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

3 Relationships

Key questions

• Does the programme meet the fidelity targets for attrition?
• Do the Family Nurses carry out the intended number of visits?
• How feasible is the visiting schedule?
• How involved are fathers in the FNP process/visits?
• Is the FNP seen to engender fathers' involvement?

Key findings

• Client retention remains very high for the first NHS Lothian, Edinburgh FNP cohort - cumulative retention by the end of the infancy phase was 86%. Attrition during infancy (12%) was well below the 20% maximum suggested by the fidelity 'stretch' goal.
• The fidelity 'stretch' goal for delivering at least 65% of expected number of visits during infancy was met for 55% of clients. The average (mean) proportion of expected visits delivered across all clients was 65%.
• Similar facilitators and barriers to meeting the visiting schedule in infancy were identified to those discussed in previous reports. However, it was also noted that fitting in 'missed' visits could be particularly challenging during infancy compared with other periods of the programme, as Family Nurses have full caseloads and are seeing most clients weekly or fortnightly. Flexibility around appointment times was viewed as particularly important in infancy as clients (re)started work or education.
• Both client retention and Family Nurses' ability to meet the visiting schedule are supported by the therapeutic relationship between clients and Family Nurses. Clients and Family Nurses reported that these relationships 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.
• The therapeutic relationship was seen as particularly valuable in cases where there was a child protection issue. Although these situations could also challenge client-Nurse relationships, the consistency of Family Nurses' contact with clients could be central in keeping clients engaged with both FNP and wider services.
• 'Relationships with others' was viewed as a key topic for FNP during the infancy period. Clients valued FNP's support in this area highly, reporting that it was helping them achieve goals around parenting and education, resolve relationship conflicts, and feel less isolated.
• The involvement of fathers and/or clients' partners specifically will be considered in more detail in the next evaluation report.

Introduction

3.1 As described in Olds (2006), an 'empathetic and trusting relationship with the mother and other family members' is key to FNP's approach. Family Nurses aim to build 'therapeutic relationships' with their clients, both to model the positive relationships they hope clients will build with their children (drawing on the existing research base for FNP which shows the positive impacts of doing so), and to create trust that will support clients' ongoing engagement with the programme. The holistic focus of FNP - exploring the social, emotional and economic context of clients' lives - also means that Family Nurses often seek to involve other family members, with the aim of enhancing the wider support available to both mother and baby. This Chapter explores how these relationships develop during infancy and how they might promote positive outcomes for clients. However, first it summarises quantitative data on client retention and attrition and the level of contact between Family Nurses and clients in NHS Lothian, Edinburgh.

Client retention and attrition

3.2 Evidence from the US indicates that to deliver FNP with fidelity and to obtain the expected outcomes, cumulative attrition from the programme should not be greater than 40% through to the child's second birthday. In addition, attrition should not be greater than:

• 10% during pregnancy
• 20% during infancy and
• 10% during the toddler phase.

3.3 These are fidelity 'stretch' goals (see Chapter 1 for definition).

3.4 Table 3.1 shows attrition and retention during the pregnancy and infancy phases of FNP in NHS Lothian, Edinburgh. Programme attrition during infancy was 12% - well below the 20% maximum specified in the fidelity 'stretch' goal for this stage. This figure comprises 6 clients who left the programme through moving out of the area or relinquishing their child into long-term care, and 11 clients who became inactive (because they had not had any Family Nurse visits) for 6 months or more by the end of the infancy phase.

Table 3.1: Attrition and retention, NHS Lothian, Edinburgh FNP test site

	Pregnancy phase	Infancy phase[6]
Total number of clients receiving this phase	148	145
Fidelity 'stretch' goal for maximum attrition for phase	10%	20%
Attrition during phase	3% (4/148)	12% (17/145)
Cumulative attrition by end of phase	3% (4/148)	14% (20/148)
Cumulative retention at end of phase	97% (144/148)	86% (128/148)

3.5 The attrition figures presented for pregnancy in Table 3.1 have been corrected since the second evaluation report (Ormston et al, 2012), which stated that pregnancy attrition was 7%. The correct client attrition rate for pregnancy is 3%.^[7]

3.6 The second evaluation report (Ormston et al, 2012) included discussion of the perceived reasons for the very low attrition rate during pregnancy and reasons for leaving or becoming inactive where this had occurred. An additional potential trigger for leaving or becoming inactive during infancy related to challenges fitting in FNP visits as clients started work or college. Although Family Nurses reported offering a high degree of flexibility around appointment times to accommodate changes in clients' schedules, the team reported that in a small number of such cases clients felt the programme involved too great a time commitment.

Level of contact between clients and Family Nurses

3.7 The Core Model Elements for FNP include a visit schedule, which specifies the frequency and timing of home visits. The fidelity 'stretch' goals then include goals for the proportion of the scheduled visits to be achieved for all clients at different stages of the programme (referred to in the FNP Management manual as 'dosage') as follows:

• 80% or more of expected visits during pregnancy
• 65% or more of expected visits during infancy
• 60% or more of expected visits during toddlerhood.

3.8 The visit schedule varies depending on the stage of the programme. The aim is for clients to receive weekly visits for the first 4 weeks after enrolment, and then fortnightly visits until the baby is born. After the birth, clients are visited weekly for the first 6 weeks, then fortnightly until the child is aged 21 months and monthly for the last 3 months of the programme. Family Nurses complete a 'Home Visit Encounter Form' after each visit, which sites use to monitor the number, length and content of visits.

3.9 The NHS Lothian, Edinburgh FNP site met the fidelity 'stretch' goal (65% or more of scheduled visits) during infancy for 55% (80/145) clients who were still participating at the start of infancy. The average (mean) dosage during infancy was 65%.

3.10 Family Nurses identified similar facilitators and barriers to meeting the visiting schedule during infancy to those discussed in the pregnancy report (Ormston et al, 2012). Key facilitators included Nurse flexibility around appointment times - which, as noted above, became particularly important in infancy as clients started returning to work or education - and client motivation. Challenges again divided into client-related factors - like availability, mobility and/or geographic location - and programme or nurse-related factors, such as additional compulsory training.

3.11 One Family Nurse view was that maintaining the visiting schedule for all their clients was a struggle across the entire programme:

I mean, I think the entire programme we struggle with time. We really do. And annual leave always makes it difficult to keep up the fortnightly contact. And I mean just time in general - managing the conflicting priorities of … of all our clients and the different programme components can make it a challenge to fit the schedule.

(Family Nurse 5)

3.12 However, the NHS Lothian, Edinburgh Family Nurse team also commented that fitting in 'missed' visits was particularly challenging during the infancy period, when Family Nurses have full caseloads and are typically seeing some of their clients weekly (in the six weeks after birth) and others fortnightly. It was noted that if the baby was not present when the Family Nurse arrived, this multiplied the number of visits required from infancy onwards (since although the mother is the client, Family Nurses are the professionals responsible for delivering Hall 4^[8] to the baby and therefore need to see the child at each visit). Meanwhile, the impact of the programme on increasing clients' confidence was also cited by the team as something that, on occasion, could result in reduced engagement with the visiting schedule in infancy:

I think there were elements of their belief in themselves, that they were doing OK and they were doing a good job and they were being good parents, even though they valued the project … and they wanted the contact they didn't see them as necessary as they had in pregnancy and the early on in infancy. That makes sense … as they grew in confidence, they felt they needed us less which is good!

(Family Nurse 1)

3.13 For discussion of ways in which Family Nurses had tried to manage their visiting schedule and other workload, see chapter 8.

Nature and impact of the client-Family Nurse relationship

3.14 As discussed in the last evaluation report, the client-Family Nurse relationship was seen as key in supporting client retention and the feasibility of meeting the visiting schedule (with this therapeutic relationship motivating clients to keep appointments).

3.15 Clients and Family Nurses interviewed for the evaluation reflected on the ways in which their relationships with each other had developed during the infancy period. In general, Family Nurses felt therapeutic relationships with clients had become 'deeper' and more trusting during infancy. Consequently, they thought clients had become more open in discussing the issues affecting them, enabling Family Nurses to provide more effective support to clients. The continuity of the Family Nurse-client relationship and the regular contact provided by the visiting schedule were seen as key by Family Nurses in underpinning the effectiveness of the therapeutic relationship in this respect.

You're not just dipping in and saying, "Well, I've given somebody a list of places to potentially go to", and not seeing them again, or seeing them again in 2 months. (…) You're building on stuff all the time … but also, people are more likely to tell you what's actually happening for them (…) Sometimes they don't, but ... over time, they tend to get to a point where they're more trusting of you and then actually saying ... what's going on.

(Family Nurse 2)

3.16 Conversely, Family Nurses noted that where contact was less frequent, the therapeutic relationship with clients was not as deep.

3.17 Family Nurses suggested that the therapeutic relationship they developed with their clients was a particular help when dealing with cases where there was a child protection issue. The NHS Lothian, Edinburgh FNP team acknowledged that these situations can challenge their therapeutic relationship with clients, particularly where the child protection referral came from the Family Nurse. However, the strength of the relationship and the consistency of their contact with clients were nonetheless seen as crucial in helping keep clients engaged with FNP during these difficult periods. This view was echoed in that of a social worker interviewed for the evaluation, who suggested that the strong therapeutic relationships Family Nurses have with clients can help multi-agency child protection groups keep clients engaged when they might otherwise have struggled because of some clients' 'fear' of social services. Family Nurses also reported that the client-Family Nurse relationship can help support challenging conversations around child protection:

… certainly in my experience (…) I can reflect on how difficult these conversations could be, and I would suggest that they were probably far easier with this client group because of the long term relationship that we had already established with them.

(Family Nurse 1)

3.18 Family Nurses' views of the ongoing development of therapeutic relationships were mirrored in those of clients interviewed for the evaluation. While some clients reported feeling very comfortable with their Family Nurses from the outset, others reported feeling more comfortable with their Family Nurses by their second or third evaluation interviews. Clients' accounts again indicate that the reliability and continuity of this relationship underpinned their willingness to seek support from their Family Nurse, whether about their child's health and development or about their own issues.

I know that she would give me advice straight away so it's a good relationship, and I think it makes it good because I know she's there.

(Client 1)

3.19 While one client view was that their Family Nurse was like a 'friend', clients also emphasised the fact that Family Nurses were professionals and that they were not a family member or friend as something they valued. Their professional status meant that clients could discuss problems with them in the knowledge that they would treat them confidentially and non-judgementally and that they would provide a valuable 'outside' and 'professional' perspective on issues or problems:

I know if I speak to (Family Nurse) it isn't going no further. Like if I speak to my mum and dad then it'll go back … within my family.

(Client 15)

(not) having just to rely on other people … who might not have brought up their kids in the best way … Whereas with (Family Nurse) … whatever she tells you, you can just sort of take it on board if you want to. You can take it on board and just use it to, like, your advantage with your child.

(Client 3)

3.20 Box 3.1 illustrates the ways in which the Family Nurse - Client relationship can develop over time through the account of the same client across three evaluation interviews, from pregnancy to 12 months after the birth of her child. In one sense, this client's relationship with her Family Nurse differed from that of other panel members, in that she was less happy with their relationship at the time of her second evaluation interview (3 or 4 months after the birth). However, it also illustrates several recurrent themes from client and Family Nurse interviews around the importance of continuity and reliability of contact on clients' willingness to stay engaged with FNP and to seek support around sensitive or complex issues.

Relationship between FNP and the client's wider family

3.21 FNP is underpinned by 'human ecological theory', which highlights the importance of mothers' social, community and family context in influencing their decisions and the ways they care for their children. This is reflected both in the focus of the programme as delivered to clients (exploring their relationships with others and their support networks, for example) and in attempts by Family Nurses to involve other family members in visits where possible and appropriate. During the infancy phase, clients' own parents were involved at some level in 17% of FNP visits; the client's partner, husband or the baby's father^[9] were involved in 29% of visits; and clients' friends or other family members in 5% of visits.

3.22 The second evaluation report discussed Family Nurses', clients' and clients' 'significant others' views on the impact of and barriers to involving the wider family with FNP. This topic was discussed in less detail in infancy evaluation interviews, in part because clients' 'significant others' were not being interviewed at this stage.^[10]

3.23 One view among Family Nurses was that other family members were less involved with FNP during infancy, though it was also suggested that family members' involvement remained similar in pregnancy and infancy. However, Family Nurses also commented that even if they were less involved with FNP, other family members were no less influential on clients during infancy - a view reinforced by the fact that, other than their Family Nurse, their own family was identified as a main source of advice about child rearing by panel clients. The fact that clients may find it challenging to weigh conflicting information or advice is illustrated by the following quote from a client, who reported following information from her Family Nurses on some issues, but advice from her mother on others:

… it's not like I ken what tae do because obviously (Family Nurse)'s obviously a nurse and my mum's brought kids up herself so it's, it's just tricky. But it's all of it is different, how like (Family Nurse) would tell it to me and my mum would tell me, it's a lot different.

(Client 11)

3.24 Family Nurses reflected on the ways in which they supported clients to negotiate situations in which they were receiving conflicting information from their Family Nurse and their own family by involving family members in visits and explaining the research behind changing advice around issues like weaning or immunisations.

3.25 Reflecting more broadly on the impact of FNP on clients' relationships with others, one Family Nurse view was that during the infancy period, relationship counselling and communication work were key client needs. This view was reflected in clients' accounts of the ways in which their Family Nurses had supported them to negotiate relationships with others during infancy, including:

• Supporting them to be more confident when making decisions, whether about their child or their own future (for example, the decision to go to college). One client described how her Family Nurse's support had encouraged her to go to college (which she had now started and was 'loving') against a lack of family support for this decision:

But then she kept saying, "Well, remember that you're doing it for her. You're doing it for your daughter.", and I was like, "Well, aye. I am, but I'm just not feeling much love and support right now!". I was like, "Everyone is expecting me to give up". She was like, "Well, prove them wrong".

(Client 12)

• Support with relationship difficulties - examples included sign-posting to couple's counselling, communication coaching, and information about access arrangements. Clients attributed improved relationships with partners and other family members to the support their Family Nurse had provided in this respect:

I spoke to (Family Nurse) about it and she obviously gave me like some ideas to try … and it's helped us. Now we're talking and we're getting on a bit better and it's thanks to the nurse that we are.

(Client 11)

• Putting clients in touch with other young mothers - which was much appreciated where clients had reported feeling 'isolated' in previous interviews.