1 Introduction

Primary Health Care (PHC), as defined by the Alma-Ata Declaration of 1978 and reaffirmed by the World Health Organization (WHO) in 2018, represents an all-encompassing approach geared towards optimising the equitable dissemination of health and overall well-being. Its overarching aim is to cater to the health requirements of individuals, families, and communities by delivering comprehensive care across the entire lifespan. This care spectrum spans health promotion, disease prevention, curative interventions, rehabilitation, and palliative services [1]. In alignment with this framework, the role of the Family Health Nurse (FN) was introduced as part of HEALTH21, the Health Policy Framework for the European Region, as endorsed by the WHO. Recognizing the pivotal role of nurses in the realm of PHC, this framework underscored their potential contributions in areas such as health promotion, disease prevention, and caregiving [2]. As the global population ages and the prevalence of chronic diseases rises, healthcare systems face significant challenges in addressing these issues. The need for a shift from a hospital-centred model to a community-centred care approach has become crucial. This transformation is evident in various countries, including the USA, Canada, the UK, and other European nations, where Family Nurse (FN) models have been introduced [3]. In response to the evolving healthcare landscape, countries have implemented reforms to integrate FN into primary health care, despite variations in community needs. However, the competencies and legally recognized scope of practice for FNs differ internationally, leading to variations in their roles, skills, and responsibilities [4]. In the Italian context, Local Health Authorities, responsible for delivering public health services, are organised into Districts. Within these Districts, multi-professional teams, including ambulatory specialists, nurses, and general practitioners, provide the first non-urgent health assistance in Community Homes. In Italy, FN roles predominantly focused on providing care to individuals, particularly those who were unwell or elderly. This was achieved through a proactive approach that involved preventive measures and interventions, often in close collaboration with other healthcare professionals, particularly General Practitioners (GPs) [5]. FN roles were acknowledged for their ability to provide substantial support to individuals and families. They frequently spent considerable time within households, which are considered the foundational units of society, where psychological and social aspects assume significance [6]. As time progressed, the role of the nurse transitioned into that of a Family and Community Nurse (FCN), as the scope of needs assessment expanded to encompass the broader community. FCNs became integral members of multidisciplinary healthcare teams, focusing on addressing both individual and community health needs [7]. To ensure the implementation of this figure it is critical to provide a clear definition of the FCN roles. In the Italian context, the nursing profession and its scope of practice were initially delineated in Ministerial Decree No. 739, dated 14 September 1994. This decree bestowed exclusive competencies upon nurses and stressed the importance of their collaboration with other healthcare professionals [8]. Subsequent clarification of the FCN role was furnished in Ministerial Decree No. 77, dated 23 May 2022, which underscored functions such as health promotion, prevention, and the assessment of community needs. Nevertheless, the implementation of FCN functions and services in Italy remains marked by inconsistencies. Moreover, it is imperative to tailor the role to the specific needs and context of a given region and the healthcare professionals operating within it. Qualitative research methodologies, such as focus groups (FG), provide a direct avenue for soliciting perspectives from these professionals. FGs serve as invaluable tools for capturing the motivations and perceptions of FCNs, involving guided discussions that are expertly facilitated by a moderator. This approach fosters meaningful social discourse among participants, yielding profound insights into the subject matter at hand [9].

The primary aim of this qualitative study is to delve into the challenges encountered in healthcare delivery by both healthcare professionals and members of the local community. Additionally, it seeks to determine the optimal roles of FCNs in an Italian context where FCNs are not currently in place but are anticipated to be introduced in the near future. This information will be pivotal in shaping the design and implementation of effective programs involving FCNs within the realm of PHC.

2 Materials and methods

Qualitative research was chosen as the methodological approach for this study with the intent of gaining in-depth insights into the potential role of Family and Community Nurses (FCNs). The selected methodology involved the organisation of three Focus Group (FG) sessions. A FG session is a method in which a researcher brings together a group of individuals to engage in a conversation about a particular subject, with the intention of eliciting insights from the participants' intricate personal experiences, beliefs, perceptions, and attitudes through a facilitated interaction [10,11,12].

Prior to the three FGs, participants were apprised of the confidentiality measures in place to safeguard their data. Moreover, the results were presented in the form of collective group perspectives rather than individual opinions. Consequently, the information exchanged during these sessions was processed anonymously, and the data was retained exclusively by the researchers, without any form of external distribution.

The study was carried out over the course of April to June 2023, taking place at three distinct centres, designated as Centre 1, Centre 2, and Centre 3. These centres primarily offer Primary Health Care (PHC) services.

To facilitate comprehensive data collection and analysis, separate FG sessions were organised, with each session corresponding to one of the aforementioned centres. Each FG session had a duration of approximately 2 h. The selection of participants was carried out by professionals responsible for the management and coordination of individual centres through personal contacts, with particular attention to involving key figures within the healthcare services offered at each of the three centres.

2.1 Procedures and data analysis

Each of the Focus Group (FG) sessions was led by a skilled facilitator, accompanied by an assistant who discreetly monitored and transcribed participants' statements, summarising the main concepts or faithfully reporting noteworthy phrases or expressions. Both the facilitator and the assistant observer had expertise in the field of public health. Although they worked within the same Local Health Authority as the participating healthcare professionals, they did not have direct employment relationships or subordination with them. The FG sessions were conducted in conference rooms located in close proximity to the participants' workplaces.

At the outset of each session, the facilitator initiated a familiarisation process with the participants, outlining ground rules that emphasised the importance of respecting one another's viewpoints, preserving confidentiality, and ensuring the anonymity of all participants. To provide a foundational understanding of the Family and Community Nurse (FCN) concept, a digital presentation was employed to acquaint the participants with this role. To cultivate a comfortable and engaging environment, the discussions commenced with an introductory round where participants introduced themselves. A semi-structured approach guided the conversations in both groups, which consisted of three distinct phases.

In the initial phase, participants were encouraged to reflect on specific challenging situations within their work where they encountered difficulties in addressing all the needs of their patients. They were invited to document their thoughts on paper and, if willing, share their experiences with the group. The second phase facilitated discussions aimed at exploring the potential utility of FCNs in their professional contexts. This involved identifying scenarios where FCNs could offer valuable assistance, articulating the tasks and responsibilities FCNs could undertake, and delineating the forms of communication that would prove beneficial. As the dialogue unfolded, the facilitator encouraged in-depth conversations to gain a more profound comprehension of the participants' aspirations and requirements. During this discourse, one of the observers recorded notes on a visible board, summarising the emerging topics. Additionally, keywords were employed to synthesise the key subjects raised. A thematic analysis approach was employed to categorise emerging themes, supported by quotations extracted and annotated during the FGs discussions. Following a framework established by Doody et al. [13], our research team thoroughly reviewed all transcribed materials multiple times to comprehend the data and note preliminary ideas. Transcripts were read to capture the overall flow of the material, and initial observations from the dataset were coded. Initial comments and codes were analysed to identify potential organisations of themes; whenever ideas shared the same concept, they were assigned to the same theme. In cases where disparities or differences of opinion arose, the authors engaged in deliberations to attain a consensus and resolve any disagreements. To ensure confirmability and minimise bias, data analysis involved research team members who did not participate in the translation or focus group discussions.

2.2 Settings

All three focus groups were conducted at Community Health Centers under the jurisdiction of the same Local Health Authority. All three Community Health Centers were situated in small mountainous municipalities within the Emiliano–Romagnolo Apennines region of Italy. Specifically, the population served by these three centres was n = 13.075 for Center N.1, n = 4270 for Center N.2, and n = 6950 for Center N.3).

3 Results

3.1 Participants

A multidisciplinary group of 16 healthcare professionals participated in the FG held at the Community Health Center N.1. The group consisted of 4 GPs, 1 paediatrician, 1 primary care physician, 2 nursing directors, 2 Clinical Nurse Specialists (CNS), 1 nursing coordinator from the Community Hospital, 1 nurse and secretary from the general medicine practice, 1 social worker, and 3 pharmacists.

During the FG meeting held at the Community Health Center N.2, a multidisciplinary group of 13 healthcare professionals participated. Specifically, the group comprised: 1 GP, 1 paediatrician, 1 primary care physician, 1 nursing coordinator, 1 administrative services representative, 1 speech therapist, 1 home care nurse, 1 nurse from the chronic care outpatient clinic, 1 nurse from emergency medical services (EMS), 1 nurse from the Community Mental Health Center (CMHC), 2 social workers, and 1 midwife.

Lastly, the third meeting, convened at Community Health Center No. 3, comprised a total of 14 healthcare professionals and representatives from third sector organisations, as follows: 2 GPs, 1 primary care physician, 1 prospective FCN, 1 nursing coordinator, 1 registered nurse, 1 pharmacist, 1 school representative, 1 local municipal representative, and 4 volunteers from third sector organisations.

3.2 Environment

The atmosphere during all three FG sessions was characterised by a continuous and respectful exchange of ideas, creating an environment where participants actively participated in discussions and expressed their viewpoints. In the first FG, a profound sense of community belonging emerged, with participants openly acknowledging and valuing each other's contributions to the network of services. Similarly, in the second and third FG sessions, participants engaged in respectful dialogues, even when differing perspectives surfaced. Nearly all participants actively contributed to the discussions, and the majority shared the emerging insights.

3.3 Critical care situations and potential responses

The FGs conducted in three different centres revealed various unmet healthcare delivery needs that are not adequately addressed by existing services. The FGs discussed complex situations where service providers feel unable to fully meet the needs of users, especially when faced with economic and social difficulties, linguistic and cultural barriers, and the need for monitoring prescribed therapies. Mistrust toward services or denial of illness, especially in cases of mental distress, were also discussed.

The participants in all groups emphasised that current services are insufficient to meet the needs of vulnerable individuals without caregivers, those with cognitive impairments, or those facing language barriers. Caregivers, when present, also require increased support and guidance in acquiring basic care practices and recognizing their own caregiving abilities. People with disabilities or chronic conditions requiring home medical equipment lack knowledge on how to handle malfunctions or seek replacements, and healthcare providers themselves are not always aware of the appropriate pathways. Management of home-based pharmacological therapies and the monitoring of health and social issues within families were specifically highlighted as challenging.

The critical moment of discharge without proper support was identified as a significant issue, leading to changes in therapeutic plans and a lack of awareness or ability to schedule follow-up visits.

Participants felt that some specific territories lacked services and resources, requiring travel to other locations. Difficulties in accessing services in close proximity led to physical transportation challenges, especially for individuals without their own means of transportation or limited public transportation options.

Participants expressed also the need for psychological and social support in addition to service provision but felt frustrated by limited time available for each user. Integration among different professionals interacting with users and their families was also considered lacking.

Users' disorientation throughout the assistance process was noted, as they often lacked knowledge of how to access services, book appointments, or prepare for diagnostic tests or visits.

3.4 The role of NFC: targeting specific needs

The FGs identified various areas where the FCN role could be experimented with, providing a potential solution to the unmet healthcare delivery needs discussed. All groups expressed a general positivity towards the possibilities arising from the FCN experimentation, while also emphasising the need to protect the role from inappropriate uses that would distort its identity.

The convergence of perspectives across the three distinct FGs revealed shared priorities in envisioning the role of the FCNs to address unmet healthcare delivery needs among vulnerable populations. In the first focus group (FG1), emphasis was placed on monitoring elderly individuals with polypharmacy, particularly those residing alone or under the care of individuals with limited caregiving competence. This paralleled the second focus group's (FG2) vision, which directed the FCN's focus towards vulnerable individuals lacking caregivers, those with cognitive impairments, and those grappling with language barriers without sufficient family support. The third focus group (FG3) underscored the significance of supporting isolated vulnerable individuals, including the elderly and those with mental health issues, emphasising the potential value of situating FCNs in community health centres.

Despite nuanced variations, all groups uniformly recognized the multifaceted responsibilities of FCNs, encompassing education, therapy adherence monitoring, and collaboration with diverse healthcare professionals. The post-hospitalization support role was specifically acknowledged by FG1 and FG2, demonstrating a common understanding of FCNs aiding in the adaptation to therapeutic plan modifications and new routines.

Additionally, the facilitation of effective communication between service providers, users, and their families was highlighted across all groups. Furthermore, both FG2 and FG3 stressed the importance of a multi-professional approach, positioning FCNs as central figures in establishing networks involving stakeholders from both hospital and community settings.

Recognizing the limitations of FCNs, particularly in urgent nursing interventions overlapping with other professional roles, was explicitly acknowledged by FG1.

3.5 Optimal communication modalities

The findings from the FGs were unanimous in their agreement that telephone contact represents the most efficacious method for initiating FCN health services. Moreover, the participants acknowledged the value of briefing sessions among healthcare professionals as a means to facilitate effective communication. There was a clear emphasis on the necessity for integration between information systems to ensure the seamless continuity of care. Additionally, participants recognized the importance of distributing informative brochures containing schedules, locations, and contact information for accessing FCN services.

4 Discussion and conclusion

Family and Community Nurses (FCNs) are increasingly acknowledged as pivotal assets in various clinical settings, contributing to the achievement of efficient and sustainable healthcare [4]. Their adoption has received policy support, especially in response to the COVID-19 pandemic, given their potential to introduce innovative strategies for health promotion and disease prevention within the realm of Primary Health Care (PHC) [5]. However, the consolidation of their role within Italy's healthcare framework remains a work in progress, marked by the inherent intricacies and challenges associated with introducing novel roles into the healthcare system [14]. Therefore, the primary objective of our qualitative study was to gain a comprehensive understanding of prevailing healthcare delivery critical aspects and needs, thereby facilitating the effective integration of FCNs on local small mountain communities in Italy.

This study centred on exploring potential FCN allocations within the context of an Italian Local Health Authority (LHA), engaging healthcare professionals working within this specific milieu, and concentrating on the distinctive needs of small mountain communities. Utilising the efficacy of focus groups—an interview methodology promoting interactive discourse—participants were encouraged to engage in candid discussions regarding healthcare delivery unmet needs, outline potential contributions of FCNs in addressing these needs, and identify valuable communication strategies [15].

The findings from the focus groups revealed a consensus among participants, highlighting shared concerns regarding unmet healthcare delivery needs, inadequate support for caregivers, obstacles to accessing services and resources, transportation challenges, and the pressing need for enhanced collaboration among healthcare professionals. Participants identified frail, chronically ill, and vulnerable populations as those most in need of care, recognizing the escalating demand for services due to the ageing population [16]. Additionally, a study conducted in another Italian region a few months earlier identified similar health needs [17]. Unexpectedly, despite profound differences in healthcare settings between the two studies (our FGs were conducted in mountainous communities, unlike Barisone et al.'s), the needs of the elderly and frail user base may be similar and cross-cutting [17].

Furthermore, our focus groups delineated various domains in which the FCN role could prove invaluable, including the monitoring of elderly individuals with complex medication regimens, providing support to caregivers, empowering vulnerable individuals, delivering education to caregivers and patients, facilitating access to services, and fostering networks among healthcare professionals.

In the context of monitoring the elderly with complex medication regimens, remote monitoring devices can be adopted to collect vital data, and mobile applications could facilitate real-time communication with the elderly [18]. To support caregivers, interactive training sessions could be organised, providing them with practical tools to address daily challenges and helping to promptly identify any issues related to medication management[19]. Furthermore, creating informative resources, such as printed guides or video tutorials, could offer ongoing support, with a particular focus on the skills needed to handle complex situations and care for the elderly. For empowering vulnerable individuals, it is essential to tailor solutions to the specific needs of the community. This may include creating social support programs, providing access to psychological resources, or facilitating inclusion through culturally sensitive initiatives [20].

Most of these competencies align with the Core Competencies outlined by the ENhANCE project [21], confirming in this instance that, despite our focus on studying small mountain communities, the expectations regarding the role of FCNs align with those presented at the European level which presented a European Professional Profile for FCNs. Nevertheless, it is crucial to recognize the contextual nuances specific to the Italian healthcare landscape, which were addressed in this qualitative study. It is interesting to note that another experience of introducing Family Care Nurses (FCNs) in the Italian context, albeit in a completely different setting (a large hospital in a major city), underscores that the goal that must be set for FCNs is to implement prevention interventions capable of minimising the main risk factors and promoting adequate lifestyles at all ages. Additionally, it highlights the importance of facilitating access to services and integrating the individual into their social context, as emerged from our focus groups [22].

In their study, Bagnasco et al., highlighted the significance of FCNs in fostering collaboration between services and healthcare professionals. Analysing statements gathered from FCNs during focus groups, the authors observed that informal relationships and physical proximity played a crucial role in establishing effective and enduring interprofessional collaboration [21].

The importance of multidisciplinary teamwork was another aspect underscored by our focus groups, with participants also acknowledging the need for clear role delineation and boundaries to prevent redundancy and maintain the distinct identity of FCNs within the broader healthcare ecosystem. To promote networks among healthcare professionals, periodic forums or thematic seminars could be organised by the FCNs, encouraging the building of a community that fosters collaboration at local levels.

International governments, including Italy, have adopted policies to provide community care through FCNs, but there is a lack of literature on their role, except for in the UK. Many European countries, besides Italy, are still in the pioneering phase of implementing FCNs [23].

Given that the role of FCNs is either newly implemented or in the process of being implemented, further research is essential to assess the effectiveness of such interventions and evaluate the economic implications of introducing FCNs into the healthcare system.

This study possesses several limitations that warrant consideration. Firstly, despite the size of the focus groups being higher than that typically recommended for non-commercial focus groups [24], the groups were based on a limited sample of professionals and users, potentially limiting the generalizability of the results to the broader sentiments of the local community. The size of the groups may have restricted each person's opportunity to share insights and observations. Additionally, the focus groups were conducted with the involvement of professionals or citizens with diverse qualifications across the three different centres. Lastly, despite similarities such as belonging to the same LHA, being situated in mountainous regions, and serving a comparable number of individuals, the three settings differ significantly in terms of locally available socio-health services, opportunities for social engagement, and proximity to more densely populated areas. The heterogeneity of services across the national territory due to regional management of health issues also represents a limitation of the study, reducing the generalizability of the results at the national level or, at least, limiting it to contexts similar to the one analysed.

5 Conclusions

The introduction of the FCN by the WHO represents a strategic shift towards prioritising primary health care over hospital-centred healthcare to better serve the healthcare needs of individuals, families, and communities worldwide. In Italy, legislative measures are also evolving to align with these transformative changes in healthcare delivery. This study offers a comprehensive and innovative overview of the FCN role in small mountain communities, shedding light on the necessity of implementing programs that incorporate FCNs within local Italian contexts. These insights can guide policymaking and organisational strategies to promote the utilisation of FCNs in areas where their presence is currently lacking.