"Running to stand still": Nurses' roles with children and families in the community in Scotland. Relationships between policy and practice.

The community care reforms, enacted in the National Health Service and Community Care Act 1990. have been a catalyst for change in the roles of community nurses and families in Scotland. The ability o f health visitors, for example, to plan and deliver comprehensive care to families is changing as their work becomes more closely linked to the priorities o f general practice. Health visitors are experiencing less control over their own priorities, including their preventive work with families. In addition, deinstitutionalization is creating pressures for nurses to deliver more acute care in the community. Children with chronic illnesses and disabilities, until recently cared for by nurses in hospitals, are now being cared for primarily by their families, even when specialized nursing procedures are required. Health visitors and other nurses are taking on new components of work, focused increasingly on hands-on care, in order to assist families with their care. The concept o f patient/family participation, where families and nurses negotiate the extent o f family involvement for hospitalized children, has taken on new meaning in the community Neither nurses nor families have sought these role changes, nor have they negotiated them. The impact o f policies on nurse and family roles thus challenges a taken-forgranted view of roles, where role behaviours and expectations are controlled and negotiated by individuals within their role relationships. Nurses’ traditional interest in and research on roles has focused primarily on this micro level o f care, the relationship between client and nurse. While important, this focus has impeded nurses’ understanding of policy and power, and the context for changes to nurse and family roles in the community. Such understanding is needed.