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

Executive Summary

1. The Family Nurse Partnership (FNP) programme is a licensed preventative programme which aims to improve outcomes for young first time mothers and their children. It does this through a structured programme of home visits delivered by specially trained Family Nurses from pregnancy until the child is two years old.

2. The FNP programme was developed in the USA (where it is called the 'Nurse Family Partnership' programme) by Professor David Olds (University of Colorado, Denver). Based around a structured programme of home visits to the mother (and, after birth, the mother and child) delivered by trained Family Nurses, it is a preventative programme, aimed at first time mothers and their babies. The programme's goals are to improve pregnancy outcomes, the health, development and well-being of first time parents and their children, and families' economic self-sufficiency.

3. The evaluation of FNP in Scotland focuses on learning from the experience of implementing FNP in the first Scottish test site, based in NHS Lothian, Edinburgh in which 148 clients were initially recruited. It is not an experimental impact evaluation, but rather focuses on learning around how the programme works in a Scottish context.

4. This summary outlines the key findings from the fourth of four evaluation reports on the individual 'phases' of FNP. It focuses on learning from the delivery of the programme in NHS Lothian, Edinburgh in the toddlerhood phase (the period when clients' children are 12 to 24 months old). The report draws on quantitative data collected for all FNP clients and qualitative interviews with the initial NHS Lothian, Edinburgh FNP team, the FNP National Lead for Scotland, and a sub-sample of FNP clients and their nominated 'significant others'.

Is the programme being implemented as intended?

5. Throughout the toddlerhood phase FNP continued to be implemented in NHS Lothian, Edinburgh, with a high degree of fidelity to the Core Model Elements and fidelity 'stretch' goals.

• Attrition during toddlerhood remained below the fidelity 'stretch' goal (5%, compared with the 10% maximum suggested for that period).
• The fidelity 'stretch' goal of delivering at least 60% of selected visits to clients during toddlerhood was met for 83% of clients.
• The average time Family Nurses spent on different topics during toddlerhood came close to the division suggested in the 'stretch' goals.
• As in previous evaluation reports, Family Nurses were highly engaged with supervision which continued to be viewed as 'absolutely pivotal' to delivery of the programme.

How does the programme work in NHS Lothian, Edinburgh?

How do Nurses, clients and wider services respond to the programme?

6. Both clients and Family Nurses continued to respond very positively to the programme during the toddlerhood period. Comments from both indicated that Family Nurses were able to deliver materials that were well-matched to client expectations and needs during that phase, while also 'agenda matching' successfully to clients' specific circumstances.

7. Varying views were expressed about individual client 'readiness' to graduate from FNP when the programme ends (shortly after the client's child turns two years-old). However, overall, Family Nurses reported that the way the programme had built on clients' strengths and prepared them for graduating meant that clients had been more confident about the programme ending than Family Nurses had anticipated at the outset.

8. Clients' views about graduating from FNP fell into three main categories: those who felt completely ready to leave and move on with their lives; those who had some reservations about graduating, but understood why the programme had to end; and those who reported not feeling quite ready to leave or who still thought they needed support.

9. The views of stakeholders outside FNP were discussed in the third evaluation report. The NHS Lothian, Edinburgh FNP team felt that by the time their first cohort of clients were graduating from the programme, working relationships with other services in general had improved as these services became more familiar with FNP and their ways of working.

What factors support or inhibit delivery of the programme?

10. As in previous reports, the therapeutic relationship between clients and Family Nurses was identified by both clients and Family Nurses as key to the success of the programme in general, to Nurses' ability to meet fidelity around numbers of visits, and to both clients' and Nurses' ability to raise and discuss 'difficult' topics (including child protection concerns) in a frank and honest manner.

11. The NHS Lothian, Edinburgh FNP team identified various factors they believed had supported successful client transitions from FNP to universal services. In particular, they commented on:

• The structure of the programme itself and the fact that graduation is discussed from very early on and supported by more specific materials and activities during the toddlerhood phase, and
• Joint visits with Public Health Nurses/Health Visitors prior to clients graduating from the programme (which were seen as important in supporting ongoing engagement with universal services after FNP comes to an end).

12. Where clients were experiencing a crisis of some kind at the time they needed to graduate, some Family Nurses reported wishing they could keep them in the programme a little longer, although accepted that this was not how FNP works. The NHS Lothian, Edinburgh FNP Team also reported some challenges around working with Public Health Nurses/Health Visitors at transition, particularly relating to client perceptions that Public Health Nurses/Health Visitors were making critical comments at joint visits that might make it hard for clients to engage with Health Visiting subsequently. The team had agreed to meet with Public Health Nurses/Health Visitors in advance of the joint visit to discuss the client's background in order to try and avoid such issues arising.

13. Early and ongoing communication with wider services about what FNP is and what it does was considered essential in supporting FNP delivery and expansion in a site. FNP's engagement with other services was also viewed as key to supporting clients' successful transitions from the programme. As noted above, the NHS Lothian, Edinburgh FNP team felt that working relations with other services had improved since the start of the programme. However, they also reported some ongoing challenges relating to differences in philosophy between FNP and other services, particularly around what it means to implement a 'strengths-based' approach to working with young parents. There was also a view that, while the team and other services had worked hard to put services in place for clients as they moved out of FNP, there was something of a gap around formal services in Edinburgh for young parents of two year-olds.

14. As noted above, supervision continued to be viewed as key to supporting nurses to deliver the programme (though views on whether child protection supervisions were as useful as they could be and whether their frequency was appropriate remained mixed). The quality of FNP training also continued to be praised. However, the team's experiences of applying their formal training also suggest that greater consideration may need to be given to the timing of training for later phases of the programme (e.g. there was a suggestion that the toddlerhood and DANCE training components may have been delivered too early). In future, there may also be a need to consider whether and what kinds of refresher training might be required, particularly where there are long gaps between the initial delivery of a particular phase of FNP and when it is next delivered by a team.

15. At the time the NHS Lothian, Edinburgh, FNP team were interviewed for this report, workloads were generally viewed as more manageable, largely because team members had smaller caseloads. At the time, they were moving from the testing stage of the programme to small scale expansion and were in the process of building up again to a full caseload of second cohort clients. The more staggered approach taken to recruiting this second cohort was felt to have avoided some of the workload pressures experienced as a result of 'front-loading' recruitment of the first cohort. However, views within the team around how manageable FNP workloads are more generally remained mixed.

What are the implications for future community nursing practice?

16. Family Nurses and other stakeholders interviewed for this report recognised that developing future community nursing practice in general involves complex issues and that FNP can only contribute to discussions about future direction if considered alongside other services. However, similar themes to those discussed in earlier reports were raised in relation to potential shared learning with wider services, 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.

17. The NHS Lothian, Edinburgh FNP team also suggested that there may be a need for further investigation of how FNP can help support other nursing colleagues, particularly Public Health Nurses/Health Visitors who were perceived to have a difficult job which was not always fully recognised.

What is the potential for FNP to impact on short, medium and long-term outcomes relevant to Scotland?

18. As noted above, the Evaluation of FNP in NHS Lothian, Scotland is not a formal impact evaluation and cannot conclusively establish causal links between FNP and particular outcomes. The 'Building Blocks' Randomised Controlled Trial in England will provide this evidence within a UK context. However, interviews with Family Nurses and clients in NHS Lothian, Edinburgh continue to highlight a wide range of areas where participation in FNP was perceived to have a positive impact in supporting clients to:

• Become more confident parents
• Manage their child's behaviour and routines more effectively
• Manage routine development activities - like potty training - more confidently
• Improve their toddler's diets
• Keep their child safe as they grow
• Manage their own mental and emotional health
• Broaden their horizons in relation to work and education.

19. However, FNP works alongside existing services and the evaluation also identified various external factors that might impact on FNP's ability to deliver these outcomes - such as the availability and perceived suitability of services specifically for young parents, or client concerns about affordable childcare to enable them to work. Thus while FNP appears to have the potential to have a range of positive impacts on short, medium and long-term outcomes, its ability to impact on these in practice will depend not only on the delivery of FNP itself, but also how it interacts with and is supported by the wider service landscape.