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

5 Parenting, Child Health and Development

Key questions

• Is there any evidence that FNP
  • Engenders positive parenting practices and bonding?
  • Improves knowledge on how infant health can be promoted and that any such knowledge is translated into behaviour?
  • Leads to improved child health and development?
• Is there any evidence that the client knows about key hazards and engages in practices to keep child safe?
• Is there any evidence to indicate that infants meet developmental milestones?

Key findings

• Family Nurses believed that the programme continued to have a positive impact on clients; that they had developed skills as competent, confident parents.
• Clients felt their Family Nurses had supported both bonding and child development by sharing practical ideas and materials for activities they could do with their child to support this.
• Although clients did not always hold off weaning until the recommended 6 months, client and Family Nurse accounts indicate that some were delaying weaning for longer as a result of input from FNP.
• 'Intergenerational influences' on clients' behaviour, particularly in relation to weaning, were cited as a potential challenge by Family Nurses. Approaches to addressing this included 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.
• Ninety percent of clients engaged with FNP at the end of the infancy phase were up to date with their child's vaccinations at 12 months. Qualitative interviews indicated that Family Nurses could play a role in reassuring clients about getting their child immunised.
• Clients reported that FNP had helped them to assess their home for safety from the perspective of their child and had provided practical support in accessing grants to buy safety equipment that they might not otherwise have purchased.

Introduction

5.1 The previous chapter reviewed the overall delivery of programme content to clients during infancy. In this and the following chapter, we focus on specific topics relating to parenting, child health and development (Chapter 5) and maternal health, wellbeing and future plans (Chapter 6). In addition to examining the perceived impact of the programme, these chapters also explore Family Nurse and client perspectives on what has worked well or less well in delivering content on these topics.

5.2 It is important to keep in mind when reading these chapters that the evaluation is not a formal impact evaluation. Further research (such as the Building Blocks RCT referred to in Chapter 2) is required to establish the nature and scale of the impacts FNP is having in a UK context. However, the findings discussed here indicate the potential for FNP in Scotland to impact on client outcomes, based on participants' accounts.

Bonding, attachment and parenting practice

5.3 Family Nurses believed that the programme continued to have a positive impact on parenting practice in the infancy period, acting as a support mechanism through the 'minefield' of parenting. They reported seeing their clients develop skills, self-belief and confidence as parents over the course of infancy. They felt clients had become more reflective about parenting, better able to consider the challenges as well as recognising what they were doing well. As noted in Chapter 4, Family Nurses mentioned specific tools (PIPE and DANCE) they had found particularly useful in helping them to explore parenting practice and the relationship between parent and child.

Bonding and attachment

5.4 Promoting parent-child bonding and attachment is a key aim of FNP. Clients again mentioned discussing a range of activities to support attachment with their Family Nurse, including hugging, talking, singing to their child, and playing with them.

5.5 As described in the second evaluation report (Ormston et al, 2012), it was not always clear whether clients felt they had a stronger bond with their child as a result of the support received from FNP. Indeed, one client view was that the information they had received around bonding and attachment was unnecessary as they already had a good bond with their child. However, clients did mention their Family Nurses providing them with additional ideas (for games) and materials (e.g. play mats) to facilitate parent-child play, which they recognised as a good way of bonding with their child. There was also evidence that they felt they had a better understanding of what their child is communicating to them as a result of information their Family Nurse had given them.

I'd like to think I was close to (baby) anyway, but, you know, my desire was always to be a mum, and she knew that, so like she knew that there was no problems with bonding.

(Client 8)

She does show me a couple o' things to do. … She was showing me ... how to sort o' ... like play with the toys that he's playing with, so that you can do it together and sort o' let him explore sort o' thing.

(Client 2)

She gave me like a leaflet on about how to recognise what cries (are) for what and things, so that was helpful.

(Client 9)

Routines

5.6 'Routines' was a recurrent theme throughout the infancy stage. Clients reported having detailed discussions with their Family Nurses around bedtime and sleeping routines in particular. They described positive impacts from these conversations in helping them establish sleeping routines, which they saw as benefiting both themselves ('(I) get a better sleep myself') and their babies. One view was that discussions around routines were the most useful aspect of FNP during infancy. Even where clients felt that information from their Family Nurses had not been the central factor in establishing a routine, they were nonetheless pleased to have had options to try when they were struggling with this.

He sleeps about 16 hours a night, but, like I said, he's always been wi' a good routine. But that's 'cos the Family Nurse Partnership showed me how to put him in a routine, like doing the same things every night - ... bath time, read a book, bottle, bed. And it's been the same since he was about 4 months old. And she taught me about that.

(Client 8)

It was just helpful to try things, 'cos I thought this is never going to be ending and it was just nice to have options to try them, so that was good.

(Client 13)

Infant feeding

Breastfeeding

5.7 Of the 130 babies whose mothers were still active in the programme at 6 months after birth, 9 (7%) were still being breastfed at 6 months. As reported in the second evaluation report (Ormston et al, 2012), 13% of NHS Lothian, Edinburgh FNP clients were still breastfeeding 6 weeks after birth (7% exclusively). It is inappropriate to draw conclusions about FNP breastfeeding rates from the small number of clients in the first Scottish cohort - the Building Blocks trial in England, alongside further data from Scottish sites, will be required before any robust conclusions can be drawn. However, the proportion of the first NHS Lothian, Edinburgh FNP cohort still breastfeeding at 6 months (7%) was similar to that identified by the 2005 Growing Up in Scotland survey for mothers under 20 (8% - see Scottish Government, 2007).

5.8 Challenges around supporting young mothers to breastfeed were discussed in some detail in the second evaluation report (Ormston et al, 2012). One Family Nurse suggestion at the time was for a volunteer breastfeeding scheme to support young mothers by linking them with other mothers who had breastfed. Since the second evaluation interviews, the NHS Lothian, Edinburgh Family Nurse team had started working with NHS Lothian's Infancy Feeding Team to support a group of FNP clients who had breastfed to become 'breastfeeding buddies', able to support other younger (or older) mothers with breastfeeding. This highlights the potential for FNP to support both co-production of services with young parents, and capacity building for wider support to meet the needs of other young parents in their area.

Weaning

5.9 Clients reported that the Family Nurses provided them with lots of information about weaning. This included:

• Recognising the behaviours in your baby that can indicate it is time to start weaning
• Telling them about weaning classes
• Explaining how to introduce foods, using finger foods and letting them try little bits of different foods
• Advice about blending or mushing up foods rather than giving them 'baby food' as it is cheaper and generally healthier
• Providing recipe books, and
• Information on what food children should and should not eat at different ages.

5.10 Family Nurses reported bringing weaning up from early in infancy, providing factual information but also exploring clients' family cultures around weaning. One approach was to explain the history of weaning so that clients and their families understand why people have done it differently at certain points in history and how new research has influenced advice. As discussed in Chapter 3, this was seen as a particularly useful approach when family members might be giving clients different advice about when to wean. While weaning was not described as a challenging topic to raise with clients, one Family Nurse view was that the FNP materials on weaning could be expanded, for example by developing more visual tools to help clients better understand this stage.

5.11 Evidence for the impact of Family Nurses on the age at which clients weaned their children was mixed. Panel clients reported weaning their babies from 2½ months to 6 or 7 months. Where they had weaned their babies earlier than 6 months, their reasons centred around the belief that they had very hungry babies and concern that their child was not getting enough food. There were also examples where panel clients appeared to have followed advice around weaning from other family members rather than their Family Nurses. 'Intergenerational influences' were viewed by Family Nurses as a significant challenge in relation to this topic in particular.

She did advise me to wait till he was 6 months, but I couldnae do it. He was starving. (...) Like my mum said as well, me and my brother were on solids by about 3 months, so (…) There's nothing wrong with it.

(Client 6)

5.12 However, there were also examples where the discussions clients had with their Family Nurses' appeared to have made a difference - where clients had held off weaning for longer than they would have without FNP's input.

He's like a real hungry baby and I like thought he needed it about 4 months, and she was asking me you 'could try and hold off as long as possible and try like the hungry baby milk?' So I tried, sort of managed to hold off 'til about 5 and a half months, which was actually quite good I think.

(Client 10)

5.13 This was reflected in comments from Family Nurses that even if clients did not wait right up to 6 months to wean, they were able to 'stretch' them to hold off for longer.

Baby health and safety

5.14 Baby and child health and safety is discussed regularly in FNP, from pregnancy onwards, and continued to feature heavily in client and Family Nurse accounts of the programme in infancy. In addition to general child health issues (such as minor ailments), key topics discussed in interviews were immunisations and safety in the home environment.

Immunisations

5.15 The UK Childhood Immunisation Schedule recommends children should receive three doses of diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type b (Hib) vaccine (the 'five-in-one' vaccine) at two, three and four months of age, two doses of Meningitis C (MenC) vaccine at three and four months of age, and two doses of Pneumococcal (PCV) at two and four months of age. Children should then receive a further dose of Hib and MenC (given as the Hib/MenC booster vaccine), the PCV booster, and one dose of Measles, Mumps and Rubella (MMR) at 12 to 13 months of age.

5.16 Of the 125 babies in the first NHS Lothian, Edinburgh FNP cohort for whom data was recorded, 90% (113) were up to date with all their child's immunisations at 12 months.^[12] Comparison figures for all children of young mothers across Scotland were not available. The target of the national immunisation programme in Scotland is for 95% of children to complete courses of the following childhood immunisations by 24 months of age (Health Protection Scotland).^[13]

5.17 Clients described Family Nurses providing them with information about what the injections were for and why they were important, as well as explaining the process so they knew what to expect (for example, that their child might cry or feel a little unwell afterwards). For clients who were apprehensive or unsure about getting their child immunised (for example, as a result of well-publicised but discredited claims about links between the MMR vaccination and autism), the Family Nurse was able to provide much needed reassurance.

She was just saying like, any research that's been done on it, it's like never really been proven, like, for what they're saying it can cause or something. So that made me feel better about that, 'cos I was quite scared about that actually.

(Client 13)

Safety in the home environment

5.18 As noted in the second evaluation report, some clients were perceived by Family Nurses to already be very knowledgeable about keeping their child safe and hazards. However, Nurses reported that clients continued to respond well to topics around the home environment and safety, exploring potential new dangers in infancy as their children reached different developmental stages. Both clients and Family Nurses commented on the usefulness of an activity where the client crawls on the floor to see their home from their child's point of view to try and spot potential hazards. Family Nurses had also helped their clients access financial support to buy safety equipment, without which clients indicated that they might not have been able to purchase equipment like safety gates, fire guards, wall socket covers, cupboard and drawer locks, door stoppers, protective corners for tables and radiator covers when they were needed. Clients' comments thus suggest that FNP has the potential to impact on keeping children safe in terms of both practical support and client knowledge and awareness.

I think the biggest thing that ... the Family Nurse Partnership's taught me was you need to change your surroundings for your child, especially when they're starting to walk and crawl. My living room was laid out differently when (baby) came. I didn't have the fireguard, didn't have the stair-gate up on my kitchen door. All that was a necessity and the Family Nurse Partnership were the ones that got me the stair-gate and the fireguard.

(Client 6)

I probably wouldn't have the safety gates by now, you know what I mean?

(Client 15)

Baby development

5.19 In terms of the perceived impact of FNP on client understanding of child development, Family Nurses believed clients appreciated having someone with whom they had a strong relationship that they could regularly ask questions of, particularly as their children hit new developmental stages. They felt that clients had a better understanding of child development as a result.

… they've said to me that they've felt that they've had a greater understanding than they possibly would have had, had we not been there with them.

(Family Nurse 3)

5.20 Clients described their Family Nurses explaining how the brain develops and showing them different activities they could do with their child to help their brains 'grow better and better'. For example:

• Talking to them to support speech development - although one client view was that they would have done this anyway, another was that they talked to their child more as a result of their Family Nurse's encouragement:

I felt stupid. You know, like in the first couple o' weeks, I felt stupid for saying to (baby), "OK, darling. We're gonna go and get your nappy changed now", because (…) like she wasn't even smiling at me. (…) And then like I think for a little while I just sort of stopped talking to her, 'cos I was like, "Oh, she's not showing any like recognition of my voice, and she's not like showing me, you know, like any love back", and (Family Nurse)'s like, "No. Coz all this is gonna keep adding, and" (…) and then like .. like she sort of explained it a bit more to me, and .. so I just started blabbing away like anything I was doing: "OK. Mummy's just putting on her socks" and "Mummy's gonna make a cup o' tea now" (…) And I think that's what made her .. like she's such a vocal wee thing now. (…) I think that me just talking to her, like being told to talk to her, has really really helped.

(Client 3)

• Reading to their child - clients reported getting their child a library card at their Family Nurse's suggestion, and being given books by their Family Nurse to read with their child.

• Playing with their child - clients reported discovering how to change their children's toys around to ensure they remain stimulated and to support physical development(e.g. moving toys just out of reach to encourage babies to learn to crawl), and learning about the potentially negative effects of watching TV during infancy from their Family Nurses.