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

Executive summary

1. The Family Nurse Partnership (FNP) programme is a licensed preventative programme which aims to improve outcomes for young first time mothers and their children. It does this through a structured programme of home visits delivered by specially trained Family Nurses from pregnancy until the child is two years old.

2. The evaluation of FNP in Scotland focuses on learning from the experience of implementing FNP in the first Scottish test site, based in NHS Lothian, Edinburgh. It is not an experimental impact evaluation, but rather focuses on learning around how the programme works in a Scottish context.

3. This summary outlines the key findings from the third of four evaluation reports. It focuses on learning from the delivery of the programme in NHS Lothian, Edinburgh in the infancy phase (specifically, the period from when clients' babies were 6 weeks old to their first birthdays). The report draws on quantitative data collected for all FNP clients and qualitative interviews with the initial NHS Lothian, Edinburgh FNP team, the FNP National Lead for Scotland, a sub-sample of FNP clients, and local stakeholders from Midwifery, General Practice and Social Work.

Is the programme being implemented as intended?

4. FNP continued to be implemented in NHS Lothian, Edinburgh with a high degree of fidelity to the Core Model Elements and fidelity 'stretch' goals.

• Attrition during infancy remained well below the fidelity 'stretch' goal (12%, compared with the 20% maximum suggested for that period).
• The fidelity 'stretch' goal for delivering at least 65% of expected visits to clients during infancy was met for 55% of clients.
• The average time Family Nurses recorded spending on different topics during infancy came very close to the division suggested in the 'stretch' goals.
• Family Nurses continue to engage with the intensive supervision required by the programme, which was viewed by the team as 'invaluable'.

How does the programme work in NHS Lothian, Edinburgh?

How do Nurses, clients and wider services respond to the programme?

5. Both Family Nurses and clients viewed the programme as matching well with client needs during infancy, reporting that individual client requirements could be incorporated by 'agenda-matching' within the broad programme framework. Clients appreciated the dual focus of the programme, on both their child's needs and their own.

6. The NHS Lothian, Edinburgh Family Nurse Partnership team praised the training, supervision and materials associated with the programme. However, they identified a few areas where they felt materials, training or support might require some further development for the Scottish/UK context. These included materials around new relationships and support for Nurses around working with clients when they have a second pregnancy, in addition to materials for working with clients when their baby is being looked-after and materials around binge drinking (discussed in the second evaluation report).

7. Stakeholders from Midwifery, General Practice and Social Work described good working relations between their services and the NHS Lothian, Edinburgh FNP team. Factors that supported this included: initial and ongoing regular and open communication between the FNP team and other services, including attending team meetings of other services; shared electronic records (between Midwifery and FNP); new Family Nurses shadowing Midwives; the quality of Family Nurses' work around shared clients (for example, the quality of their written reports in Child Protection cases); and building on pre-existing working relationships.

8. Suggestions for further improving communication between FNP and other services included: more and/or earlier sharing of the theoretical and research base for the programme and how it would work with particular services, and more regular meetings between Family Nurses and GP practices. The FNP National Unit (Scotland) are currently considering issues around organisational preparation for delivering FNP, including how sites can best engage with GPs and other stakeholders.

9. Local stakeholders were also very positive about what they had seen of the impact of FNP on individual client outcomes. However, some reservations were apparent around:

• eligibility criteria for the programme - in particular, whether these were too strict
• sharing learning - which was believed to be difficult because of the FNP license, and
• The resources associated with FNP - particularly against a background of resource challenges in mainstream services.

What factors support or inhibit delivery of the programme?

10. The key factor identified by Family Nurses and clients as supporting both delivery of and client engagement with the programme was the strength and nature of the therapeutic relationships Nurses develop with clients. They reported that these relationships had continued to grow during infancy, enabling Family Nurses to provide more effective support as clients became more willing to share issues and feelings with them - particularly around mental health and emotional wellbeing. Family Nurses noted that this therapeutic relationship could be particularly valuable in cases where there was a child protection issue. Although these situations could also challenge Nurse-client relationships, the consistency of Family Nurses' contact with clients was seen as a central factor in keeping clients engaged with both FNP and with wider services.

11. The Partners in Parenting Education (PIPE) and DANCE tools were described by Family Nurses as particularly valuable in supporting delivery of content around parenting and parent-child interactions during infancy. They suggested that refresher training around these tools would be helpful to ensure Family Nurses are able to make the most effective use of them in visits.

12. Supervision continued to be viewed as 'invaluable' in supporting Family Nurses to deliver FNP: one Family Nurse view was that 'You couldn't do it without supervision or the level of supervision.

13. Managing workload to deliver scheduled visits and meet other requirements of the job remained a key challenge for the NHS Lothian, Edinburgh Family Nurse team. Delivery of the programme was described as presenting many challenges in terms of working patterns. While one view was that there was an improving trend, another was that difficulties containing the work without working additional hours persisted.

14. As in previous reports, factors identified by the NHS Lothian, Edinburgh Family Nurse team as contributing to high workloads included a combination of different kinds of issues. Additional hours at this stage of the programme related to:

• The fact that the team is embedded within the NHS and has to adapt to changing demands and processes within the wider service.
• Administrative changes within the team and the implementation of an improved system of electronic record keeping. The loss of the data administrator post compounded pressure on the team during this period. During the three month gap before the post was re-filled, there was recognition by the team of how essential this role is for sites. An additional nurse was also funded at this time to support the development of an new team Supervisor and increased responsibilities of national lead Supervisor.
• The fact that NHS Lothian, Edinburgh was the first Scottish FNP site, so was called on for advice and support more than may be the case in the future as FNP becomes more established in other areas.

15. In relation to barriers to meeting the fidelity 'stretch' goal around the number of visits, the team also noted that fitting in 'missed' visits could be particularly challenging during infancy. Family Nurses have full case loads and are seeing most clients weekly or fortnightly during this period. A high degree of flexibility around appointment times is also required as clients (re)start work or education. The FNP Supervisor has worked closely with the nurses to develop strategies for addressing these challenges. One Family Nurse suggestion was that additional training around capacity planning and different electronic tools that could be used to support this might be helpful.

16. Additional challenges the NHS Lothian, Edinburgh Family Nurse Team identified in relation to delivery of the programme during infancy included:

• 'Intergenerational influences' on clients' beliefs about parenting, particularly in relation to weaning. Family Nurses reported addressing this by exploring family cultures around weaning with clients and explaining the changing nature of research and advice in this area to both clients and their wider families.
• The availability of appropriate local services. FNP aims to ensure young mothers feel more supported by linking them with appropriate local services. However, while Family Nurses in NHS Lothian, Edinburgh were referring clients to a very wide range of services, they also reported some concerns around the both the availability and suitability of generic services for teenage parents (for example, in relation to mother and baby groups or domestic violence support).
• Balancing the requirements of child protection supervisions with supervision of other FNP clients. 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 since the start of the programme in NHS Lothian was felt to be impacting on the time available for focusing on other clients within the Supervisor-Family Nurse supervision schedule. It was recognised, however, that this issue may need to be considered at a Scotland-wide level.

What are the implications for future nursing practice?

17. Some potential implications for future nursing practice were discussed in the second FNP Scotland evaluation report. FNP continues to contribute to formal discussions around supporting Public Health nurses and Health Visitors through links with the Chief Nursing Officer. NHS Tayside (the second FNP site in Scotland) has begun work on a programme of development for Health Visitors, building on some of the principles of FNP - around motivational interviewing and the nature of leadership and supervision, for example. It was also felt that FNP has the potential to contribute to learning around co-production with service users - including older people and others beyond FNP's own client group.

What is the potential for FNP to impact on short, medium and long-term outcomes relevant to Scotland?

18. As noted above, the Evaluation of FNP in NHS Lothian, Scotland, is not a formal impact evaluation and cannot conclusively establish causal links between FNP and particular outcomes. The 'Building Blocks' Randomised Controlled Trial in England will provide this evidence within a UK context. However, interviews with Family Nurses and clients in NHS Lothian, Edinburgh continue to highlight a wide range of areas where participation in FNP was perceived to have a positive impact. In particular, there was evidence that it has the potential to support young mothers to:

• Develop skills as competent, confident parents
• Engage in activities to support attachment with their child
• Delay weaning
• Assess their home for safety from the perspective of their child, and access practical home safety equipment
• Become more physically active
• Access contraception when they might not otherwise have pursued this
• Feel better supported in relation to their own mental and emotional health and wellbeing
• Link with appropriate community support to help them feel less isolated
• Resolve or manage relationship conflicts
• Navigate and access housing and benefit services and grants, and
• Broaden the options they consider around education or work, formulate goals and overcome barriers.