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Family Health Nurse (FHN) Project Education Programme Report Introduction The following report covers the delivery

y of the FHN programme over the period of the Scottish pilot project, which ran from 2001-2005. The educational programme will be described in its evolving format over the two phases of the project; that being the remote and rural context of the Highlands and Islands in 2001/2003 and subsequently the modification of the programme ahead of the urban phase of the pilot project in 2004/05. The conceptual framework that underpinned the development of the curriculum will be described and the programme situation within a national and local context vis--vis the NHS in Scotland. The student evaluation of the programme is discussed as are the views and experiences of those involved in the delivery of the programme. Finally recommendations are made regarding the future delivery of the curriculum. National and Local Education Context The WHO produced The Family Health Nurse: Context, Conceptual Framework and Definitive Curriculum (2000), in which the FHN was described as a nurse who is a:

care provider decision-maker communicator community leader manager

Nurses in all sectors and in all settings would claim most of these roles but it is the particular way in which these emerge in the context of families and Family Health Nursing that was the hallmark of the students who successfully completed this Programme. The Scottish Executives paper, Nursing For Health: a Review of the Contribution of Nurses, Midwives and Health Visitors to Improving the Publics Health (2001a), highlights the potential for the role of the Family Health Nurse in stating that it is based on the following principles: A skilled generalist role encompassing a broad range of duties, dealing as the first point of contact, with any issues that present themselves, referring on to specialists where a greater degree of expertise is required. A practitioner who will base practice on a model based on health rather than illness - the family health nurse would be expected to take a lead role in preventing illness and promoting health as well as caring for those people who are ill and require nursing care.

A role founded on the principle of caring for families rather than just individuals within them. A concept based on the nurse as a first point of contact.

In addressing the development of the University of Stirling curriculum the above principles, both WHO and Scottish Executive Health Department (SEHD) played a major role in informing and guiding the decisions of the curriculum development team. The Programme was designed around the roles as described by the WHO. The curriculum outlined by the WHO Curriculum Planning Group detailed the broad thrust of the Programme and set this in the context of the potential practice roles of the FHN. The curriculum was modified to be responsive to the context in which it was delivered, whilst staying faithful to general principles and precepts.

The programme addressed the educational needs of both staff nurses working in the community and experienced qualified community nurses. The academic award was a Bachelor of Nursing in Community Studies (FHN), and Graduate Certificate in Community Studies (FHN) for those undertaking a shortened programme. The Programme was also approved by NES against the NMC standards for Specialist Practitioner Qualification. The current programme is an adaptation of the original programme that was delivered during the initial two-year remote and rural pilot phase. It has been amended in response to internal and external evaluation, the details of which will be covered later. The phase-two programme acknowledged the challenges posed by an urban pilot albeit there were some students from remote and rural areas within the phase-two pilot. The main concern of the curriculum development team was to remain true to the philosophy of the original programme and the principles that underpin the concept of the FHN. The Curriculum in Context Family and community Family perceptions about health and related behaviours are central to the work of FHNs, including issues relating to family health promotion, self-care and family adaptation to illness or disability. In order to support families effectively an ecological perspective was adopted which allows FHN's to take account of the inter-relatedness of individual, family and community. Families have very different resources at their disposal and use these in different ways, whether in social, economic or health terms. Family resources include income, wealth, time, education, knowledge, networks and emotional energy. What is important is not merely identifying what families have access to, but also how they use their resources (Christensen, 2004). The impact of a wide range of psychological, as well as physical, factors on human health and well-being has been long recognised, both in social and health services research. Societal and governmental concerns with breakdown in traditional family norms (and a concurrent rise in diverse family structures) have focused attention in welfare terms on buffering this trend through attention to family within community (moving beyond individuals within families) (Scott, 1997). Additionally, parallel attention to the role of social networks and social capital to health and well-being has begun to shed light on the complexity of relationships and importance of place. For example, this is demonstrated by the importance attached to joining in as explored by Putnam in relation to social capital. Social capital refers to the networks, norms and values that arise from the connections between people and the social networks and norms of reciprocity and trust which arise from

them (Putnam, 2000). These concepts form an important framework for developing programmes of learning for practitioners whose focus is families and their communities. Policy Attention to family well-being and good health underpins the central themes in current health and community policy and practice. Emphasis has been placed on joint working between professionals and agencies with a view to organising services around the needs of individuals, their carers and families. Policy trends give recognition to the multi-facetted nature of the causes of ill health and the factors that contribute to good health and well-being (Scottish Executive, 1999). Government plans in Our National Health: A plan for action, a plan for change (2000) and more recently in Delivering for Health (2005), set out a programme which aims to be both responsive to patient needs while setting health promotion at its centre. Increasingly this has required an acknowledgement of the holistic and contextual aspect of health and social experiences as identified earlier. The emphasis on promoting health rather than illness also sets an agenda for partnership working between professionals, agencies and families, bringing together issues of poverty; inclusion; homelessness; community; education; nutrition; and substance abuse to attempt to create a comprehensive approach to improving family health. One key concept when working with families, that of well-being, is best considered as multi-faceted, experienced at individual and group levels, encapsulating among others, characteristics such as trust; tolerance; safety; and contentment and happiness. This concept can therefore be seen to be closely entwined with concepts of community and social networks. Policy makers have identified positive and negative influences on well-being (British Heart Foundation, 2000; Lauder et al, 2004), the former including relationships and networks, as well as physical and economic activity; the latter including stigma, fear of crime, lack of safety, boredom and inactivity (Scottish Executive, 2003). Family and community well-being has been identified as central within a recent Scottish Parliament programme given the importance of developing capacity and coping skills, not only on an individual level, but also recognising the importance and impact of relationships within families and communities. Key within the programme is the tenet that primary care practitioners need to be prepared to take account of social and cultural as well as health needs (Scottish Executive, 2003). Family Health Nurse: Conceptual Framework The concept of a 'family health nurse' comes from the 1988 Vienna Conference on Nursing, but it is developed particularly in Health21: Health for all policy framework for the WHO European Region. Several sources have commented on it since, including the WHO European Regional Adviser for Nursing and Midwifery, and the latest authoritative document (EUR/00/5019309/13) concerns itself with "Context, Conceptual Framework and Definitive Curriculum". There have been a number of subtle shifts in the idea since its inception. Health21, for example, does not refer to communities in the relevant paragraph; but this term has, at a later stage, been added to the list of things the FHN will take responsibility for - not only working in partnership with communities but also actively "empowering" them. As a result of these shifts, the literature on the FHN role incorporates, at some point, virtually every primary care function. It follows that any attempt to implement the role, and to educate people for it, presupposes some interpretation that may well not reflect every chapter and verse of the current WHO literature. However, there is an obvious model for the FHN concept: the General Practitioner (medicine). The FHN is, in effect, a General Practitioner (nursing) a specialist generalist who can both provide a range of therapeutic interventions, and recognise through skilled

assessment when particular specialist referral is required. To this extent, the idea can be seen as a logical development of various trends in the shifting of boundaries between medicine and nursing. For example, (and in particular) the way in which practice nurses have taken on progressively more responsibility such as managing patients with a chronic condition; conducting minor illness clinics; health education; and so on. At the simplest level, if this new practice nurse figure is moved out of the health centre and into the community, or at least into the home, then we have at least a part approximation of the FHN. Still, the range of potential roles appears to go well beyond 'community-based practice nurse' - not just the work with families, largely in their homes, but also working in partnership with communities. Therefore an already long list of health care activities - health promotion; disease prevention; early detection; rehabilitation; palliative care; etc. is augmented by epidemiology; public health; and community development. What was new in the concept of the Health21 Family Health Nurse is the particular combination of the various elements of the role, the particular 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. The FHN has a special relationship with families, though the focus on individual patients was not abandoned. Beyond this, the FHN's prompts the family into recognising itself as a health unit. This involves, mainly: (i) (ii) (iii) The family as a health care resource, caring for the patient. The family as a forum for health promotion and health education. The family as a socio-economic environment, embodying health risks.

In systems terms then, the FHN delivers inputs to the family, which is thereby equipped to deliver outputs to its individual members. Still, this FHN role runs parallel to (and may often be superseded by) the more conventional professional / patient relationship. In all these contexts though, the FHN's work must be evidence-based. However, there are professional and ethical constraints on the FHN's relationship with the individual patient, and these are likely to conflict with the FHN's role as a systems analyst and change agent. Bringing the family system to bear on the health-related problems of a particular family member will often, if taken literally, risk offending against imperatives of confidentiality, privacy, equity, and so on. These key areas are addressed across all three semesters of the Programme. In its description of the FHN role, the WHO Curriculum Development Group drew not only on systems theory, but also on "interaction theory" and "developmental theory" (EUR/00/5019309). It is not clear what "interaction theory" is in this context, and the documentation is rather vague. However, the reference to developmental theory is worth quoting: "[it] is important in aiding an understanding not only of individual human beings but also of the development of the family in the context of the major life course events that are faced by all people and which vary in intensity and impact, depending on many complex factors". Of course, there could be an entire degree programme implicit in this observation; but more realistically, one can home in on the idea of "life events" in the family and their relation to illness, with at least one eye on the cultural diversity of families. Equally important is the impact of conditions that potentially affect other members of the family - through genetics, especially.

Beyond the family, the FHN is part of a system, which includes other health professionals and a potentially wide range of public sector agencies. Understanding the various roles and functions, and being able to work with people whose main priority is not necessarily health, will obviously be significant. One could say this about most welfare professionals in a multiagency, collaborative environment; but the front-line nature of the FHN's role (especially the emphasis on the socio-economic environment) does give it added emphasis. Drawing all this together, it can be said that the FHN works within a systems framework: (i) The family system's environment (socio-economic, demographic, epidemiological, service network). The family as system, viewed synchronically (family dynamics, theoretical and ethical constraints). The family as system, viewed diachronically (development, life events, normality and crisis). Evaluation of interventions in the family system (case study, single-case experimental design).

(ii)

(iii)

(iv)

This framework is inherent in both the WHO discussions, and in the theoretical approach of the modules offered to students in this programme, that in turn shaped placement experiences. Further, it translates in an assessment strategy, since the FHN should be able to demonstrate competence in each of the four key areas, roughly as follows: (i) Analysis of a particular family's health-related environment (community profiling can be justified in terms of some of the WHO statements, but it may be more important to demonstrate an understanding of how the environment, whether rural or urban, impacts on the family). Analysis of, and a demonstrated ability to manage, the dynamics in a particular family, in a case that involves consultation for a specific health issue. Development of a (probably cross-generational) family health narrative based on interviews with family members. Systematic evaluation of FHN intervention in a particular family (or group of families, or community), using appropriate design and methods.

(ii)

(iii)

(iv)

Programmes of Study The above concepts were used to underpin the development of a series of modules that made up the FHN programme. Across the two phases of the programme these concepts and emerging influences such as the NES competency framework (NES 2004) led the ongoing development of the modules. The following section outlines the development of the programme over the lifetime of the FHN pilot project. See appendix 2 and 3 for key features of the curriculum and a detailed outline of current modules.

Table One: Phase-one (2001-2003) Modules Working with Families in the Community Semesters One 15 weeks 8 weeks practice-based learning, 7 weekscampus based. Clinical Practice - 2.5 days working with families and 2.5 days student learning some of which is directed study. Two 13 weeks 7 weeks practice-based learning, 6 weeks campus-based learning (including one week private study). Three 12 weeks 8 weeks practice-based learning, 1 week campus-based learning and 3 weeks computer mediated distance learning.

Communication Advanced Family Health Nurse Practice

Research, Decision-making and Evaluation in Clinical Practice

Period and Mode of Study: The period of study was 45 weeks, which included 5 weeks annual leave. Study was undertaken by mixed mode including video-conferencing and other distance learning means, with clinical practice constituting 50% of the Programme. Students used WebCT mainly as a communication tool Table two: Phase-two (2004-2005) Modules Semesters Introductory Week 1 week 1 week campus based (attended by APL students as well) Research, Decision-making and Evaluation in Clinical Practice (Practice Frameworks) One 15 weeks

9 weeks practice based learning; 6 weeks campus based learning. Clinical Practice 4 days per week engaging with families and the community and 1 day student learning, some of which is directed study. Two 12 weeks 8 weeks practice based learning; 4 weeks campus based learning. Clinical Practice 4 days per week engaging with families and the community and 1 day student learning, some of which is directed study. Three 12 weeks 8 weeks practice based learning; 4 weeks

Working with Families in the Community

Communication

Principles and Practice of Family Health Nursing

campus based learning. Clinical Practice 4 days per week engaging with families and the community and 1 day student learning, some of which is directed study. Period and Mode of Study: The period of study was again 45 weeks, which included 5 weeks annual leave. Study was undertaken by mixed mode including WebCT and other distance learning means, with clinical practice constituting 50% of the Programme. WebCT was used within all semesters to deliver some elements of the learning experiences and to provide students with communication tools for both learning and administrative purposes. Internal and External Evaluation The phase-one FHN programme emerged from a desire by the Scottish Executive Health Department to explore options for both collaborating with the WHO (and their desire to pilot the FHN curriculum and role across a number of European countries), and to explore alternative models of nursing care within remote and rural areas of northern Scotland. The findings from the initial pilot project recognised the need to explore the potential of the role within an urban setting and NHS Glasgow was keen to participate in this part of the project (Macduff and West, 2003). In consultation with the SEHD and NHS Greater Glasgow it was agreed that the first cohort would consist of a maximum of 20 whole-time equivalent students (this also included three students from the original pilot sites). Subsequently 18 students undertook the programme. The FHN programme was originally delivered by the Department out of the Highland Campus. The project ran for two years and was evaluated by a team from the Robert Gordon University, (Macduff and West, 2003). The evaluation was generally positive about the programme as delivered by the University but they did make some specific recommendations as detailed below Main recommendations of the evaluation team (with regard to the education programme): The programme structure should be amended to enable APFL / APEL for those students who undertake the course and are already qualified as a District Nurse or Health Visitor. There should be two generic community units at the start of the programme to facilitate credit exemption and closer articulation with the NMC Standards for Specialist Practice. The use of the OSCE assessment within semester two did not adequately address the assessment requirements of Advanced Family Health Nursing module and that this module required further development and closer articulation between content and assessment. Preparation of Mentors should be addressed to ensure that adequate support mechanisms are in place.

Students identified communication skills, family health assessment and health promotion skills as the most valuable skills they had learned on the programme. The mixed mode of learning with campus based sessions and the use of online distance learning was seen to be a key element of the programme. Family systems theory, communication, IT skills and research were highlighted by students as key elements of content.

The issues identified above were also highlighted in module and programme evaluations by the students with the exception of the recommendation regarding APL; most students were against the idea of undertaking a shortened programme as they felt they needed the whole year to assimilate the key FHN concepts both in theoretical and practice terms. Students felt that the nature of working with families necessitated long-term relationships, which were more difficult to establish over a shortened programme. In reviewing the findings of the evaluations every effort was made to ensure that those elements of the programme that worked well were retained in some form. The curriculum development team made amendments to the module structure of the programme accordingly (see tables one and two above). The module entitled Research, Decision-making and Evaluation in Clinical Practice, which was in semester three of the original programme, was amended significantly. Firstly, the module was placed at the beginning of the programme, thus moving the other modules forward. Secondly, this module was modified to ensure that it addressed the main elements of the common core content of Specialist Practice as required by the NMC. This work was undertaken with appropriate changes made to both the assessment of this module and to the assessments used in subsequent modules. Therefore the original semester one became semester two, and semester two has become semester three. This more readily enabled the programme to address the concerns raised by the evaluation about APL. The assessment of this module reflects the need for this module to address the core FHN competencies as specified by NHS Education Scotland (NES). The Advanced Family Health Nursing module from the phase-one programme was radically modified and renamed Principles and Practice of Family Health Nursing and was delivered as the final module instead of the middle module of the programme. The case report and systematic review assessment that was used in phase-one was retained as an assessment for this new module as it was viewed as an excellent way of enabling students to demonstrate evidence based practice at the terminal point of the programme. The use of this assessment at the end of the programme was evaluated well by the external team and students alike as it was seen to explicitly bring theory and practice together within the context of an evidence base portfolio. Other assessments have been modified in light of the experience of the first phase of the pilot project. In addressing the need for programme modifications the curriculum development team were significantly influenced by the work undertaken by NES in producing the Framework of Core Competencies for Family Health Nursing (NES, 2004). In undertaking this work a panel of experts was put together by NES, which included a significant contribution from those FHNs who had undertaken the original programme. This group considered a wide range of resources such as the WHO Competencies for Family Health Nursing; the International Council of Nurses (ICN) Framework and Competencies for the Family Nurse (2003); the NMC Standards for Specialist Practice (UKCC, 2001); the NMC Third Part of the Register Consultation Document; the NHS Knowledge and Skills Framework Working Draft (DoH 2003); and the Evaluation of the first phase of the SEHD FHN pilot (Macduff and West, 2003). The curriculum therefore represented both the work undertaken by NES and the Robert Gordon University Evaluation Team and addressed their key findings within the

redesign of the University of Stirling FHN Programme. The modules articulated explicitly with both the requirements of the NMC for Specialist Practice and the FHN competency framework developed by NES. The FHN competency framework was mapped against the modules of the Programme, which in turn, formed the basis of the practice assessment document (evidence base portfolio). WebCT proved to be a crucial element of the original programme. Students used the communication tools extensively and in particular those more remote students found it invaluable. The phase-two programme expanded the use of WebCT by continuing to use the communication tools but also enhancing the use of guided learning within the WebCT environment. Each module had a dedicated area where learning resources were made available. WebCT was used to support learning in practice and to bridge the theory / practice experiences throughout the programme. Designated discussion boards and topics for online discussion facilitated both student-tutor and student-student learning. A dedicated area for mentors was created within the WebCT site to facilitate interaction with each other and with the University Programme Team this was under utilised by the mentors over the phase-two pilot. A bespoke mentor preparation programme was developed which all mentors attended in phase two of the pilot. Mentors were also invited to meet with the programme team at the end of each semester with the clinical teaching fellow providing support on the ground as it were on a regular basis. The preparation and support of mentors was highlighted in the evaluation as an area requiring attention. Mentor preparation and support worked reasonably well during phase-two, possibly due to the reduced distances involved in comparison to phase-one. Despite this level of support there were some mentors who found the role challenging and thus were less able than some at providing the necessary support for students. The Student Experience: Specific Comments Students were encouraged to reflect upon their practice and their reflective diaries have proved to be a valuable resource both to the students and the programme team. This programme resulted in steep learning curves for all concerned and the experience has been described as that of life in a goldfish bowl. The reflective accounts have assisted the students in their critical analysis of their own practice and have contributed to the evaluation process in a major way. Students use comments that emerge from their reflective accounts as evidence statements within their practice portfolio. Reflection in turn stimulates further reading and study, which can also contribute the students evidence base. The subsequent analysis of the discussions on WebCT clearly demonstrated the existence of a vibrant learning community where very rapidly, given the distances involved, ideas spread across the ether and solutions and proposal winged there way back. This material is very rich in the detail of how these students operated as a learning community and further research using this material is anticipated. The following extracts give a flavour of the student experience: The reflective diary is a very useful learning tool and one which I hope will be maintained throughout my future nursing career. Reflection for me has been a way forward and has assisted me to look at the situations and critically analyse various situations where a scenario could have been avoided or improved upon. Students clearly found the process of reflection a valuable experience during the programme. In particular student benefited form the on-line contact that WebCT enabled and for some students in more remote areas this proved to be crucial in maintaining morale at times of stress. The WebCT has been a godsend...to have contact with the other students was all that kept me going

I can really see the need for the change in community nursing and I hope that family health nursing is one of the ways forward Im enjoying working with families and its good to see the effect of the change in perspective from ill health and illness to health and lifestyle and the way the families respond to my intervention Students commented favourably on how this programme changed their practice and their outlook on learning. The following comments are a few of many that reflect this sentiment. I can trace the development process from an isolated district nurse to a confident Family Health Nurse mentality (sic) with the associated diversification and extension in health care outlook The course has prepared me well for my future role and I plan to continue with evidencebased practice and encourage my colleagues to do the same Distance learning is an isolating experience, but accessing the email and chat-room was an important way to communicate with colleagues and tutors and the support and reassurance received was invaluable The experiences reflected in these comments indicate that these nurses developed both professionally as practitioners and academically as learners as a result of undertaking this programme. The feedback so far from the students is largely positive. A number of students in phase-two of the pilot met with significant challenges within their practice environment. Some colleagues were less than helpful and found it difficult to set aside their prejudices about the FHN role. This improved slightly over the course of the programme, which was partly due to the inputs of the programme team, but also to the resilience and determination of the students to ensure that their experiences were as positive and productive as they could be. WebCT provided students with a valuable link to each other at times of high stress. Programme Team Experiences In addressing the redesign needs of this programme the curriculum development team consisted of a wide range of Departmental staff from across all three University of Stirling campuses. The Department also secured external guidance from a member of staff from another university who had experience in the development of Community Nursing SPQ programmes. This individual, acting on a consultative basis, provided invaluable advice particularly on the process of assessment of competence and the NMC requirements for Specialist Practice. Qualified FHNs contributed to the programme redesign and the Department secured the contribution of one FHN in the capacity of a part-time Clinical Teaching Fellow to support both students and mentors within the practice environment. This is a role that had worked well within the original programme, and did so again during phasetwo. Given that this individual was a FHN (and during phase-one there were no FHNs to fulfil this role), the support provided to mentors in particular was immense. The programme team generally feel that the phase-two programme is a significant improvement on phase-one. As mentioned previously the need to enable qualified community nurses to undertake a shortened programme means that some FHN concepts that one would want covered early in the programme have to be either repeated for those undertaking the shortened programme or left until semester two. Both teachers and students alike found this limiting. The challenges experienced by some students in practice was a major distraction from the delivery of the programme; students requiring additional support when both teachers and students had little influence over the factors crating the problems.

External Examiner Comments Over the course of the two phases of the programme external examiners comments have been generally positive in nature. Separate externals were in place for the two phases of the pilot. In phase-one the external consistently commented on the high quality of work submitted by students, he felt that the modules were well taught and assessed and appropriate for the programme. During phase-two of the pilot the external passed some helpful comments regarding marking and student feedback. Generally both externals and students alike have commented positively on the feedback provided by markers; however, its unfortunate that the modular nature of the programme, with high levels of assessment, sometimes means that students are unable to benefit from such feedback when the re-submission dates for work end up running into the next submission deadlines. Conclusions and Recommendations A total of 49 Family Health Nurses have graduated from the University of Stirling programme since its inception in 2001. There have been three cohorts of students; two from the Highlands, Western and Orkney Islands and one from Glasgow. Of these nurses all but two are currently practicing as FHNs. They have adapted to their new roles and continued to develop their knowledge and skills through the practice of family health nursing. The evidence from their university evaluations and the national evaluation (Macduff and West 2003) indicate that these nurses are breaking new ground in the delivery of community nursing. There are numerous examples both via course work and the external evaluation that indicate these nurses are identifying and meeting unmet health needs in the families they work with. The students describe their experience of the programme as a journey of deconstruction followed by a reconstruction of their approach to the delivery of family health care. The programme appears to be fit for purpose and the graduates fit for practice. The model of delivery and the programme content is distinct in many ways from current community nursing programmes albeit there is a degree of overlap, particularly around competencies and anecdotal evidence would suggest that FHN content is finding its way into existing community nursing education programmes. The programme teams experience to date suggests that future programme development should, where possible, include the involvement of key staff members from the pilot practice areas. Whilst this was done, to a point, in phase-one and two of the project, tight timescales limited its effectiveness. In addition it is essential to ensure that the key members of staff within practice settings are involved. The interventions of the SEHD FHN Coordinators for phase-two of the pilot made a significant contribution to the introduction of the FHN role within new settings and to the development of the role within phase-one settings. Any future development should ensure that sufficient time and effort is devoted to bringing practice and education together within a context of change management and within a spirit of partnership.

References British Heart Foundation (2000) Walking the Way to Health. Newsletter, 5. Bruner, J. (1960) The Process of Education. Harvard University Press, Cambridge, Massachusetts. Christensen, P (2004) The health- promoting family: a conceptual framework for future research. Social Science & Medicine. 59 377-387 Department of Health (2003) The NHS Knowledge and Skills Framework (NHS KSF) and Development Review Guidance Working Draft. Department of Health, London. International Council of Nurses (2003) Framework and Core Competencies for the Family Nurse, ICN, Geneva. www.icn.ch Lauder W, Sharkey S & Mummery K (2004) A community survey of loneliness. Journal of Advanced Nursing. 46 (1) 88-94 Macduff, C. and West, B. (2003) Evaluating Family Health Nursing Through Education and Practice. Scottish Executive Social Research, Edinburgh. Malik, M. (1997) Advocacy in nursing-perceptions of practising nurses. Journal of Clinical Nursing 6: pp 303-313. Mayall, B., Foster, M.C. (1989) Child Health Care: Living with Children, Working for Children. Heinemann Nursing, London. NHS Education for Scotland (2004) Partnerships in Education: Guidelines for the Design and Delivery of Family Health Nurse Education Programmes in Scotland, NES Edinburgh. Putnam R (2000) Bowling Alone: the collapse and revival of American Community. New York. Simon & Schuster Scott, J (1997) Changing Households in Britain: do families still matter? The Sociological Review. 591-620 Scottish Executive (1999) Working Together for a Healthier Scotland. SEHD, Edinburgh. Scottish Executive (2000) Our National Health: A plan for action, A Plan for Change. SEHD, Edinburgh. Scottish Executive (2001a), Nursing for Health: a review of the contribution of nurses, midwives and health visitors to improving the publics health in Scotland. SEHD, Edinburgh. Scottish Executive (2001b), Caring for Scotland: The Strategy for nursing and midwifery on Scotland SEHD, Edinburgh. Scottish Executive (2003) Building Community Well-being. An Exploration of Themes and Issues. Prepared for the Scottish Executive by the Scottish Development Centre for Mental Health in association with Scottish Council Foundation and OPM. Scottish Executive (2005), Delivering for Health SEHD, Edinburgh.

Scottish Office (1999) Towards a Healthier Scotland -A White Paper on Health. Scottish Office, Edinburgh. United Kingdom Central Council for Nursing, Midwifery and Health Visiting (2001) Standards for Specialist Education and Practice. UKCC, London. World Health Organisation (1998) Health for All Policy Framework for the European Region for the 21st Century. [EUR/RC48/R5]. WHO, Denmark. World Health Organisation (2000) The Family Health Nurse Context, Conceptual Framework and Definitive Curriculum. [EUR/OO/5019309/1300074] WHO, Denmark.

Appendix 1 Calendar Entries Bachelor of Nursing in Community Studies (Family Health Nurse) Programme of Study: The Programme will consist of 6 Level 9 credits. Semester 1 will be a double weighted module - Research, Decision Making and Evaluation in clinical practice (Practice Frameworks). This module will address the main core elements of the Specialist Practice Qualification outcomes as per the Nursing and Midwifery Council guidelines. Semester 2 will consist of two single modules and will focus on family systems theory and communication. Clinical placement will centre on the study of family dynamics and health needs assessment. Semester 3 will be a double weighted module, underpinned by research and evidence based practice. Study will be focused around families in transition and the necessary skills required to support such families. Clinical placement will concentrate on working with increasing numbers of family units. Period of Study: 40 weeks Full time; September August Graduate Certificate in Community Studies (Family Health Nurse) Programme of Study: The Programme will consist of 4 Level 9 credits. Semester 1 will consist of two single modules and will focus on family systems theory and communication. Clinical placement will centre on the study of family dynamics and health needs assessment. Semester 2 will be a double weighted module, underpinned by research and evidence based practice. Study will be focused around families in transition and the necessary skills required to support such families. Clinical placement will concentrate on working with increasing numbers of family units. Period of Study: 24 weeks Full time; February August

Appendix 2 Key Features of the Curriculum The curriculum is derived from a comprehensive review of the relevant literature and policy documents that have been produced over the recent years relating both to family health nursing and community nursing (Scottish Executive, 2000, 2001(a), 2001(b); WHO 1998, 2000). As previously identified the various standards and competencies identified by bodies such as the WHO and the NMC have played a central part in determining the content and organisation of this Programme. The Programme is based on six modules of study (two of which possess double weighting) that extend over three semesters of the university. The design of the curriculum is purposely based upon the principles of constructivism and may be described as spiral in nature (Bruner, 1960). The key feature of this type of curriculum design is the way that concepts are first introduced in a relatively simple way, and then revisited to provide a deeper understanding, perhaps several times. Bruners seminal work advocates that curricula should foster intuitive graspings that, once mastered, can then be reconstructed more formally and connected to other knowledge. In this way the learning and practice experience gained by the FHN students will be used throughout the Programme as learning resources, when concepts are revisited and reconstructed. Active dialogue between tutors and students, such as via WebCT discussion board / chat room, facilitates Socratic learning and enables students to progressively discover FHN principles for themselves. The rationale for this design is both theoretical and pragmatic. By adopting a build on build approach and revisiting concepts developmentally, students will be able to demonstrate progression in both their thinking and FHN practice (despite the SCQF academic level remaining the same throughout the duration of the Programme). Pragmatically, such a curriculum design facilitates the integration of the short course within the overall Programme. The common core content for SPQ courses (and associated core FHN competency statements) is addressed in semester one and via WebCT for those undertaking the long course. For those undertaking the short course this material will be available via WebCT, should students wish to refresh aspects of their learning in these areas. Necessarily, these core concepts will be revisited in semesters two and three (and via WebCT) in order to build specialist FHN knowledge and practice onto the core SPQ foundations. The Programme commences with an introduction to the concept of Family Health Nursing. This will be undertaken during an introductory week where all students (those doing both the long and short Programmes) will come together and undergo induction to the University, the Programme and in particular the use of WebCT. All students will be registered to use WebCT at this time. This means that those students undertaking the short course will be able to access electronically (and remotely) the same module resources and communication tools available to the students undertaking the long course. During this introductory week students will also have the opportunity to meet with their personal tutors, practice mentors and the rest of the teaching team. The assessment of practice documentation (evidence base portfolio) will also be distributed and explained. Semester one allows students without an existing SPQ award or equivalent to develop their understanding of practice frameworks. They will begin to explore the communities within which they work and develop their understanding of the community resources available. This semester will begin the focus on the core content for Specialist Practice and will introduce areas such as working in the community, health need identification, health promotion,

problem-solving and decision-making, leadership and management, ethics, health and social policy, evidence based practice, research appraisal, teaching and learning, and continuing professional development. Semester two builds on the SPQ core content and introduces the concepts associated with working with families and an exploration of the key communication and interpersonal skills required to work with families. Public health, health promotion and behaviour change are key elements that are revisited in semester two for further development and application within the context of FHN practice during semester three. Semester three addresses the principles and practice of Family Health Nursing by building on the knowledge and skills developed in semesters one and two, and encouraging the student to apply a range of theoretical concepts within the context of working with families. A feature of this semester is that a life course approach is adopted whilst ensuring that national and local issues are adequately addressed with regard to both urban and rural settings. In semester three the student is encouraged to explore the application of research, clinical decisionmaking, evaluation in clinical practice, leadership and management within the context of family health nursing, thus reconstructing previous learning with a specialist focus. This semester provides the student with an extended period of practice that enables them to prepare for the role of the FHN within the context of a Specialist Practitioner. Such a Specialist Practitioner will demonstrate higher levels of clinical decision-making and so enable the monitoring and improvement of standards of care through: supervision of practice; clinical audit; development of practice through research, teaching and the support of professional colleagues; and the provision of skilled professional leadership.

An evidence based approach is adopted throughout the Programme and every effort is taken to ensure that face-to-face, distance and experiential learning is integrated and fully supported by the supervision provided by both the academic team and the clinical mentor. A number of specific strategies have been adopted to facilitate such theory / practice integration: The assessment strategy each assessment explicitly relates to practice, whether directly (such as the video-taped session of a family interaction) or indirectly (such as the essay asking students to select key aspects from a framework or policy and review the implications of this for community nursing roles providing specific examples from practice). WebCT discussion boards and timetabled online chats Asynchronous discussion boards and synchronous chat room discussions on practice related topics (such as decision-making or inclusive practice) will be scheduled during practice placement study time. Students are expected to contribute to these forums, raising issues and sharing their learning from practice with colleagues and tutors. Action plans for placements Students are expected to negotiate a series of action plans for their practice placements in negotiation with their personal tutor and mentor. Action plans will focus on theoretical elements of the appropriate module(s) for further exploration and development within the practice setting. In this way students will also be able to focus on addressing the specific FHN competencies linked to the module(s) in question.

Practice based activities related to theoretical content In order to make particular concepts and ideas tangible within FHN practice, a number of practice-based activities will be suggested throughout the Programme to be undertaken during allocated study time, both on campus and whilst on placement. Examples of such activities include the creation of a visual representation of the community and resources worked with, and exploration of anti-oppressive practice with families through asking about the meaning of particular images. The activities can be used as part of the Evidence base portfolio. Evidence base portfolio creation The Evidence base portfolio is the tool used within the Programme for practice assessment. Its creation involves mapping evidence of competence against the FHN competency statements. For each of the 17 broad statements relating to the FHN competencies, four pieces of evidence are required that span both theoretical and practical sources of learning

Close collaboration with mentors Mentor / tutor collaboration is a two-way process whereby mentors can learn about the Programme philosophy, content and expectations; and tutors can learn about the sort of placement issues and experiences likely to be encountered. Mentors are linked to the University, and specifically the Programme team, through a number of means. The mentor area within the FHN WebCT site facilitates remote communication between mentors and tutors and provides mentors with resources related to the Programme. Mentors also have a preparatory session with the Department prior to undertaking the role. Mentors will be supported by their employer through the Unified Health Board Senior Nurse for the Family Health Nurse Project.

Clinical teaching fellow post A qualified FHN, who has been involved in developing this curriculum, will take up post as a part-time Clinical Teaching Fellow within the Department. This post provides the opportunity for support to students, mentors and tutors alike with regard to the different academic, clinical and personal demands of the FHN Programme.

Appendix 3 Programme Structure Introductory week

Indicative content: Registration with the University Overview of Programme Introduction to FHN, background and context Group cohesion and support Study skills and academic writing (DAICE) WebCT and IT Library resources Evidence Base Portfolio and placement issues (with Mentors) Overview of second pilot FHN Programme Meet with Personal Tutors and Teaching Team Taster sessions of FHN modules Legal, ethical and professional issues

Some of the above programme was also attended by Mentors thus ensuring consistency in the understanding of the role of the FHN

Module Descriptors Semester One Research, Decision-Making and Evaluation in Clinical Practice (Practice Frameworks) (44 SCQF at Level 9) Module Co-ordinator: Ian Murray Introduction: The Family Health Nurse, like other Specialist Practitioners, is required to practise within a number of broad overlapping frameworks. These frameworks include evidence-informed practice; decision-making; and governance in health and social care. The intention of this double-weighted module is to develop an understanding of these three frameworks by exploring the concepts relating to, and the reality of, working with families and communities. The core concepts explored within these frameworks will be revisited and further developed in subsequent modules. This module forms the first in the series of modules that constitutes the Family Health Nurse Programme. It is a mixed theory and practice module spanning the fifteen week semester (including two weeks annual leave). The module is structured to enable students to gain core Specialist Practitioner knowledge about families and community, evidence, governance and decision-making, in order to explore and embed this knowledge within practice settings. It will also support students to develop skills to critically engage with knowledge underpinning practice. Students will be encouraged to engage with theory and knowledge based practice relating to families and community and to explore, discuss and debate issues relating to theoretical and practice based frameworks that are utilised in the health and social care systems and organisations. This module will enable the students through interaction with both peers and teachers to explore the variances that may exist with regard to rural and urban healthcare. Both formative and summative assessments require the application of these frameworks to students practice experiences and assist students to meet a number of the core FHN competencies. Clinical practice: Students will undertake periods of clinical practice in which they will explore the influences on and features of the community in which they work, and begin to develop contacts with a number of families. This clinical practice will be supervised by an experienced practitioner who will be prepared for this role and act as Mentor to the student. Dedicated time will be set aside for clinical supervision during periods of clinical practice. Each week of practice includes a day of practice-related study time. Students will be able to use this time to develop their Evidence Base Portfolio through use of both structured and unstructured activities, towards achievement of the FHN Competencies. As the period of practice continues and students gain knowledge and experience with a number of families and communities, students will be guided to critically analyse the implications for effective interventions and evaluation of their practice. This understanding and synthesis is central to high level decision-making which is the hallmark of excellence in clinical practice. Learning will be supported through: Directly taught sessions Group work

Self-directed study WebCT

Module Outcomes: The primary aim of this module is to enable FHN students to develop high-level critical appraisal, decision-making, and evaluation skills in the context of family nursing practice. This aim will be realised through the following outcomes. The student will: 1. 2. 3. 4. 5. 6. Conduct a critical appraisal of evidence-based family nursing. Critically analyse research evidence for applicability within the practice setting. Evaluate her / his own practice in the light of evidence and the use of that evidence in decision-making. Compare and contrast whether the local health provisions meet the holistic needs of the family and community. Provide a comprehensive appraisal and analysis of the Family Health Nurse practice community, including demographic and epidemiological data. Consider ways in which families can be involved in decision-making.

Relevant NES Indicative Content Core 1. Professional, Ethical and Legal Issues Professional practice and accountability Models and frameworks for practice Legal practice Ethics Epidemiology and environmental studies Health economics and health/social care policies 3. Care Management Evidence based practice Clinical governance Problem solving and decision making Quality enhancement audit and evaluation Leadership theories Resource management Change management 4. Professional Enhancement Theoretical approaches to teaching and learning Learning contracts Clinical supervision Preceptorship, mentorship and peer review Continuing professional development Specialist (introduction to) 2. Care Provision Evidence base for FHN practice 3. Care Management Risk management individuals, families and communities

Health economics and resource management Evaluation and clinical governance Change management 4. Professional Enhancement Research agenda FHN policy implementation and development CPD and clinical supervision models Assessment: 1 x 3000 word essay on evaluating frameworks in relation to FHN practice (addresses module outcomes 4 and 6) 1 x 3000 word research critique related to FHN practice (addresses module outcomes 1, 2 and 3). Formative assessment (visual representation of a community worked with) (addresses module outcome 5.)

Semester Two Working with Families in the Community (22 SCQF at Level 9) runs concurrently with following module Module Co-ordinator: Patrick Bradley Introduction: This module develops core SPQ principles and explores prior knowledge and experience in Community nursing and the rationale for change to Family Health Nursing. The identified conceptual framework of the Family Health Nurse will be critically analysed, compared and contrasted with other models of community care. Emphasis will be placed on WHO Health 21 targets for health. This will encompass primary, secondary and tertiary prevention of illness aimed at the individual, the family and the community as a whole in an effort to reduce morbidity and set targets in collaboration with others for health improvement. Building on content within semester one, local and national policies and recommendations will be analysed. An exploration of the management of change and inter-agency collaboration for the provision of health and social care will be facilitated. Reflective practice, ethical and legal matters will also be developed further in this module. Recognising that the students undertaking the short course will join with those undertaking the long course students at this time, a number of supportive measures will again be made available to all students. Further computer training will be available, along with the use of library facilities, study skills, tutorial and mentor support to meet the learning needs of the students, as individually required. This module provides the student with a strong grounding in the exploration of the FHN role; issues surrounding autonomous practice; and an examination of the need and dynamics of collaboration with families, liaison with peers and relevant others. Clinical Practice: Clinical experience will enable the student to apply theory to practice with a limited number of families, and enable the student to carry out a three generational family assessment and identification of health needs. Module Outcomes: 1. Analyse and discuss Family Health Nursing as a vehicle to increase insight into, and understanding of, the potential implications of illness and disability in one family member for the family module as a whole. Critically appraise WHO Document Health 21. Demonstrate understanding of Public Health Issues as they relate to Family Health Nursing. Discuss the social, political and economic factors which influence family health care. Utilise assessment methods informed by theory to identify factors which influence family health care provision

2. 3. 4. 5.

6. 7. 8. 9. 10. 11. 12. 13. 14.

Examine the current state of inter-agency interface, co-operation and collaboration in health care practice from the perspective of recipient families. Evaluate models of health behaviour and approaches to behaviour change. Apply Family Development Theory to family health concerns. Construct care plans which use Family Development Theory and knowledge of models of health behaviours in clinical practice Promote health and prevent disease in individuals, families and communities. Gain insight into the dynamics of working with individuals and families in the community to bring about behavioural change. Review the concept of decision-making taking into consideration ethical and legal principles. Critically explore issues of practitioner autonomy and dependence within the health care team, and in relation to other relevant external agencies. Demonstrate the importance of providing accurate and rigorously collated health data to employing authorities and purchasers through health profiles in order to inform health policies and provision of health care.

Mapping to NES Indicative Content Core 1. Professional, Ethical and Legal Issues Models and frameworks for practice Epidemiology and environmental studies Health economics and health/social care policies 2. Care Provision Health promotion/health education, theoretical models, strategies Health needs assessment Principles of public health Preventive and intervention strategies and procedures for domestic abuse and violence 3. Care Management Management of care Risk assessment and management Specialist 1. Professional, Ethical and Legal Issues FHN models and concepts Record keeping and confidentiality in relation to family records, ecomaps and family care plans Family contracts Culturally sensitive care Domestic violence and abuse 2. Care Provision FHN concepts family systems theory, interaction theory, developmental theory FHN models Evidence base for FHN practice FHN process advanced assessment skills Health promotion and public health approaches 3. Care Management Risk management individuals, families and communities Team working, referrals and liaison Change management

4. Professional Enhancement FHN practice development Change management Multi-disciplinary working and education Assessment: Written Case Study presentation demonstrating the use of Family Systems Theory in the construction of a care plan to address the health issues of a family the student is involved with 50% (2500 words) (addresses outcomes : 1,4,5,6,8,9,10,11,12,14) Examination Questions will address application of key theoretical principles to clinical practice 50% (2Hrs) (addresses outcomes 1,2,3,7,8,10,13) Semester Two Communication (22 SCQF at Level 9) runs concurrently with previous module Module Co-ordinator: Maggie Robertson Introduction: This Module has been planned to run concurrently with the module: Working with Families in the Community, both in theoretical preparation and in clinical practice, and will focus specifically on those communication skills fundamental to delivering effective family nursing and those skills required to facilitate an understanding of the dynamics presented by families within students caseloads. This module is designed to allow the students to examine and analyse the foundation of their own preferred communication methods and styles in conjunction with theoretical underpinning relating to relationship building within the cultural and sub cultural context of a particular family setting. Thus core SPQ concepts from semester one, such as empowering patients in decision-making, will be revisited, further developed and applied within this module. Studies relating to the specifics of family communication patterns, both adaptive and maladaptive, will be further developed within the context of family diagnosis; whilst therapeutic interventions within families will allow the student, within an identified model, the skills and opportunity to effect positive change where appropriate. Although the module will include the opportunity for the student to examine a counselling framework, this is intended to provide an overview. The aim of the module is to give the student some basic counselling skills and understanding, along with the expertise to recognise when such issues require be referred on to more specialised care providers. Integrated within the module will be a number of associated skills areas where the focus would be on such issues as presentation skills, special communication needs, and record keeping skills. The overall aim of the module is to help the student develop skills and knowledge which would facilitate in them a better understanding of family through an understanding of the communication processes exhibited, and an enhanced ability to deal with these issues through increased self awareness and understanding of therapeutic use of self. This module is closely linked to, and is co-requisite to, the remainder of the modules within the FHN Programme. It provides the student with the knowledge and skills base to allow

them to evaluate the impact of the familys dynamics within its internal system, the influence this dynamic exerts on the nurse, and the skills to facilitate an appropriate response. It therefore allows the student to explore the issues of roles, autonomous practice and empowerment within the context of a family setting. Clinical Practice: The students will have the opportunity during their clinical experience to practice and develop these general therapeutic communication skills, the culmination being an assessment presentation in which they must submit a detailed critical analysis, with reference to theoretical underpinning, of an interaction they have undertaken with a family within their case load. Module Outcomes: 1. 2. 3. 4. 5. 6. 7. 8. Critically analyse the theoretical and research knowledge and skills that health care professionals require to display effective communication in a family setting. Develop strategies to meet the client needs in a family setting. Evaluate theories and concepts of therapeutic communication and apply these in a family setting. Assess the dynamics involved in family communication. Recognise and debate the ethical issues related to family nursing practice. Critically analyse different ways of working with families in a variety of environments. Identify and support the family in the development of strategies to meet their own needs. Review and evaluate the acquisition and effective use of high level communication skills in self and peers.

Mapping to NES Indicative Content Core 1. Professional, Ethical and Legal Issues Social and behavioural and biological sciences 2. Care Provision Empathy/therapeutic use of self 3. Care Management Information management 4. Professional Enhancement Therapeutic relationships Communication Negotiation and personal effectiveness Counselling Specialist 1. Professional, Ethical and Legal Issues Record keeping and confidentiality in relation to family records, ecomaps and family care plans 2. Care Provision Therapeutic relationships

Family communication studies Group dynamics Collaborative and interagency working Assessment: A video-taped session of a family interaction in which they have been involved. This assessment will constitute 30% of the overall grade (a written component of 1,000 words covering the preparation for the exercise is required). (addresses module outcomes 1 and 3). A detailed and supported case study analysis of the video taped interaction. This assessment will constitute 70% of the overall grade and as such should be approximately 3000 words in length excluding appendices (addresses module outcomes 1-8).

Semester Three Principles and Practice of Family Health Nursing (44 SCQF at Level 9) Module Co-ordinator: Sheena Williamson Introduction: The intention of this double-weighted module is to develop an understanding of the phenomena and underlying dynamics within the family system that may be indicative of the dysfunctional or pathological processes, thus giving an indication regarding therapeutic interventions or referrals. It is also intended to develop in the student an understanding of the connectedness of the various theoretical underpinnings of the Family Health Nurse, initially introduced in previous semesters. Therefore semester threes main outcome is to effect an integration within each student which will help develop their competence to apply these constructs in day to day practice, within the context of an evidence-based framework. The module provides the opportunity for a period of sustained study and practice of those therapeutic skills considered necessary for effective clinical practice with families and communities. The development has been influenced largely by qualified community nurses, with the support of academic staff and it therefore reflects practising nurses expert understanding of the skills needed for family health nursing practice. Students will be exposed to a wide range of interventions, some of which are currently the province of other community nursing roles. The family health nurse must possess a range of competencies, which cross traditional role boundaries in existing community nursing practice. A multidisciplinary focus in the Module provides richness and breadth of learning, together with an understanding of the various professional roles and agencies that affect families and communities. The module will be tailored to the specific needs of students - an arrangement which is important given the fact that qualified and unqualified community nurses will undertake the Programme. The campus-based learning will be facilitated via a series of focused workshops that alternate with practice throughout the semester. A life-course approach is adopted along with a clear focus on the key national and local health issues such as cardiovascular health, mental health, cancer care and child health. Clinical Practice: Clinical practice is necessary within this module to utilise skills, consolidate learning and produce evidence of integrated understanding. Research based management of specific clinical issues and their application to the family will be examined. The student will be required to work independently at times to gather clinical information, analyse, discuss, evaluate and review it in relation to practice. The three main sections: management, social / sociological understanding and therapeutic interventions will be subsumed within the overall semester heading of Principles and Practice of Family Health Nursing. Module Outcomes: 1. 2. 3. Evaluate and discuss the theoretical and research knowledge relating to Family Health Nurse specialists. Critically examine skills and knowledge essential to the Family Health Nurse and apply them to the practice area using an evidence based approach. Examine the theoretical underpinnings associated with promoting lifestyle and behavioural change.

4. 5. 6. 7. 8. 9. 10. 11. 12.

Identify the latent and manifest content underlying family needs from theories of dynamic understanding. Act independently within a multi-disciplinary / multi-agency context. Support and empower families to take appropriate action to influence health policies. Be aware of available services, use information and apply skills to develop / practise the role of the Family Health Nurse. Demonstrate an awareness of health and care needs at both family and structural levels. Concord with families in decisions concerning the care of families and communities. Identify and select, from a range of health and social agencies, those which will assist and improve the care of families and communities. Compare and contrast whether the local health provisions meet the holistic needs of the family and community. Provide a comprehensive appraisal and analysis of the Family Health Nurse practice community, including demographic and epidemiological data.

Mapping to NES Indicative Content Core (building on previous input) 2. Care Provision Nature and causation of disease and/or conditions plus their physical, emotional and social consequences Advanced pharmacological studies and prescribing from a nursing formulary where legislation permits Diagnostic, therapeutic and resuscitative procedures Preventive and intervention strategies and procedures for domestic abuse and violence 3. Care Management Quality enhancement audit and evaluation Leadership theories Management of care Resource management Change management Risk assessment and management Specialist 1. Professional, Ethical and Legal Issues FHN models and concepts Family contracts Culturally sensitive care Domestic violence and abuse 2. Care Provision FHN concepts family systems theory, interaction theory, developmental theory FHN models Evidence base for FHN practice FHN process advanced assessment skills Health promotion and public health approaches Collaborative and interagency working 3. Care Management Risk management individuals, families and communities Safe environment and infection control

FHN leadership Delegation and supervision Team working, referrals and liaison Health economics and resource management Evaluation and clinical governance Change management 4. Professional Enhancement FHN practice development Change management Research agenda FHN policy implementation and development CPD and clinical supervision models Multi-disciplinary working and education Assessment: 2 x 1500 word annotated case reports 25% (addresses all module outcomes which is reflected in the marking criteria). 1x 3000 word systematic review of clinical cases 25% (addresses all module outcomes which is reflected in the marking criteria). Clinical assessment based on evidence base portfolio 50% (addresses all Programme outcomes which in turn correspond to all the FHN competencies).

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