Evaluation of the Family Nurse Partnership Programme in NHS Lothian, Scotland: 4th Report - Toddlerhood

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' perceptions of the training they received to support them in their role remained highly positive. However, there were some ongoing queries about timing - in particular, whether the toddlerhood and DANCE training were delivered too early.
• Family Nurse comments on delivering the pregnancy phase of the programme to a second cohort suggested that there may be a need for some refresher training - particularly when Nurses are delivering the programme to one cohort at a time, with large gaps between when they first deliver a phase and when they next deliver it.
• Supervision continued to be viewed as 'absolutely pivotal'. Family Nurses commented on the role supervision had played in supporting and preparing them for graduating their first cohort of clients from the programme.
• Views on whether child protection supervisions were as useful as they could be and whether their frequency was appropriate remained mixed. The FNP National Unit (Scotland) was commissioning a review of child protection support requirements within FNP at the time of writing.
• At the time they were interviewed for this report, Family Nurses in the first NHS Lothian, Edinburgh FNP team had smaller caseloads due to their first cohort of clients starting to graduate, while recruitment of their second cohort was ongoing. While workloads were generally viewed as more manageable as a result, views of how manageable FNP workloads are more generally varied.
• The more staggered approach to recruitment adopted for the second cohort of clients in Lothian was felt to have avoided some of the workload pressures experienced as a result of 'front-loading' recruitment of the first cohort.

Introduction

8.1 This chapter moves from discussing views on the delivery of specific elements of the FNP programme to clients, to professional perspectives on those programme components intended to support FNP delivery more generally. In particular, it looks at views of Family Nurse training and of supervision - both of which are mandatory elements of FNP set out in the manual. It starts, however, with a broader discussion of the main achievements and challenges of the NHS Lothian, Edinburgh Family Nurse team in delivering the programme over the period from spring/summer 2012 (the time of their third evaluation interviews) to early 2013 (the time of their fourth and final evaluation interviews).

8.2 During this period, the first FNP team in NHS Lothian saw a majority of its first cohort of clients graduate from the programme and, from September 2012, began to recruit a new cohort. Although the focus of this evaluation is on delivery to the first cohort of FNP clients in Scotland, a key element of the team's experience of delivering the programme from late 2012 to early 2013 was recruiting the second cohort. Moreover, given NHS Lothian is the first Health Board in Scotland to recruit a second cohort, there may be learning from the team's experience of this for other sites who are considering, 'scaling up' their FNP service. This chapter therefore also explores the NHS Lothian, Edinburgh FNP team's perceptions of working with a new cohort, focusing particularly on areas where they feel they have learned from their experiences of delivering FNP to the first cohort of clients.

Achievements

8.3 As in previous evaluation reports, the NHS Lothian, Edinburgh Family Nurse team's perceptions of their key achievements over the period from mid-2012 to early 2013 focused on, first, clients' achievements within FNP and, second, perceived improvements in their own professional practice. Family Nurses' accounts of clients' achievements were sometimes framed with reference to graduation, which provided a focus and opportunity for reflecting on clients' 'journeys' and how far they had come since enrolling:

I think one of the nice bits has been … to reflect back on what their assessment of their parenting journey has been like and that's been really lovely. They themselves are able to see their own achievements, its not just all about "this is what you've done and haven't you done well?" They're able to look back and they recognise that themselves - how their child has grown, how they've grown - and that's probably been the nicest bit about it to be honest.

(Family Nurse 5)

8.4 Family Nurses in the first NHS Lothian, Edinburgh FNP team were unanimous in their view that delivering FNP had positively impacted on their own professional practice, from learning specific techniques (like motivational interviewing) to developing a more sophisticated understanding of 'respectful' ways of working with their client group. Nurses' reflections on their own developing professional practice were often discussed in the context of how they were able to approach the programme slightly differently with the second cohort of clients compared with the first cohort. For example, Family Nurses reported feeling more confident about 'agenda matching' with second cohort clients from a much earlier stage, even from the enrolment visit, as well as finding it easier to give prospective clients the information they need to make an informed decision about enrolling

I think it's easier to say what the programme's about, the successes of it, … to be honest about what the commitment is to the client, so that they know what they're getting themselves into. And in terms of the actual materials in early pregnancy, I don't feel as bound to do every single bit of every single session. I can mix and match in terms of where individual clients are at, and what I'll do more .. much much more of what we call the agenda-matching.

(Family Nurse 2)

8.5 The FNP National Lead for Scotland also commented on what she saw as the key achievements of the NHS Lothian, Edinburgh FNP team, which included:

• Maintaining a high level of fidelity to the Core Model Elements and 'stretch' goals of FNP
• Low levels of staff turnover (only one of the original team of Family Nurses has left since the start of the programme. In addition, the team also recruited a new Administrator after their original administrator left.)
• The level of involvement the NHS Lothian, Edinburgh FNP team have had in contributing to Scotland and UK-wide initiatives - including, for example, their supervisor acting as National Lead Supervisor for Scotland two days a week, one of their team leading training on DANCE (a tool for evaluating caregiver-child interactions) in Scotland, the team's contributions to UK-wide development of FNP materials, and the wider team's contributions to national conferences and events.
• Involving clients in "telling their story" - for example, through clients' attendance at FNP events and/or media involvement

Challenges

Workloads

8.6 As in all three previous evaluation reports, workload remained the main challenge to delivering FNP discussed by the NHS Lothian, Edinburgh FNP team. However, in general, views of Family Nurse workloads at the point in time at which they were interviewed for this fourth evaluation report were less negative than those previously discussed. It was suggested that although it remained 'quite a heavy workload' it had 'reduced greatly from what it was in the beginning', in part this was due to having fewer clients, less training to attend and greater familiarisation with the materials.

8.7 At the point of their fourth evaluation interviews (in early 2013), none of the Family Nurses in the original NHS Lothian team had a full caseload (25 clients per full-time equivalent Family Nurse is specified as the maximum permissible caseload within FNP). Their first cohort of clients had begun to graduate from FNP in April 2012, while recruitment of the second cohort began in September 2012 and runs for 12 months^[21]. While the NHS Lothian, Edinburgh FNP team remained busy (e.g. taking on an additional training role), they were also in a transitional phase where many of their first cohort clients had graduated but they were still in the process of recruiting a full new caseload.

8.8 However, although perceptions of workload were generally less negative, there nonetheless remained a range of opinions among the team about how manageable FNP workloads are in general. One view was that, whether or not the workload was more manageable in early 2013 than it had been at the start of the programme, there remained a mismatch within FNP between the volume of work it entails and the hours available in which to deliver it. Another, as described above, was that the workload had been heavier at the start of the programme but had eased gradually as training reduced and nurses became more familiar with delivering the programme. Finally, a third view was that workload on FNP simply fluctuated, from very busy to more manageable.

8.9 As discussed in the previous evaluation reports, Family Nurses reported a range of factors that either increased or helped to reduce or manage workloads at different points of the programme. Similar challenges were raised again in the team's final interviews, including:

• Requests for input and support from both other Scottish FNP sites and from the FNP National Unit (Scotland) - for example, it was estimated that around 100 potential Family Nurses who were thinking of applying for posts in NHS Lanarkshire had contacted the NHS Lothian, Edinburgh FNP team for advice.
• Travel time between clients - it was noted that because FNP clients often move during the two and a half years of the programme, by the time they reach the toddlerhood phase, any positive impact on travel time from initial 'zoning' of clients had significantly reduced.
• A perception that there was a 'huge amount' of record keeping required between FNP and other requirements (like GIRFEC ^[22] reporting and additional reports for meetings like Child Protection case conferences).
• The balance of different kinds of cases within individual Family Nurse's caseloads, with Family Nurses who reported high numbers of clients with social work involvement continuing to report that this was associated with considerable additional work.

8.10 In addition, it was noted that managing clients' transition out of FNP is time consuming. One view was that this had probably involved more work than the team initially anticipated - including carrying out handover meetings and joint visits with Public Health Nurses/Health Visitors, and making sure all the paperwork was tied together. Finally, it was noted that the NHS Lothian, Edinburgh FNP team set themselves very high standards and goals, and that sometimes they might need reminding to 'take their foot off the accelerator' in order to avoid consistently high workloads. Supervisor workloads within FNP were discussed in the previous evaluation report (Ormston and McConville, 2012).

8.11 The key factor that had helped reduce workloads since the previous evaluation interviews was the smaller caseloads resulting from the fact that the team were still in the process of recruiting their second cohort. The team were also adopting a slightly different strategy for recruiting the second cohort. As reported in Martin et al (2011), recruitment of the first FNP cohort took place over nine months and was 'front-loaded'. Every woman registered with NHS Lothian's system for tracking women through pregnancy (Maternity Trak) who was eligible (i.e. under 20, under 28 weeks pregnant and living in Edinburgh CHP) at the start of the recruitment period was offered FNP. As discussed in the first evaluation report, this was believed to have caused unsustainable workload pressures early on in delivery of FNP. For the second cohort, NHS Lothian had adopted a more staggered approach over a longer (12 month) period. The programme was offered to women who met eligibility criteria and became known to maternity services from the start of the recruitment period (rather than to all eligible women already registered at a set start point). The team felt this had meant that the start of recruitment to cohort two was more manageable - if anything, it was reported that there was something of a 'lag' at the start, where eligible women were becoming known to maternity services but were too early on in their pregnancy to approach about FNP. One view among the team was that there was a possibility this 'lag' at the start would mean that recruitment needed to accelerate towards the end of the twelve months to meet the target caseload. Given the various different paces and approaches to FNP recruitment now being employed across FNP sites, there may be a need for the FNP National Unit (Scotland) to review the impact of different strategies in terms of their impact on client take-up patterns and Nurse workloads.

8.12 Other factors contributing to workloads feeling more manageable included:

• The fact that Nurses were not undergoing long periods of training at the same time as recruiting the second cohort (as had been the case with the first cohort - see Martin et al, 2011)
• Improvements in Family Nurses' own strategies for managing their workloads, including clustering visits with clients living in the same area for the same day; more organised to-do lists/filing systems; and arranging visits for lunchtimes or picking clients up and carrying out visits on clients' way to their work. Although this latter strategy sometimes involved carrying out contacts in the car, which it was recognised was not ideal, one view was that it was the only way of avoiding evening working once clients started returning to work or college.

8.13 Asking other Family Nurses to cover visits had also been tried within the team, but was reported not to work as clients tended not to accept being visited by another team member with whom they did not have the same therapeutic relationship.

8.14 Team suggestions for improvements that might further help them manage their workloads included:

• Family Nurse supervisors and sites to consider options for more flexible working patterns (for example, a nine day fortnight - which it was reported was being tried in some FNP teams in England)
• reviewing and attempting to reduce the volume of record keeping, particularly where there were perceived to be duplications/overlaps (for example, in relation to the Public Health Nurses/Health Visitors handover report and GIRFEC reports), and
• further limiting the geographical spread of each Family Nurse's caseload (though as noted above, another view was that this would only be effective early on as the FNP client group tend to be highly mobile).

Database

8.15 Ultimately, a fully functional, user-friendly database will be key to the sustainability of the programme. As reported in previous evaluation reports (see Martin et al, 2011 and Ormston et al, 2012), there have been delays to the delivery of a database for FNP in Scotland which can both store data and, crucially, allow Supervisors easy access to reports that can inform reflective supervisions on both a team and one-to-one basis. For the first cohort, the NHS Lothian, Edinburgh FNP team used a database developed in-house to store data from their visits. While this was not viewed as a suitable long-term solution, because of the significant manual intervention required to develop meaningful reports, it did allow the data to be interrogated, used in supervision and to inform client outcomes. However, the perception of the NHS Lothian, Edinburgh FNP Team was that the time it took to get some of this information on client outcomes (e.g. on subsequent pregnancies) meant that potential issues were not always identified as early as they could have been.

8.16 Since the NHS Lothian, Edinburgh FNP team started recruiting the second cohort in September 2012, they have been using a new bespoke database. At the time of writing, however, it was not possible to generate system reports at local level, although detailed information could be extracted on their behalf by the FNP NU Information Team for static reports.

Training

The best training I've had in all my years of nursing has been the FNP training

(Family Nurse 4)

8.17 As discussed in previous evaluation reports, the NHS Lothian, Edinburgh FNP team's views of the training they had received to support them delivering FNP were extremely positive. However, at the time of their fourth interviews, the team found it very difficult to comment in any detail on the mandatory training received for the toddlerhood phase, as this had been completed more than two years previously. On further probing, recollection of the toddlerhood training content varied: some team members said they could not remember details, while others talked about specific elements, such as content around 'goodbyes' which they had found helpful when approaching graduation. One Family Nurse view was that there had been too big a gap between the toddlerhood training and when you deliver that part of the programme. However, another view was that by the time the team were delivering the toddlerhood phase they had more time to consolidate learning from across all the FNP training, so the fact the initial training was some time ago was less of an issue. Now the team were delivering the pregnancy phase of the programme to a new cohort, there was also a view that the team had forgotten some of their learning about that stage. This may suggest a need for some additional refresher training, particularly when sites are delivering to one cohort at a time (if sites move to a continuous model of delivery they are more likely to have clients in different phases of the programme at the same time, which may help Family Nurses to maintain skills and knowledge about different phases more easily).

8.18 Other suggestions for further improving Family Nurses' training experience included.

• More training being provided in Scotland
• More training on additional materials and tools that support FNP, like PIPE (Partners in Parenting Education), DANCE and ASQ
• More training on child protection.

8.19 At the time of writing, the majority of compulsory FNP training (with the exception of Communication and DANCE training) was still being delivered in England, by the Tavistock and Portman NHS Foundation Trust.^[23] However the FNP National Unit (Scotland) was working with Tavistock to develop capacity to deliver training in Scotland in the longer-term. In doing so, they were looking at models of FNP training outside the UK as well as the model adopted in England. For example, the US education programme involves more online learning and fewer face-to-face sessions. There was interest in understanding the international evidence on different models of training and how these support delivery of FNP in order to inform Scotland's own programme.

8.20 As noted above, further DANCE training is now being provided in Scotland (supported by a member of the NHS Lothian, Edinburgh FNP team). One view among the FNP team was that DANCE training had initially been provided too early in the programme. At that stage the children were too young for the Family Nurses to practice these skills and consolidate their learning. Appropriate timing for each of the elements of FNP training may be another issue for the FNP National Unit (Scotland) to consider as they move to delivering more training in Scotland.

Supervision

Supervision is absolutely pivotal in FNP ... all aspects of it. (…) I think we've got a fantastic team (…) who want to share, who want to learn, and are dead keen to share everything with each other. So ... it's not just the one-to-one. It's everything ... it's all-encompassing.

(Family Nurse 3)

8.21 Supervision is an integral and mandatory component of FNP. It continued to be highly valued by the NHS Lothian, Edinburgh FNP team, as illustrated by the quote above. The team discussed in particular the role that supervision had played in preparing them as nurses for their clients graduating from FNP. This was supported through team days and through sessions with both the Supervisor and the team Psychologist, where the team could talk about what graduation meant, their feelings about clients leaving FNP, and how they were going to manage the process in general and with individual clients.

8.22 Views of Child Protection supervisions, as discussed in previous evaluation reports (Ormston et al, 2012, Ormston and McConville, 2012), remained more mixed. One Family Nurse view was that they were less useful than other supervisions as they were mainly just checking what they had done in particular cases. Another was that they were useful but too frequent. At the time of writing, a national review of Child Protection support requirements within FNP was being commissioned, which will consider the most appropriate and robust model of supporting sites in this area.

8.23 Other suggestions for improvements to supervision again included a suggestion that it would be useful to look at programme materials in general rather than focusing on specific clients, in order to share learning about creative ways of using the materials.