and, I believe, very productive."

The principle of HEIs working together is also reflected in the evaluation system devised for the transitional education programme. While education programmes run by individual HEIs are normally evaluated individually, the plan here is for the transitional education programme to be evaluated jointly.

Liz Denny, workload and workforce coordinator to the project, believes this flexible approach is both necessary and sustainable because a "one-size-fits-all" approach to community nursing education won't work.

"The flexible nature of the transitional education programme moves away from the notion that there is a prescribed syllabus and content list that you must follow to perform a nursing role in the community," she says. "It takes a very different slant by recognising that the practitioners undertaking the programme will arrive with similar underpinning knowledge and experience, but will each have very individual learning and development needs.

"And these learning and development needs are being determined by the health needs of the local community - it's the community's needs that are driving the education."

NES has developed a guide for practitioners who are undertaking transitional education. It can be accessed at: www.nes.scot.nhs.uk/nursing/review/transitional/

"The light-bulb moment ..."

Nurses in the pilot sites recount their experiences of undertaking and supporting the transitional education programme.

"I think we were all a bit anxious at the beginning - I remember our director of nursing telling us we looked like 'rabbits in the headlights' - but we were excited too, because we felt we were pioneers on a new journey, a new adventure."

So says Sue Simpson, a public health nurse in NHS Tayside, about the emotions she and her colleagues experienced on taking the first tentative steps towards the transitional education programme run by the University of Abertay and University of Dundee in partnership with the health board.

Sue and her fellow-participants on the groundbreaking first cohort in Tayside found that far from entering a conventional education course, the transitional educational programme offered the chance to design the modules to meet their individual learning needs.

"It meant that I could identify learning objectives that were very important to me," she explains. "I wanted to look at change management and leadership styles and models of care for long-term conditions in relation to the community health nurse (CHN) role."

The value of the model for nursing in the community on which the transitional education is built became apparent to Sue when she was visiting a family with an 8-month-old child. She performed the normal assessments of the child and the mother, who was at risk of postnatal depression, but another child in the family had recently been discharged from hospital with a surgical wound. The district nurse in Sue's team had been asked to visit the home to manage the wound, but with her agreement, Sue performed the wound assessment as part of the total package of care she was offering the family.

"It was good for the family, as they only had one professional visiting them, and good for me, because I was able to offer a more comprehensive and valuable service," she explains.

Sue was also able to offer advice on asthma management techniques to the son of another new mother she was visiting, not by replacing the advice the child had previously been given by the practice nurse, but by reinforcing it and improving the chances of the advice being followed.

"We've been encouraged to become very discipline-specific in nursing in the community, which can in fact de-skill us," she reflects. "This programme has enabled us to develop our skills and broaden our knowledge."

But this is a message that some of Sue's colleagues have found difficult to grasp. "They see the education programme as being about a dilution of knowledge and skills, but that's not how I see it," she says.

"For me, undertaking the transitional education has enhanced my enquiring skills and enabled me to challenge negative behaviour and resistance to change. I've also discovered my political voice! But most of all, I've learned that we have a huge job to do in empowering our patients and clients to self care."

Challenging process

Work-based learning was a new, and challenging, process for Diane Parry, a district nurse in Arbroath who also accessed the Tayside programme.

"It requires a commitment to self-directed study that some of us aren't accustomed to giving," she says. "But it really helps you to adopt a critical and questioning approach to what you're doing, allowing you to develop a clear understanding of the CHN role and the advantages it could bring to patients and clients."

Diane used the process of completing her individual learning development plan to identify child protection as an area she would wish to examine further.

"I was pretty well-versed in issues surrounding protection of vulnerable adults, but child protection is something that we all have a responsibility to pursue, and there are particular elements that make it different," she explains.

Through her portfolio of evidence, Diane was able to demonstrate that she had acquired key learning and experience in an area that was central to her role and which she herself had identified as an important shortcoming in her knowledge base.

Completing the module had its challenges, not least of which was the fact that it had never been done before, meaning there was no body of peer experience on which to draw. Diane also experienced some difficulties organising appropriate shadowing opportunities, but eventually succeeded in securing very valuable support from her local social services team and other agencies. And at the end of the day, she believes it has been worth all the effort.

"I felt a huge sense of achievement when I handed my portfolio in," she says. "The question now is, where do I go from here? Wherever that might be, I believe my options have been widened by undertaking the transitional education."

Paying dividends

The particular circumstances of services in remote and rural areas delivered by practitioners in parts of NHS Highland mean that work-based support to enable time for study is sometimes difficult to secure. But the inbuilt flexibility and e-learning mode of the programme offered by the University of Stirling mean that practitioners taking the transitional education programme can organise their learning activity to suit their own and their work colleagues' commitments.

Practitioners in the Highlands are also being supported by locally delivered study days which complement their identified learning needs and by senior colleagues, including associate lead nurse Christina West.

Christina feels the transitional education is paying real dividends in changing attitudes and practices, even among nurses who are not necessarily undertaking the programme but who are clearly being influenced by the general thrust of the Visible, Accessible and Integrated Care report.

"The main thing is the change in attitude," she says. "Nurses on the ground are starting to think about communities, and that's a real shift in focus. The public health agenda is coming very much to the fore.

"I now sit in meetings and hear district nurses speaking about the health needs of communities and showing evidence of thinking in a very different way," she continues. "That's really encouraging, because they are now beginning to develop a shared understanding with public health colleagues about service priorities."

Christina is also seeing beneficial effects on the development of team working in the area.

"I can see many nurses, not just those on the transitional education programme, but also specialist nurses, staff nurses and healthcare assistants, who are changing the way they engage and communicate with each other and with community nurses," she says. "They are thinking more about the priorities from the team perspective, which means we're getting a much more cohesive approach to delivery of services.

"It's as if the CHN role gives them greater opportunity to work in this broader way, rather than being restricted by a discipline-specific outlook."

Broader skills base

In NHS Lothian, participants on the in-house programme developed and delivered by the board receive five days of shared core learning on topics of relevance to all nurses in the community, such as record-keeping, adult support and protection and the implications of the Getting it Right for Every Child initiative, before tailored sessions are organised for those with district nursing and public health nursing backgrounds.

"The idea is that we give staff nurses a broader skills base," explains Alison Jarvis, project manager for NHS Lothian. "We are looking to support the nurses with action learning approaches in practice settings to back up the learning from the days. There is then a plan to ensure the participants can consolidate their learning by practising for three months with different disciplines - district nurses and public health nurses - to meet their learning needs."

Jenny Horsburgh, a newly qualified staff nurse working within district nursing in Edinburgh, feels that the programme offers a fantastic opportunity to enhance the knowledge and skills required to support a holistic approach to care.

"People's needs are changing, and I believe that the service has to evolve to meet these needs," Jenny says. "If a nurse can establish a comprehensive understanding of each family's health needs by providing care across all age groups, they are likely to develop stronger relationships and build trust. In this way, we will be better positioned to empower individuals and families to look after their own health.

"Participating in the review of nursing in the community, together with the five-day programme, has supported my development towards these goals."

Light-bulb moment

Sharon Thomson, a health visitor in NHS Borders, was aware of some negativity about the review of nursing in the community in her area, but was not daunted when the opportunity came to forward herself for the transitional education programme being run in a partnership involving Queen Margaret University (QMU) and NHS Borders.

The "selling point" for Sharon was the seven core elements of nursing in the community. These encapsulate for her the focus of her practice.

"There was a 'light-bulb' moment when the value of the seven core elements model really hit home," she says. "There was controversy around the CHN role at that time, but no one could argue about the logic and the value of the seven core elements as the underpinning for community nursing practice."

Sharon believes her new CHN orientation to providing services is supporting a genuinely team-based approach to care.

"As a health visitor, I've always had contacts with the school nursing services in the Borders, but traditionally most of my work has been carried out within the nursery setting," she says. "But I identified through my personal learning development planning process an opportunity to expand my role to the school setting to provide support for school nurses, working within a team to meet children's needs."

The transitional education programme presented opportunities for Sharon to "shadow" colleagues in school nursing services in her area, joining them at the heart of their practice and learning from the way they go about their business.

"It would have been possible to organise that kind of opportunity outwith the transitional education programme," she says, "but the programme sets the challenge of making sure it happens."

Any questions or doubts Sharon may have had about the review, the model, the transitional education and the role were dispelled when she recognised one key fact - "no change" is not an option for community services.

"You realise as a practitioner that things are changing," she says. "I think the review of nursing in the community, and especially the seven core elements of practice, put nursing in a powerful position to contribute to, and lead, change for the better."

"Three-headed monster ..."

"Some people wondered what I was going to be 'transitioned' into - some three-headed monster or something," jokes Sharon's colleague Julie Churchill, a district nurse in Peebles, about the response of colleagues and others to her decision to undertake the QMU/NHS Borders transitional education programme.

"But underlying the jokes was a genuine uncertainty," she continues. "It was clear there had been nothing like the transitional education before. And it was quite tough sometimes to convince people that this particular step into the unknown was one worth taking."

As was the case with her colleague Sharon, the seven elements of nursing in the community provided the impetus behind Julie's realisation that here was a positive and appropriate way to address the need for change.

"I think the education has really brought the importance of the seven elements home to me," she continues. "It's a practical model than can actually enlighten practice. None of the elements is unique, or original, or new, but bringing them all together in a single model gives them real power."

As a district nurse, Julie sees special value in the potential of anticipatory care and public health approaches to her practice.

"By tradition, much of district nursing is reactive," she explains. "But when you take on board a consciousness of public health and anticipatory care approaches, it encourages you to adopt a much longer-term and proactive perspective.

"Yes," she continues, "you might be there dealing with the person's leg ulcer, but you're also beginning to think about where you want that person to be in two weeks, or three months, or one year's time. It gives you a much clearer idea of where you are going with the person's care."

Julie has gained a number of benefits from taking the programme, including developing her confidence, her analytical skills and her awareness of change management practices. She has a wider perspective now and consequently believes she is more effective in what she does. But there was one unanticipated benefit - she feels she is now a "braver" nurse, one more likely to challenge patients to adopt healthier lifestyles.

"There is definitely a feeling among some patients that their illness is someone else's responsibility, and they look to nurses and doctors to do something about it," she says. "But now, having learned about the importance of promoting self-care as part of the seven core elements, I find myself saying to patients 'yes, I'm here to help you, but what are you going to do to help yourself? And how will you keep helping yourself after I've gone?' Some patients - not all of them, but most - have really taken that on board and have responded positively.

"It's all part of the changing culture in nursing, away from the idea of 'doing for' to 'doing with'."

"I'm all for it ..."

A service user provides an insight into what it's like being on the receiving end of the new service delivery model for nursing in the community ...

My family and I have been seeing Helen Keir, a community health nurse (CHN) from our health centre in Tayside, for a while now. Helen trained as a CHN and was keen to see how her new role was different from being a district nurse or health visitor. We were only too happy to help.

Because, you see, my family has a number of health problems. A genetic condition that causes muscle problems runs in the family - two of our children have it. My wife has had physical and mental health problems for a long time. Each of our children has health problems of some description, and our youngest, who is 18-months-old, has spent practically all of his life to date in hospital. And me, I'm addicted to smoking.

So we need people like Helen a lot.

Helen told me that she felt the training she went through and the new CHN role might give her a chance to really focus on all my family's health needs.

She was able to spend a lot of time with me talking about the family's genetic history, which was a really positive experience. We shared information and learned together.

Helen used all her contacts in the health and social services to help us to access the professionals we needed, but she was always there, making sure everything ran smoothly. That was especially obvious when our youngest was being discharged from hospital and she made sure, along with other health professionals, that we had everything we needed in place at home and knew where to get more support.

But as well as helping us to get the care we need from others, she's also been giving care to us herself, especially to our 3-year-old who has the genetic condition and to my wife. It's meant that we haven't had to meet with loads of different professionals - she's been there to keep that to a minimum.

And Helen has been really helpful for me personally. When she learned I was addicted to smoking, she immediately gave me one-to-one smoking cessation counselling. I stopped smoking then, and I'm still stopped to this day.

Helen has worked for our family. She isn't like the usual nurse or health visitor you would see. I've been able to talk to her about all my family's health problems, instead of having to chase around half a dozen professionals, and she's got the knowledge and the contacts to be able to do something about solving them. If that's what a community health nurse does, I'm all for it.

James Todd, Tayside (the name has been changed)

Scottish Government

Chief Nursing Officer Directorate

1 East Rear

St Andrew's House

Regent Road

Edinburgh

EH1 3DG

Telephone: 0131 244 2817

Email: CommunityNursingReview@scotland.gsi.gov.uk

Download from:

http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/nursing/review

Published December 2009

Page updated: Wednesday, December 02, 2009

Scottish Government