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

9 Learning from Implementing FNP in Lothian

Key findings

• Early involvement of key stakeholders from universal health services and wider services was viewed as key to successful implementation of FNP in a new area.
• In thinking about FNP expansion, Health Boards may need to consider not only quantitative data on site performance, but also qualitative evidence about team readiness, universal service responses, and senior stakeholder commitment to FNP.
• There may be a need for future work at a national level around supporting Health Boards to plan effectively for expansion. In particular, further guidance may be needed on how to estimate things like recruitment rates and likely numbers of clients at different stages of the programme for several years into the future.
• Expanding an FNP team brings both challenges and opportunities and requires careful planning - e.g. around timing of new team members starting and ensuring that new and existing team members integrate effectively.
• The successes of the NHS Lothian, Edinburgh FNP team suggest areas of potential learning to be shared with wider services - around supervision, nurse education, and managing risk within a strength-based framework. However, developing other services involves complex issues and FNP is only one contributor to discussions about this.

Introduction

9.1 Previous chapters have focused on the detail of delivery of FNP to the first Scottish cohort of clients, in NHS Lothian, Edinburgh and have shown that throughout the toddlerhood phase, FNP continued to be implemented with a high degree of fidelity to the Core Model Elements and Fidelity 'stretch' goals. This final chapter focuses on broader, more strategic level learning from the experience of implementing FNP in Lothian, both for other FNP sites and potential shared learning for wider services. Again, it focuses on new themes raised in interviews with the NHS Lothian, Edinburgh FNP team and the FNP National Lead for Scotland in the fourth round of interviews with these professionals.

Learning for FNP roll-out in Scotland

Supporting sites with introducing and expanding FNP

9.2 The experience of Lothian as the first site to introduce FNP had contributed to the FNP National Unit's (Scotland) considerations on what support new sites might need in terms of organisational readiness to start the programme. In particular, the National Unit was clear on the importance of involving key stakeholders from universal health services and wider services who might come into contact with FNP clients at a very early stage of preparing for delivering the programme. Working with these stakeholders to develop understanding of a strengths-based approach was seen as key to successful implementation of FNP in a Scottish context.

9.3 In terms of supporting Health Boards with determining if and when they might wish to expand their delivery of FNP - to recruiting a second cohort, or to permanence, where every eligible woman in a given area is offered the programme - data on performance against fidelity was seen as only one criteria for judging organisational and team wellbeing. Open dialogue with the team, psychologist and (especially) the supervisor is also required, alongside reviewing how universal services are reacting to FNP and evidence of commitment to the programme at a senior level in terms of funding and leadership.

9.4 In relation to planning for permanence, it was noted that there is no simple formula for working out what size of FNP team is required to enable a Board to offer the programme to every eligible woman. One suggestion was that, as learning increases across Scotland, the National Unit provide guidance to sites (especially supervisors) drawing on experience across sites. This guidance would help sites to think through annual recruitment rates, how many clients the Board is likely to get month by month over a period of years, the different stages that different clients are likely to be at concurrently, and therefore how many Family Nurses and Supervisors are needed. Other factors that may need to be considered in planning expansion include how best to schedule recruitment and training in relation to each other and which stakeholders to involve in early discussions about the programme.

9.5 Finally, in terms of advice to other areas, it was suggested that if recruitment does close for a period (as it did in Lothian after the first nine-month recruitment of cohort one), it may be better to continue to collect local figures on the number of potentially, eligible mothers coming through maternity services month-by-month. It was suggested that it is then easier to review and monitor these figures when considering expansion, rather than trying to compile them retrospectively.

Recruiting and developing staff

9.6 The model of recruitment for Family Nurses and supervisors adopted initially in Lothian has now been used for recruiting other FNP teams in Scotland, and was viewed as a 'tried and tested' model - in particular, the involvement of clients in interviews.

9.7 The development model used with the second supervisor in the NHS Lothian, Edinburgh team, whereby a Family Nurse acted up to supervisor on a part-time basis initially and was mentored by the original supervisor, was also seen as an effective model that might be emulated by other UK sites.

9.8 The NHS Lothian, Edinburgh FNP team has expanded since the start of the programme from a team of one supervisor and six nurses to a team with two supervisors and eight nurses. The team reflected on both the opportunities and challenges associated with expanding an FNP team. It was suggested that the new team members had been able to learn from the original team's expertise while the original team members were able to learn from the new team's more recent experiences of FNP mandatory training. At the same time, it was suggested that, where possible, having at least two new nurses start together worked better so that new team members had each other for moral support, since they could sometimes be daunted by the level of expertise of more experienced team members.

Potential learning for wider services

9.9 Earlier evaluation reports have discussed stakeholder perceptions of some of the areas in which FNP may be able to share learning with wider NHS and non-NHS services. Similar themes were raised again in the fourth wave of evaluation interviews, including:

• Learning about how to support nurses working in intensive roles, particularly through developing models of supervision that facilitate effective reflection and help nurses feel supported when stretched
• How different models of education might help nurses feel equipped for their roles or for working with specific client groups, and
• Learning about how to manage risk but within a client-focused, strength-based framework.

9.10 It was acknowledged that developing other services involves complex issues and FNP can only contribute to discussions about future direction, alongside others. Family Nurses in the first NHS Lothian, Edinburgh team suggested that there may be further ways of looking at how FNP can help support Public Health Nursing/Health Visiting colleagues in particular, as they face challenges which Family Nurses felt are not always recognised:

There's a lot of people, you know, working very hard in … related areas and if we can work together in a way to structure that in a more focused way we'd probably find that we get a lot better outcomes for not just our clients but all babies and children across Lothian.

(Family Nurse 4)