Evaluation of the Family Nurse Partnership Programme in NHS Lothian, Scotland: 3rd Report - Infancy

8 Professional Views and Experiences of Delivering FNP

Key questions

• Does the team receive the training and support intended and develop the knowledge and skills required?

Key findings

• Family Nurses continued to praise the quality of the training received through FNP. An additional potential training need was around capacity planning, given the challenge of managing FNP caseloads to meet fidelity criteria.
• Family Nurses felt they had further consolidated their skills over the last six months. In particular, they said they were making better use of some of the specific tools that support FNP delivery, like DANCE. At the same time, there was a desire for refresher training around some of these tools.
• Supervision continued to be viewed as 'invaluable'. Additional suggestions for supervision included discussing experiences of using FNP materials in general (rather than with specific clients).
• There was some ongoing concern about the appropriate balance between child protection supervision and supervision of other clients. It was suggested this may need to be considered at a Scotland-wide level.
• Family Nurses viewed the changes they had seen in their clients' parenting skills, confidence and self-efficacy as the key achievements of the programme. A specific achievement was the team's support for a group of FNP clients to become 'breastfeeding buddies', who will support other mothers with breastfeeding.
• The team expressed divergent views on their current workload. One view was that it was more manageable than it had been earlier in the programme; another was that it continued to be difficult to contain without working additional hours.
• Factors that may have helped ease workloads included: increased familiarity with the programme; clients starting to graduate; and the completion of preparation work for this transition. On the other hand, issues around the record keeping process, additional meetings associated with child protection cases, tasks associated with being the first Scottish test site, and a temporary gap in administrative support were all cited as contributing to high workloads in the first half of 2012.

Introduction

8.1 Family Nurse's experiences of delivering FNP to clients in infancy have been discussed in some detail in the preceding chapters. The programme of client visits is supported by extensive training and structured supervision, specified in the FNP manual. This chapter summarises the team's views on these aspects of the programme. It starts, however, with a more general discussion of the NHS Lothian, Edinburgh Family Nurse team's views of the main achievements and challenges associated with delivering the programme over the six months since the second round of evaluation interviews.

Achievements

8.2 Family Nurses' accounts of the team's key achievements in the period from late 2011 to mid-2012 reflected similar themes to those discussed in the second evaluation report (Ormston et al, 2012). Again, the impacts for and achievements of their clients featured strongly, as evidenced by their accounts of the changes they saw in clients' parenting skills, confidence and self-efficacy (discussed in earlier chapters). And again, the team took obvious pride in the strength of the relationships underpinning their work with clients, particularly where these had been more challenging to maintain.

Achievements? I think I'm just so proud o' my clients, d'you know? And in how .. how much they've come on.

(Family Nurse 3)

The girls that ... have had more going on in their life, and are more tricky to see, you know, the fact that you are still seeing them, and they do still, you know, want to see you, I think that's … a real achievement.

(Family Nurse 6)

8.3 More specifically, the development and training of a group of FNP clients to become 'breastfeeding buddies', able to support other young (and older) mothers with breastfeeding was viewed by the Team as a key achievement.

8.4 In terms of their own developing professional practice, the six months from late 2011 to mid-2012 appeared to be viewed by the Family Nurse team as primarily a period of 'consolidation' rather than major change. Although there was a view that it can be 'hard to measure your own progress', Family Nurses reported feeling they were becoming more 'skilled delivers' of the programme. They also believed they were becoming more experienced at agenda matching and making better use of some of the tools which support the delivery of FNP - for example, the DANCE tool that helps with assessing and offering feedback on parent-child interactions:

I think just having an awareness of that tool now helps me better assess the interaction that I see, and ... it allows me to offer positive feedback to parents (…) That's not to say that ... that there aren't areas that require further development, but it's .. it's much easier to pick out the positives in that parent/child than it would have been previously for me.

(Family Nurse 5)

Challenges

Workload

8.5 Workload was identified as a major challenge in delivering FNP in both the previous evaluation reports (Martin et al, 2011 and Ormston et al, 2012). It remained the key challenge discussed by the NHS Lothian, Edinburgh FNP team in mid-2012. However, at this point somewhat divergent views were expressed by the team in relation to their current workloads. One view was that the workload was in fact 'much more manageable now' than it had been previously. Nurses' increased familiarity with the programme, the fact that clients were starting to graduate, and the fact that the team had finished their main preparation work for this transition were all seen as helping the job become 'more containable' within standard working hours. However, at the same time there remained a strong view that the workload remained 'very, very heavy' and that Family Nurses were still working additional hours to carry out their role.

8.6 The Family Nurse Supervisor in NHS Lothian also reported finding it extremely difficult to contain her role within a standard working week. While this in part reflected the challenge of balancing her role in NHS Lothian with her one-day a week role as National Lead Supervisor, she also felt that there were a lot of component parts to the Supervisor job alone that made it very challenging to deliver. She felt that workload within the Supervisor role needs to be contained 'because you couldn't continue to work at the pace'.

8.7 Some of the factors to which the team attributed heavy workloads reflected those already listed in previous evaluation reports, including:

• The move to an electronic record keeping system within NHS Lothian. Although the team recognised the benefits of being able to access other health professionals' notes, there was an ongoing perception that electronic record-keeping took somewhat longer. It was suggested that if the system could be adapted for FNP, so that the fields better fit with their domains and the information they need to gather for FNP, this might help reduce the additional time taken. The team also noted that during infancy the volume of record-keeping required increases, as Family Nurses need to complete notes for both mother and baby.
• Family Nurses with cases involving a child protection issue again noted the additional time these added to their workload in terms of attendance at meetings and hearings, writing reports, etc.
• Additional work associated with being the first test site for FNP in Scotland. It was acknowledged that the Scottish Government had attempted to prevent the NHS Lothian, Edinburgh team from being over-burdened with requests as FNP was rolled out in Scotland. However, since the last evaluation interviews the team had regularly received requests for information or advice from other Health Boards and prospective Family Nurses from other areas.

8.8 Additional factors that the team viewed as adding to their workload in the first half of 2012 included:

• The need to produce reports for Getting it Right for Every Child (GIRFEC). It was suggested that GIRFEC was not yet fully incorporated within NHS Lothian's electronic record keeping system, necessitating further cutting and pasting between the two. There was also time associated with familiarisation with GIRFEC reporting templates and language.
• Changes within the team towards the start of 2012. In particular, the team's first administrator left in early 2012 and there was a three month gap before a new permanent administrator started. The team commented on the importance of administrative support and found this gap particularly challenging:

I think that's been one of the hardest things that we've had to do in the whole ... since the team started. So the workload was horrific whilst ... when we didn't have our admin

(Family Nurse 3)

8.9 Finally, the team also acknowledged that they sometimes put additional pressure on themselves because of the strength of their commitment to the programme and to their clients.

8.10 While one view among the team was that nothing had proved very effective in terms of managing their workloads, strategies that some team members had adopted and found helpful (to an extent) included:

• Developing an excel sheet to look at capacity and plan their own visits and other commitments across a month, with reference to fidelity targets, and
• Keeping sessions with clients more strictly to time.

8.11 As discussed in Ormston et al (2012), the Scottish Government has funded a 1:6 ratio of Family Nurse Supervisors to Nurses in NHS Lothian, rather than the maximum allowed within FNP of 1:8. Given that workload has consistently been reported as a major challenge by the team throughout this evaluation, it may be necessary to carry out further research and analysis around team workloads as FNP is rolled out in Scotland. This work could explore the extent to which the factors identified in this evaluation persist or dissipate over time, the extent to which any issues appear to be specific to a Lothian, Scotland or UK context, strategies for managing Family Nurse workloads, and whether Nurse and Supervisor workloads do become more manageable as the programme becomes more established.

Other challenges

8.12 As noted in chapter 1, there were a number of changes to the NHS Lothian, Edinburgh FNP team in the first half of 2012. While the team was very positive about the new Family Nurses who had joined them, there was also some discussion of the challenges associated with team changes mid-way through the FNP programme cycle. In particular, the experience of trying to move clients from an existing Family Nurse who had been promoted to supervisor two-days a week had been 'really complicated' because 'clients don't accept being swapped'. The number of clients who had been successfully moved to a new Family Nurse was thus fewer than originally planned, which meant the acting Supervisor had not had as much capacity to support the lead Supervisor as hoped. Given the challenges they had experienced with moving clients between Nurses, it was suggested that although the model of having an existing Family Nurse 'act up' to Supervisor is a good one, it needs very careful planning and ideally should not be started when the Nurse has a full caseload.

Training and supervision

8.13 Team perceptions of the training and supervision received as part of FNP were described in detail in the previous evaluation reports. By mid-2012, Family Nurses in NHS Lothian, Edinburgh found it difficult to reflect back on the mandatory training they had received for the infancy period, as this was completed in 2010. However, they reiterated the view that the training offered by FNP was 'phenomenal' in terms of its quality. In terms of additional training requirements, the team commented that it would be useful to have refresher days for some of the tools introduced to support FNP delivery. DANCE, PIPE, Smart Choices and Compassionate Minds were all mentioned in this context, as tools that Family Nurses valued highly but did not necessarily feel completely 'up to speed' with.

I think we could have done with more training on PIPE, I think the days that we had were fine but I think its one of these things that it takes to go away and think about it, try and implement it, and then have a better grasp of concept yourself to then come back and then revisit it and look at it differently. For me I think that would have been helpful and possibly the same with DANCE and possibly the same with compassionate minds.

(Family Nurse 1)

8.14 It was also suggested that the team might benefit from some training around capacity planning and electronic tools to support this, given the challenges around managing workload identified above.

8.15 Supervision is an integral and mandatory component of FNP. It continued to be viewed extremely positively by the Family Nurse team in NHS Lothian, providing 'time, space, somewhere that you feel comfortable and you can actually just unload'. Indeed, it was described as 'invaluable':

You couldn't do it without supervision or the level of supervision. You really need to have that reflective space just to look and analyse what you've actually done and what you've actually seen to plan ahead.

(Family Nurse 4)

8.16 Although there had not been any major changes to supervision since the previous evaluation interviews, it was suggested that the process was becoming deeper and more 'refined' over time. For example, it was commented that one-to-one supervisions with the Supervisor were able to focus more in-depth on levels of engagement within visits and the reasons for this, rather than reflecting at a more general level on client-nurse relationships.

8.17 In terms of improving supervisions, Family Nurses again commented that it would be helpful if group supervisions were also used to look again at training on tools like PIPE and to discuss experiences of using FNP materials and facilitators in general. There was also a view that a more open discussion about hours within group supervisions might be beneficial.

8.18 Increased face-to-face supervision using a tri-partite process which includes the FNP Supervisor and local Child Protection Advisor has now been implemented across all FNP sites in Scotland. The increase in frequency of Child Protection supervisions, discussed in the previous evaluation report, was still felt by the NHS Lothian, Edinburgh FNP team to be impacting on the time available for supervision other clients in the programme who did not have child protection issues. It was reported that the Scottish Government Child Protection lead was reviewing this. One suggestion from the team for addressing this balance was that the number of Child Protection supervisions could vary across individual Family Nurses and their own level of child protection understanding or training. However, it was also felt that this issue needed to be addressed in a Scotland-wide context and take into account views outside the NHS Lothian, Edinburgh FNP team. Work has also commenced across FNP in the UK to examine what benefits this additional supervision brings to sites.

8.19 Finally, although at the time of writing a bespoke database for FNP in Scotland was still being developed, data was now being used somewhat differently by the NHS Lothian, Edinburgh FNP team. Each Family Nurse now received their own individual report once a month from the Supervisor. This meant that Family Nurses now lead the conversation in supervisions around their own data, which the Supervisor reported was working well. The Supervisor also reported an increased understanding of how to extract data herself, which she felt had been helpful in terms of being able to access specific data during supervisions.