By Poulton, Brenda Lyons, Agatha; O’Callaghan, Anne
Abstract There is evidence to suggest that population-focused public health nursing is more rhetoric than reality. This quantitative study compares the self-perceived public health competence of qualifying student specialist community public health nurses (SCPHNs) (n=35) with those of the practice teachers (PTs) facilitating their practice learning (n=31).
Findings suggest that PTs felt more competent than qualifying students on leadership and management for public health, working with communities, and communication skills. However, the qualifying students self-rated higher than the PTs on principles and practice of public health, suggesting that the PTs in this study felt less competent than their qualifying students in key public health skills, such as epidemiology, population health needs assessment, research and evidence-based decision-making.
It is recommended that the triennial review of PTs should address not only educational skills but knowledge and skills in contemporary public health practice, a continuing professional development framework for SCPHNs should be developed and funded, providers should assist PTs in keeping up with contemporary public health, and the role of the PT should be recognised and given appropriate support and remuneration.
Key words
Public health nursing, education, practice teachers, professional regulation
Community Practitioner, 2008; 81(9): 31-4.
Introduction
Recent policy documents promote the role of health visitors and school nurses in the delivery of the public health agenda.1,2 While community-focused public health practice has long been seen as part of these roles, there is evidence to suggest that this is more rhetoric than reality. In a review of the literature exploring the public health roles of health visitors and school nurses, Hawksley et al3 concluded that there was little evidence of population- focused activity. This is supported by earlier study findings in one area of the UK,4,5 that public health activity concentrated largely on intervention at an individual and small group level.
Although there are a range of models for implementing the public health nursing role,6,7 nurses often experience constraints in fulfilling family-centred public health roles. Smith8 conducted focus groups with health visitors in England and found that the key factors in the development of the public health nursing role were:
* Leadership in clarifying the role
* Development of public health networks
* Support for change in practice.
These mirror the findings of Plews et al,9 that practitioners reported limitations in their public health skills. Refocusing the public health role of health visitors and school nurses requires not only robust academic models, but also experienced and committed practice teachers (PTs) who feel competent in their public health role.
The opening of the specialist community public health nurse (SCPHN) part of the NMC register in 200410 constituted a radical change to the delivery of health visiting, school nursing and occupational health nursing educational programmes. Not only were these programmes extended to 52 weeks in length, with 10 weeks’ consolidation of practice, but their educational standards have a broader public health focus based on specific national occupational standards (NOS).11 The NOS are divided into 10 broad public health areas, including population needs assessment and surveillance, health promotion and health protection, tackling health inequalities, partnership working and community development.
A recent study12 designed to evaluate qualifying SCPHN students’ self-perceived competence found that they reported a significant improvement in public health skills following exposure to a populationbased public health programme. This study developed and validated a questionnaire based on the NOS that was administered to students before and after the programme.
Educational preparation of competent SCPHNs who are ‘fit for purpose’ and ‘fit for practice’ requires competent PTs, who must have advanced public health and research skills in addition to being effective practitioners. The NMC have developed revised standards for learning and assessment in practice13 that require all SCPHN students to be facilitated by a PT on a live register, maintained by the local health provider. To be registered, PTs must have undertaken a dedicated PT programme that meets NMC standards. PTs who have undertaken an earlier preparation programme must successfully map across their knowledge and experience to demonstrate that they meet present NMC standards. Furthermore, PTs must be reviewed every three years to ensure that only those who continue to meet the standards remain on the local register. The PT standards are arranged in eight domains (see Box 1). While these domains and related competencies reflect contemporary practice, a study of 35 community PTs14 found that they required educational updating in order to fulfil their public health role.
This paper reports on a study that used a previously validated measure to enable PTs and qualifying SCPHNs to self-assess their public health competencies, the results of which were then compared.
Aim
To investigate PTs’ self-assessed knowledge and skills in the 10 key areas of public health practice, and to compare the results with those of qualifying SCPHN students.
Method
A quantitative study design was used, employing a questionnaire validated in a previous study.12 This questionnaire was developed using the NOS, NMC standards for SCPHNs and the public health skills audit tool developed by the Health Development Agency.15 A questionnaire design was considered appropriate due to the specific nature of nursing competencies, which require practitioners to assess knowledge and skills against a required standard of practice. Furthermore, a questionnaire study affords anonymity to respondents16 and is less time-consuming.
Participants
The sample comprised students registered on the BSc/postgraduate diploma in community and public health nursing at one university (n=98). They were enrolled on the specialist public health core module, but then followed one of two routes:
* Specialist community nursing – district nursing, community mental health nursing, community children’s nursing or community learning disability nursing
* SCPHN – health visiting, occupational health nursing or school nursing.
Additionally, qualified practitioners acting as PTs for these students were invited to participate (n=86).
Questionnaire
The questionnaire asked for respondents’ background details, including their specialist area of practice. Competency statements were divided into six categories:
* Personal skills
* Professional skills
* Underpinning public health principles
* Policy and strategy
* Leadership
* Management.
Respondents were asked to rate on a fivepoint Likert scale, in which five signified ‘highly competent’, four ‘competent’, three ‘average’, two ‘barely competent’ and one ‘not at all competent’. The questionnaire was distributed to the students prior to and on completion of the public health programme. It was also distributed and completed during a study day for PTs.
Ethical considerations
This study forms part of a larger study, for which ethical approval was granted by the university ethics committee prior to implementation of the new Research Governance Framework, which was implemented in the study area later than in the rest of the UK. Participants were assured that completion of the questionnaire was a matter of personal choice, that anonymity and confidentiality would be maintained throughout the study, and that results would only be published in aggregated form so that no individuals could be identified. Anonymity was important in order to encourage participants to self-assess honestly.
Data analysis
Data were analysed using the Statistical Package for Social Sciences (SPSS) version 11. Descriptive statistics were generated initially to check the data for errors and to describe the characteristics of the sample. The distribution of the scores for the questionnaire scales were assessed and found to be normally distributed, so parametric analyses were completed throughout.16 The questionnaire comprised 54 variables (see Table 1), and in the previous study12 these were subjected to factor analysis and reduced to three scales. Two variables did not load on to any of the scales. One was omitted from the analysis, but the other (working with communities) was considered important and treated as a discrete variable. These scales all demonstrated acceptable levels of scale reliability.
t-tests were used to compare scores between PTs and qualifying students. While the t-test can indicate a statistically significant difference between the two groups that it has not occurred simply by chance – it does not measure the degree to which the variables are associated with one another. Pallant16 advocates calculating the ‘effect size’, which is the amount of the total variance in the dependant variable (selfperceived competence) that is predictable from the independent variable (PT or qualifying student). Therefore, the partial etasquared was calculated for statistically significant results.
Results
Of the 98 questionnaires distributed to qualifying students, 59 were returned completed (response rate=60%). Of the 86 PTs invited to participate, 58 returned completed questionnaires (response rate=67%). As this paper relates to SCPHN students and PTs, data were analysed only for this group (n=35). This included students qualifying as health visitors (n=23), school nurses (n=8) and occupational health nurses (n=4). Of the SCPHN PT respondents (n=31), 25 were health visitors, four school nurses and two occupational health nurses. Comparison of post-course assessments
Achievement of professional competencies assumes that qualifying students are ‘fit for’ practice and purpose. To explore this assumption, qualifying SCPHN students’ self-perceived competence in public health was compared with that of the PT group using an independent sample t-test (see Table 2).
Although the PTs rated themselves higher than qualifying students did on the dimensions of leadership and management for public health practice and working with communities, the difference between these ratings was not significant. Not surprisingly, the PTs rated themselves significantly higher than the qualifying students did on communication skills (p=
This latter finding suggests that the PTs in this study felt less competent than their qualifying students in key public health skills, such as epidemiology, population health needs assessment, research and evidence-based decision-making.
Discussion
Due to the small sample size and restricted geographical location, the results of this study cannot be generalised to all SCPHNs. However, the results support previous research3’8 that has demonstrated that the community-focused public health role of SCPHNs is not being enacted in line with national policy.
The previous study12 found that qualifying SCPHNs rated themselves to be more competent in the principles and practice of public health following exposure to a dedicated public health programme. In this study, although PTs rated themselves more competent in leadership and communication skills, they felt less competent in the more specific skills of public health practice than the qualifying students they supervised during the SCPHN programme. This might call into question the ‘fitness to practice’ of the existing SCPHN workforce, as clearly they are not confident in some crucial elements of public health practice. The reverse argument is that the legacy of GP fund-holding, high caseloads and understaffing5 renders them ‘fit for purpose’ in a climate that offers limited scope for the acquisition and development of public health skills.
These results are in keeping with those of Byers,14 who found that mentors for district nursing, health visiting and school nursing required an updating programme to equip them to move from a caseload approach to one that was public health focused. The skills deficits identified by Byers are similar to those within the principles and practice dimension of this study. These include population health needs assessment, developing and sustaining partnership working, and research skills. Such identified skills deficits imply that qualified SCPHN practitioners are not engaging in true public health practice, and supports the results of other studies that suggest inconsistent interpretation of public health nursing, poor interprofessional and interagency collaboration, and a reactive rather than proactive approach to practice.
While the revised standards for teaching and assessment in practice are to be commended, it could be argued that they focus on educational facilitation of students rather than pushing forward the boundaries of practice in order to meet public health challenges. If the triennial review of PTs is to be effective, it needs to assess their practice as well as educational skills, and any good appraisal system should do this. Furthermore, there is a responsibility on higher education institutions (HEIs) providing SCPHN programmes to facilitate study days for PTs in order to address the perceived deficits in their knowledge and skills. The majority of PTs are committed practitioners who take a pride in their role and dedicate huge amounts of time in providing a broad range of experiences and learning opportunities for students. Many do this while carrying large caseloads and without additional remuneration.
Conclusions
In spite of the rhetoric that surrounds community-focused public health nursing, many SCPHNs still practice in the traditional way, working at individual and family level. If they become PTs, they consequently do not feel competent in key public health skills. Conversely, students qualifying on the new SCPHN programmes have acquired these skills, but there is a danger that they will lose them if they are employed within a culture that does not support community-focused public health practices.
Recommendations
* The triennial review of PTs should address not only educational skills but knowledge and skills in contemporary public health practice
* Essential skills clusters18 should be developed for each SCPHN pathway, and used in the development of a continuing professional development (CPD) framework for qualified practitioners similar to that proposed by the American Nurses’ Association19
* Such CPD should be supported and funded by employers/ commissioners and delivered by HEIs
* HEIs should work in partnership with PTs to assist them in keeping up to date with contemporary public health practice, not only by organising study days as appropriate, but allowing access to student learning materials and learning alongside students in the sharing of experiences and ideas
* The role of the PT should be recognised as crucial and given the support and remuneration that it deserves
* Extension of the study to a wider population of SCPHNs across the UK, to get a better national picture of the public health skills of PTs, would enhance this research.
Box 1. PT standards
Adapted from NMC standards:13
* Enabling effective working relationship
* Facilitation of learning
* Assessment and accountability
* Evaluation of learning
* Creating an environment for learning
* Content of practice
* Evidence-based practice
* Leadership
Key points
* Evidence suggests that population-based public health nursing is more rhetoric than reality
* Use of a tool developed and validated to measure self- perceived competence in public health skills found a small group of qualifying SCPHNs to rate their competence in public health principles and practice more highly than their practice teachers rated their own
* Practice teachers who work at an individual and family level may not feel competent in key public health skills, and qualifying SCPHNs who possess these skills risk losing them if they are not utilised in practice
* Review of practice teachers should address knowledge and skills in contemporary practice, and they should be better supported, recognised and remunerated
References
1 Department of Health. Facing the Future: a review of the role of health visitors. London: Department of Health, 2007.
2. Department of Health. School nurse: practice development resource pack 2006. London: Department of Health, 2006.
3. Hawksley, B, Carwell, R, Callwood I. A literature review of the public health roles of health visitors and school nurses. British Journal of Community Nursing, 2003; 8(10): 447-54.
4. Poulton BC, Mason C, McKenna H, Lynch C, Keeney S. The contribution of nurses, midwives and health visitors to the public health agenda. Belfast: Department of Health, Social Services and Public Safety, 2000.
5. Turner J, Poulton B, Lazenbatt A, Patton L, Curran C. Community health nursing: current practice and possible futures. Belfast: Department of Health, Social Services and Public Safety, 2003
6. Carr SM. Refocusing health visiting: sharpening the vision and facilitating the process. Journal of Nursing Management, 2005; 13(3): 249-56.
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9. Plews C, Billingham K, Rowe A. Public health nursing: barriers and opportunities. Health and Social Care in the Community, 2000; 8(2): 138-46.
10.NMC. Standards of proficiency for specialist community public health nurses. London: NMC, 2004.
11.Skills for Health. National occupational standards for the practice of public health. Bristol: Skills for Health, 2004.
12.Poulton B, McCammon V. Measuring self-perceived public health nursing competencies: a quantitative approach. Nurse Education Today, 2007; 27: 238-46.
13.NMC. Standards to support learning and assessment in practice. London: NMC, 2006.
14.Byers P. Report on the Practice Educator Project. London: Amicus/CPHVA, 2002.
15.Burke S, Meyrick J, Speller V. Public health skills audit 2001: research report. London: Health Development Agency, 2001.
16.Parahoo K. Nursing research: principles, process and issues. Basingstoke: Macmillan Press, 2006.
17.Pallant J. SPSS survival guide (third edition). Maidenhead: Open University, 2007.
18.NMC. Guidance for the introduction of essential skills clusters for pre-registration nursing programmes. London: NMC, 2007.
19.American Nurses Association. The Framework, Concepts and Methods of the Competency Outcomes and Performance Assessment Model. Silver Spring, Maryland: American Nurses Association, 2000. Available at: www.nursingworld.org/mods/archive/mod110/ copafull.htm#copa (accessed 14 August 2008).
Brenda Poulton PhD, BA, MSc, RGN, RSCPHN, CertEd
Professor of community health nursing,
University of Ulster
Agatha Lyons PGCertEd, BSc, RGN, RSCPHN SCPHN lecturer and course director, University of Ulster
Anne O’Callaghan PGCertEd, BSc, RGN, RSCPHN
SCPHN lecturer, University of Ulster
Copyright TG Scott & Son Ltd. Sep 2008
(c) 2008 Community Practitioner. Provided by ProQuest LLC. All rights Reserved.
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