Evaluation of the Family Nurse Partnership Programme in NHS Lothian, Scotland - Late Pregnancy and Postpartum

5 SERVICES, RESOURCES AND REFERRALS

5.1 FNP provides clients with information about other services throughout the programme. This Chapter presents data on the numbers and types of referrals made by Family Nurses during the pregnancy phase of the programme. It discusses clients' and Family Nurses' views about FNP's role in linking clients with services and their perceptions of the differences, if any, between the services provided by FNP and by others. It also explores the NHS Lothian, Edinburgh Family Nurse Team's perspective on establishing working relations between FNP and other services. It is hoped that subsequent reports will be able to explore these issues from the perspective of other stakeholders (particularly midwives, social workers and GPs).

5.2 While the monitoring and evaluation framework only includes one specific question relating to use of other services (Is there any evidence that the FNP leads to use of screening/antenatal services and recommended antenatal practices?), the use made of referrals clearly has the potential to contribute to other outcomes for clients, while the relationship between FNP and other services is of wider interest in terms of understanding how the programme operates in a Scottish context.

Referrals to other services

5.3 Routinely collected data shows that FNP recorded 148 referrals for 84 clients prior to 36 weeks gestation and 166 referrals for 87 clients during the pregnancy phase as a whole. As indicated in Table 5.1, Family Nurses referred clients to a very wide range of services.

Table 5.1: Numbers of clients referred to services

	36 weeks gestation	Pregnancy phase
Smoking cessation	16	17
Mental health services	7	7
Other health care services	72	84
Financial assistance	13	15
Housing services	9	9
Antenatal classes	24	24
Social care (including child protection/child in need and adult disability services)	9	10
Other (including Community Support, Legal Services, Citizen's Advice Bureau, Edinburgh Fun initiative, Granton Information Centre, Kids Love Clothes, Mehip, Relate, Stepping Stones, Young Mums Group, Children's Centre, Bethany Trust, Amethyst and EVOC)	12	15

5.4 In addition, FNP recorded that 96% of clients attended for a second trimester fetal ultrasound scan.¹⁷ Again, while it is not possible to say what proportion of clients would have attended for this scan in the absence of FNP, this figure shows that uptake of routine antenatal checks was very high among the first FNP cohort in Scotland.

Perceptions of Family Nurses' role in linking clients with other services

5.5 Family Nurses suggested that the fact the programme covers a whole city was very helpful in getting to know all the different services available for clients. However, covering a whole city can also pose challenges in terms of gaining familiarity with services in every area (and with ensuring that all those services are familiar with FNP). This was reflected in comments both from the NHS Lothian, Edinburgh Family Nurse team and from clients. While one client view was that where their Family Nurse did not know their area they were nonetheless 'doing their best' to find local services they could use, another was that their Family Nurse needed 'to get familiar with this area'.

5.6 The accounts of both clients and Family Nurses highlight variations in how involved Family Nurses are in actually liaising with other services on behalf of clients or whether they adopt more of a 'sign-posting' role. As FNP aims to foster self-efficacy, Family Nurses may sign-post clients to services but encourage them to actually contact them for themselves. However, sometimes additional support was viewed as necessary to ensure clients actually engage with other services, either because clients lacked the confidence or motivation to engage with other services on their own, or because they were in particularly difficult situations. This balance between encouraging self-efficacy (i.e. encouraging clients to contact and access services themselves) and providing support in accessing services may occasionally create some tensions and client resistance, as illustrated by following client account:

I just stop asking stuff because … I dinnae think that there's any point because she doesnae ken the answer, so what's the point in me keeping asking her when she's just gonna keep telling me the same thing about 'just go to the JobCentre or just go to the Citizen's Advice and ask them, … or check the internet' … So I end up doing that myself. (Client 6)

5.7 Although this client appeared frustrated by the fact that her Family Nurse did not just know or find out the answers to her questions, she did confirm that she eventually found the information she needed herself - so the Family Nurse's approach may actually have supported her to develop self-efficacy. Finally, Family Nurses also suggested that 'feeling judged' could act as a barrier to young mothers accessing other services.

A lot of these young women find it very difficult to take that first step and engage because they do fundamentally bring with them the baggage of always feeling judged, and feeling judged because, you know, they're very young and they've got a baby. (Family Nurse 1)

Impact of FNP referrals on clients

5.8 As indicated by the figures in Table 5.1 above, many of the referrals FNP makes during pregnancy are for health services. These referrals were clearly appreciated. In particular, the comments of clients and significant others suggest without the advice of a Family Nurse they trusted, maternal health issues may have gone untreated for longer:

There's things that you would have let just go had you not known. … She's pointed out something that I would never have known. It could have gone on for long enough without (client) knowing any better. (Significant other 3)

5.9 Clients also reported regularly consulting their Family Nurses about their babies' health, both within and outwith their pre-arranged home visits. Family Nurses appeared to play a role in both spotting symptoms the client might have missed (like oral thrush) and helping them decide whether or not minor symptoms (like rashes or coughing) merited a trip to the doctors, as well as giving them confidence in their own judgement about when to contact their GP.

Yesterday I kinda phoned her up because for the past couple o' days like he hadn't been feeding. He'd been coughing and sneezing. Just didn't seem himself. And she was quite helpful, and said that I should just go with my instinct. Coz he does sound a bit poorly, phone up a doctor and see if I can get an appointment. (Client 10)

5.10 As discussed in the first evaluation report, clients also discussed a range of ways in which they felt their Family Nurses had helped them with housing and benefits. This was echoed in the second round of client interviews. Clients mentioned their Family Nurses: writing to the Council to help them with getting their own accommodation; supporting them with setting up meetings with Housing (including actually attending meetings with them); giving the client (or their family, where they were living with others) lists of different Housing Associations; giving information about the pros and cons of different types of tenancies; giving them information about tax credits, grants and benefits they might be eligible for; and helping them work out what number to ring for benefits advice. Again, the information and support received from FNP in this area was clearly valued:

She's helped me obviously with all the major things. Like helped with like obviously housing and getting my money sorted and that kind of thing … She's done a lot for me … She's done enough, basically! (Client 2)

Perceptions of differences between FNP and antenatal and postnatal services

5.11 Clients reflected on some of the differences they perceived between the support they received from FNP and support from other services. In particular, they reflected on the differences between Family Nurses, Midwives and Health Visitors, and on the differences between receiving advice and information through antenatal education and through their Family Nurse.

5.12 As discussed in Martin et al (2011), before the birth, clients reported mixed relationships with their midwives, either reporting that they were fortunate to have a good midwife as well as a Family Nurse, or that they did not really know their midwife and did not seem to get enough time with them to ask questions or raise concerns. It was suggested that clients were sometimes left with unanswered questions after seeing their midwife, and that they felt they 'got a lot more' information from their Family Nurse. One client view was that some midwives might not always be well equipped to support younger mothers in particular:

My midwife was really bad. She'd never dealt with anyone my age I don't think … they were all like 30 plus, and she just … me and her did not get on, so having my family nurse meant that somebody who like kinda understood me a lot more than my midwife. (Client 17 - paired interview)

5.13 Client perceptions about the level of contact they had with their midwives were, to an extent, echoed in the views of Family Nurses, who suggested that while some clients were seeing their midwives regularly in late pregnancy for others it seemed they did not have a lot of contact with them other than for scans and check-ups in this period.

5.14 With respect to antenatal education, although all FNP clients were made aware of available antenatal classes, they differed in whether they intended to or wanted to attend such classes. When interviewed after the baby's birth, clients and significant others again commented on the fact that standard antenatal classes were seen as intimidating for young women. There was a perception that these were mainly attended by older women and that young mothers felt too shy or embarrassed to attend. As noted in the Martin et al (2011), the main service offering antenatal classes specifically geared towards younger women stopped delivering before the end of the recruitment period for the first FNP cohort in NHS Lothian, Edinburgh. While the NHS Lothian, Edinburgh Family Nurse Team had expressed some concerns about the content delivered by this service, at the same time they noted that clients did not appear as keen to attend routine antenatal services after this service ended. The finding that teenagers are less likely to engage with traditional antenatal support, including classes, is acknowledged in both the Better Health Better Care Action Plan (Scottish Government, 2008) and the refreshed Maternity Services Framework (Scottish Government, 2011).

5.15 Similar perceptions were also apparent among clients in relation to post-natal mother and baby groups. While some clients were very keen to attend these as a way of meeting new people and getting out of the house after the birth, others were not comfortable attending a group with (older) strangers:

I think everybody at those groups would just be too old anyway. They'd be like twenty … mid-twenties or something. (Client 3)

5.16 FNP may thus play an important role in providing antenatal education for young mothers who might not otherwise engage with antenatal classes. At the same time, these findings suggest that young women may be better served if there were more antenatal and postnatal groups targeted specifically at their age group.

FNP perceptions of working relations with other services

5.17 In their second interviews for the evaluation, the NHS Lothian, Edinburgh Family Nurse team reflected on their working relationships with colleagues in health and other services and on how these relationships had developed since FNP was launched in NHS Lothian in 2009.¹⁸ It was suggested that both midwifery and public health nursing/health visiting were initially unclear about the role of FNP and perhaps worried that they would start taking over their jobs. However, by late 2011, the relationship between midwifery and the FNP team in NHS Lothian, Edinburgh appeared to be viewed positively by the FNP team as a result of midwives seeing the impact of the programme on clients.

I think by the time our later clients were giving birth I think the midwives were beginning to come on board with understanding what it was we were trying to achieve and were able to see … the girls … were gaining knowledge etc. and were preparing well for their babies. (Family Nurse 5)

5.18 In comparison with midwifery there had been relatively less contact between FNP and Health Visiting in Lothian to date, since (as of late 2011) the first cohort of FNP clients had yet to make the transition back to universal Health Visiting services. Where Family Nurses did have contact with Health Visitors, however - for example, where there were child protection concerns - they were believed to view FNP positively and any initial concerns were seen to have reduced as contact with the programme increased.

5.19 Relationships and joint-working between FNP and social work were also believed to have improved since the start of the programme. Initial perceived barriers to building understanding of FNP among social workers included:

• The number of social work teams across Edinburgh, meaning it takes time to reach them all
• The fact that the programme in NHS Lothian, Edinburgh is still in a test phase and is therefore closed to new recruits - meaning you 'build up a level of understanding which then starts to erode again'
• Challenges in communicating what working with a 'strength-based' approach means. Initially at least, Family Nurses felt that social workers were not clear about how risk was handled within a 'strengths-based' approach and that a lot of 'open communication' had been required to build understanding of the potential benefits of this approach.

I think sometimes it was just seen as 'strengths-based approach, you don't see any of the risks'. And it's not that you don't see the risks, you maybe just deal with them in a slightly different manner. … so I think it was sometimes a challenge to just … get over the .. perspective we were coming from. However, when people started to see the fruits of the labour, they actually then got the approach … they really got behind us. (Family Nurse 5)

5.20 It was also noted that in general social workers have sometimes expressed a desire to 'stretch' the eligibility criteria for FNP to include, for example, teenagers with concealed pregnancies who present after 28 weeks. However, in general this was seen as something that could be resolved by explaining the rationale for FNP and the fact that it is designed as an early intervention programme.

5.21 Finally, the NHS Lothian, Edinburgh Family Nurse team felt that after some initial challenges, the relationship between FNP and the Housing Team in Edinburgh was now good. Building relationships with key staff within Housing was seen as key to building understanding between the services. It was also suggested that the support that FNP clients receive from their Family Nurses was reassuring for Housing Workers who might otherwise have concerns about an unsupported young person taking on a tenancy. It was suggested, however, that benefits services had been less helpful and that both Family Nurses and clients had often found them more difficult to deal with.

Key points

• Family Nurses referred clients to a wide range of services during pregnancy. In addition to health and antenatal care, these included housing, social care, financial assistance and a variety of other public and voluntary sector services.
• Referrals from Family Nurses for both maternal and child health issues were clearly appreciated by clients and significant others. It was suggested that without the support of the Family Nurse, maternal health issues might have gone undiagnosed or untreated for longer. Family Nurses also appeared to play an important role in giving clients confidence in their own judgement about when to contact their doctor about their baby's health.
• The information and support Family Nurses provided in relation to accessing housing and benefits were highly valued (as also discussed in the first report, Martin et al, 2011).
• Clients reported mixed relationships with their midwives. One client view was that they 'got a lot more' information from their Family Nurse. Another was that midwives were not always best placed to support young mothers in particular.
• FNP may play an important role in providing antenatal education for young mothers who may not otherwise engage with antenatal classes - perceived by clients and significant others as being more suited to older women. At the same time, there may be a need for more antenatal and postnatal groups aimed more specifically at young women.
• Variations were apparent in whether Family Nurses liaised with other services on behalf of clients or acted primarily in a 'sign-posting' role. Client and Family Nurse comments suggest there is a (sometimes challenging) balance to maintain between encouraging self-efficacy and ensuring clients do actually access other services.
• Delivering FNP city-wide was seen as advantageous in terms of getting to know the range of services clients might be able to access, although at the same time gaining familiarity with all the services available across the whole city could be challenging.
• From the perspective of the NHS Lothian, Edinburgh Family Nurse team, working relationships between FNP and key services like midwifery, health visiting, social work and housing had all improved since the start of the programme as they had become familiar with each other and with FNP's ways of working. However, Family Nurses noted some initial challenges in communicating to social work what working with a 'strength-based approach' means. They commented that a lot of 'open communication' had been required to reassure social work that this did not mean ignoring risk.
• It was noted that FNP has had relatively less contact with health visiting to date, while the number of social work teams across Edinburgh meant it took time to build relationships with them all. Relationships with benefits services were also reported to be more difficult.