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

4 Overall Delivery and Views of Programme Content During The Infancy Phase

Key questions

• Do Family Nurses conduct visits in line with fidelity criteria?
• How is the FNP structure experienced by clients and Family Nurses?^[11]

Key findings

• The average time Family Nurses in NHS Lothian, Edinburgh recorded spending on different topics during infancy was very close to the breakdown of coverage of different content domains suggested in the fidelity 'stretch' goals.
• Family Nurses and clients viewed the programme as matching well with client needs during infancy. Both were happy that individual client needs were being met by agenda-matching within the broad programme framework.
• The Partners in Parenting Education (PIPE) and DANCE tools were described by Family Nurses as particularly valuable in facilitating delivery of content around parenting and parent-child interactions.
• Family Nurses comments suggested that it may be worth considering whether materials around new relationships need any further development for the Scottish or UK context.

Introduction

4.1 FNP combines a manualised programme, containing detailed information materials and worksheets for each visit, with an approach that encourages Family Nurses to 'agenda match' to clients' needs at particular points in time. Thus while FNP includes fidelity 'stretch' goals around topic coverage in visits at different stages of the programme, within this Family Nurses are expected to 'flex' the programme to clients' specific needs.

4.2 This chapter briefly reviews the overall delivery of programme content during the infancy phase in NHS Lothian, Edinburgh. In addition to examining whether Family Nurses undertake visits in line with fidelity criteria, it also briefly considers clients' and Family Nurses' overall views of the programme content during this phase, and their perceptions of any topics that were particularly challenging.

Visit content figures

4.3 Fidelity 'stretch' goals around the suggested division of topic coverage are intended to reflect variation in the developmental needs of parents and infants at different stages. For example, the amount of time allocated to personal health is highest during pregnancy, while after the birth more time is allocated to maternal role. As shown in Table 4.1, the average time Family Nurses in NHS Lothian, Edinburgh recorded spending on different topics during infancy came very close to the fidelity 'stretch' goals for this period. The time recorded for personal health and life course development were within this range, while the amount of time spent on environmental health, maternal role and relationships with family and friends were all within 2 percentage points of the suggested range.

Table 4.1: Visit content figures, NHS Lothian, Edinburgh FNP site, infancy

Overall views of programme content during infancy

4.4 The FNP programme content during infancy is extremely wide ranging. Key topics Family Nurses mentioned covering included:

• Maternal role, child health and development (including how clients interact with their children, how they understand and meet their needs, developmental stages, weaning/feeding, routines, toilet training)
• Client health (including diet, exercise, smoking, drugs, family planning, post-natal depression)
• Environmental health (including safety within and outwith the home, which was described as an ongoing theme given the focus within the programme on preventing accidents)
• Health and other services (including accessing universal services, local groups, immunisations)
• Family and friends (including relationship dynamics and, where applicable, domestic violence)
• Life course (clients' goals around work and education and their goals for their children).

4.5 The variation in clients' individual needs over the course of infancy is underlined by their views on what aspects of the support provided by FNP they found most helpful over this period. Across the 13 clients interviewed for the evaluation, responses were wide-ranging, including: weaning/feeding; child health; safety; information about playing and interacting with their child; information about child development; support establishing routines with their child; support with applying to college; support dealing with relationship breakdown; and help around financial issues. However, in spite of this diversity, both Family Nurses and clients viewed the programme as matching well with client needs during infancy. Family Nurses described 'tweaking' or 'mixing and matching' the content to meet specific needs at the times they arose, while clients appeared happy that their own agendas could be incorporated within the broad programme framework for infancy:

Obviously she's got a pack to work to, but she has said to me before like, "is there anything you would like to work on first?" So she just gives me like the option, but it's usually what I want to talk about.

(Client 10)

4.6 Family Nurses also noted the benefits of the structured, long-term approach of FNP in terms of engaging clients with issues they might not feel ready to discuss at the start:

There's a lot of repetition in quite subtle ways in FNP that really work. So for example you can bring up - as the child's beginning to move around / become more independent - the idea of them going out to a mother and baby group, and they said, "No. No. No. No. I don't want to do that". And it comes up again in terms of looking at other resources, looking at how they spend their time (…) - and they still don't want to do it. (…) And then it comes up again, and then, hey presto, the child's 13, 14 months, running around, and they say, "You know, I think … I really think we should be getting out somewhere and going to something."

(Family Nurse 2)

4.7 In terms of tools Family Nurses felt had particularly facilitated delivery of the programme content during infancy, the Partners in Parenting Education (PIPE) activities were described as 'like gold dust' (Family Nurse 2) in terms of being able to show clients how to 'play, interact, support, balance, love their child' (Family Nurse 6). The DANCE tool for evaluating caregiver-child interactions was also praised by Family Nurses. While DANCE is only licensed for use within FNP, it is possible for other services to purchase PIPE. It may, therefore, be worth considering whether health or other professionals working with young mothers outwith FNP might benefit from PIPE training and materials.

Challenging topics

4.8 As in the second evaluation report, one view among clients and Family Nurses was that there were no topics that they found particularly difficult to discuss with each other. If anything, this view appeared even more dominant by the time clients were interviewed 12 months after their babies were born. In particular, where clients had previously indicated finding feelings of stress or depression difficult to discuss with their Family Nurse, they suggested they were now less uncomfortable with these issues. As discussed in Chapter 3, this appeared to reflect the further development of their relationship with their Family Nurse:

Probably at the start like when I started telling her I feel right down and depressed and everything like that, I probably felt like out of my comfort zone. Because she's here to … she's here to help and everything like that but I just … she's not family. And like I know I can trust her, but like that was really personal, so there was a doubt in the back of my head "what happens if she runs and then goes and tells somebody that's not meant to…like I dinnae want them to know." There was always that doubt. But I know I can trust her now. I've always been able to trust her, but like I know not to feel self conscious about it.

(Client 1)

4.9 Family Nurses did, however, identify a few topics they felt remained challenging to discuss with some clients, including:

• Relationships with partners - in particular, the impact that new relationships might have on clients' children. Although it was recognised that the FNP materials do cover relationships with new partners, one Family Nurse view was that they were insufficiently detailed. Family Nurses reported trying to approach the topic from the child's point of view, encouraging the client to think about what their baby experiences when a new partner enters their lives. As noted in Ormston et al (2012), the FNP National Unit (Scotland) has a remit to consider (in collaboration with colleagues in England and now Northern Ireland) where materials may require expanding or developing to meet specific local needs. Relationships with new patterns may be a topic worth further examination, alongside binge drinking and the content to be delivered when a child is being looked after, which were both identified as potential areas for further development in the second evaluation report (Ormston et al, 2012).
• Contraception - Although there was some evidence of discussions about contraception impacting on client behaviour (see Chapter 6), Family Nurses also described some clients reacting with 'ambivalence' to this topic - 'they don't want another baby, but they don't want to do anything else' (Family Nurse 6) - which could make it a challenging issue to tackle.

4.10 Family Nurses also commented on the fact that it could be challenging to encourage clients to 'focus' on goals around work or education during infancy, because they tended to be very focused on their child and their maternal role at that stage. They suggested that these 'life course development' issues became easier to engage clients with during the toddlerhood phase of the programme.