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

3 Relationships

Key questions

• Does the programme meet the fidelity targets for attrition?
• Do the Family Nurses carry out the intended number of visits?
• How feasible is the visiting schedule?
• How involved are fathers in the FNP process/visits?
• Is the FNP seen to engender fathers' involvement?

Key findings

• Client retention for the first NHS Lothian, Edinburgh FNP cohort was very high - cumulative retention by the end of the toddlerhood phase was 81%. Attrition during toddlerhood, (5%) was below the 10% maximum suggested by the fidelity 'stretch' goal.
• The fidelity 'stretch' goal for delivering at least 60% of the expected number of visits during toddlerhood was met for 83% of clients. The average (mean) proportion of expected visits delivered across all clients was 75%.
• While feelings about individual clients graduating from the programme varied, one Family Nurse view was that overall clients had been more confident about leaving the programme than Family Nurses had anticipated at the outset. This was attributed to the systematic way in which FNP prepares clients for graduation and the ways in which the programme builds and affirms clients' strengths.
• 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.
• The therapeutic relationship they had with clients was believed by Family Nurses to have contributed to more positive experiences and in some cases outcomes for those clients involved in child protection processes.
• The data collected for FNP makes it difficult to distinguish how involved fathers in particular are in the FNP process/visits. In general, significant others interviewed for the evaluation reported that they attended fewer visits as the programme progressed. However, those significant others interviewed for the evaluation gave examples where they felt FNP had been beneficial both for themselves and for clients.

Introduction

3.1 As described in Olds (2006), an 'empathetic and trusting relationship with the mother and other family members' is key to FNP's approach. Family Nurses aim to build 'therapeutic relationships' with their clients, both to model the positive relationships they hope clients will build with their children and to support clients' ongoing engagement with the programme. The holistic focus of FNP - exploring the social, emotional and economic context of clients' lives - also means that Family Nurses may seek to involve other family members, with the aim of enhancing the wider support available to both mother and baby. This Chapter explores how these relationships develop during toddlerhood and how they might promote positive outcomes for clients. However, first it summarises quantitative data on client retention and attrition and the level of contact between Family Nurses and clients in NHS Lothian, Edinburgh.

Client retention and attrition

3.2 Evidence from the US indicates that to deliver FNP with fidelity and to obtain the expected outcomes, cumulative attrition from the programme should not be greater than 40% through to the child's second birthday. In addition, attrition should not be greater than:

• 10% during pregnancy
• 20% during infancy and
• 10% during the toddler phase.

3.3 These are fidelity 'stretch' goals (see Chapter 1 for definition).

3.4 Table 3.1 shows attrition and retention during the toddlerhood phases of FNP in NHS Lothian, Edinburgh. Programme attrition during toddlerhood was 5%. Cumulative retention for the first Scottish FNP cohort across the whole programme was 81%.

Table 3.1: Attrition and retention, NHS Lothian, Edinburgh FNP test site [7]

	Pregnancy phase	Infancy phase	Toddlerhood phase
Total number of clients receiving this phase	148	145	128
Fidelity 'stretch' goal for maximum attrition for phase	10%	20%	10%
Attrition during phase	3% (4/148)	11% (17/148)	5% (8/148)
Cumulative attrition by end of phase	3% (4/148)	14% (20/148)	19% (28/148)
Cumulative retention at end of phase	97% (144/148)	86% (128/148)	81% (120/148)

3.5 The attrition figures presented for infancy in Table 3.1 have been corrected since the third evaluation report (Ormston and McConville 2012), which stated that infancy attrition was 12%. The correct attrition rate for infancy is 11%.^[8]

3.6 The second and third evaluation reports (Ormston et al, 2012, Ormston and McConville 2012) included discussion of the perceived reasons for the low attrition rates during pregnancy and infancy, as well as reasons for leaving or becoming inactive where this had occurred. An additional (or more common) potential trigger for becoming inactive during toddlerhood related to the challenges of fitting in FNP visits alongside more numerous changes in a clients life.

New job, new house, new everything and it was just too much ... it was just that. It wasn't right for her, which was fine.

(Family Nurse 4)

Level of contact between clients and Family Nurses

3.7 The Core Model Elements for FNP include a visit schedule, which specifies the frequency and timing of home visits. The fidelity 'stretch' goals then include goals for the proportion of scheduled visits to be achieved for all clients at different stages of the programme (referred to in the FNP Management manual as 'dosage') as follows:

• 80% or more of expected visits during pregnancy
• 65% or more of expected visits during infancy
• 60% or more of expected visits during toddlerhood.

3.8 The visit schedule varies depending on the stage of the programme. The aim is for clients to receive weekly visits for the first four weeks after enrolment, and then fortnightly visits until the baby is born. After the birth, clients are visited weekly for the first six weeks, then fortnightly until the child is aged 21 months and monthly for the last three months of the programme. Family Nurses complete a 'Home Visit Encounter Form' after each visit, which sites use to monitor the number, length and content of visits.

3.9 The NHS Lothian, Edinburgh FNP site met the fidelity 'stretch' goal (60% or more of scheduled visits) during toddlerhood for 83% (106/128) of clients who were still participating at the start of that phase. During pregnancy the fidelity 'stretch' goal (80% or more of schedule visits) was met for 52% of clients and during infancy (65% or more of scheduled visits) it was met for 55%.

3.10 The average (mean) dosage during toddlerhood was 75%, compared to 79% in pregnancy and 65% in infancy^[9].

3.11 Family Nurses reported that they had expected to find meeting fidelity around the visit schedule in toddlerhood more challenging than it had been in practice. By this stage, clients often had a lot more going on, for example getting a job or continuing with their education. In fact, where FNP was successful in helping clients to meet goals around work and education, this often meant that Family Nurses found it more challenging to fit their visits into clients' busy schedules.

And it was quite interesting where you know you are in a situation where (…) pretty much the programme has allowed them to help meet their outcomes, yet you're struggling to meet your fidelity because they've met their outcomes

(Family Nurse 1)

3.12 However, in spite of these challenges, Family Nurses thought they had either met or were close to meeting fidelity on visit numbers with most clients during toddlerhood. The quality of the relationship between the Family Nurse and clients was again viewed as a key factor in whether or not Family Nurses met fidelity (see discussion in previous evaluation reports). Other enablers and barriers to meeting the visiting schedule during toddlerhood were also similar to those discussed in the infancy and pregnancy reports. Key enablers included Nurse flexibility around appointment times and client motivation. Challenges again divided into client-related factors - like availability, occasionally forgetting, other issues in their lives making keeping appointments difficult - and programme or nurse-related factors, such as Nurses taking on additional responsibilities involving delivering or attending additional training.

3.13 Family Nurses also noted that cancelled or missed visits in the final months can lead to prolonging the programme and Family Nurses having to deliver 'last visits' after the 24 month mark. A suggestion for the future was that when clients drop down to monthly visits, Family Nurses should start to arrange final visits with clients further in advance in order to provide some leeway if there is a need to re-schedule.

3.14 Clients graduate from the FNP programme when their child is 24 months old (plus or minus two weeks). While contact between Family Nurses and clients can occur post graduation, this is part of clients' transition to universal services rather than a continuation of the programme. Family Nurses in NHS Lothian, Edinburgh reported that in general their contact with clients post graduation has been limited to the occasional text message, with clients updating their Family Nurse on how they are doing. There had also been some contact when clients were unsure who to speak to when their Public Health Nurses/Health Visitor was off sick or had left the Health Visiting team. Instances of Family Nurses meeting up with their client post graduation were reported to be rare and one-off. These instances were sometime initiated by the client - for example, inviting the Family Nurse round to see a new house.

Nature and impact of the client-Family Nurse relationship

3.15 In general, Family Nurses reported that their therapeutic relationships with clients had grown and strengthened further during toddlerhood. Again, the factors Family Nurses and clients associated with developing effective relationships were very similar to each other, and echoed those discussed in previous reports - trust, level of contact, a non-judgmental approach, and consistency of having the same Family Nurse throughout. Where contact was less regular, Family Nurses tended to view the therapeutic relationship as less strong.

…the relationship seemed very effective and very deep [with some clients, but with others - who I (…) struggled… with contact - it was less so.

(Family Nurse 5)

Perceived impact of client-Family Nurse relationship in child protection cases

3.16 Perceptions of the ways in which the client-Family Nurse relationship could help when dealing with clients where there is a child protection concern were discussed in the previous evaluation report (Ormston and McConville, 2012). In their fourth evaluation interviews, the NHS Lothian, Edinburgh FNP team again reflected on this area. They felt that their therapeutic relationship with clients could help improve client experiences of the child protection process, general perceptions of Social Work involvement (and sometimes the results of this process) by:

• Ensuring that initial concerns are raised by someone who knows them rather than another professional they may not have met before
• Making it possible to discuss concerns in a way that might be perceived by the client as less judgmental
• Being able to explain the process to clients and help to break down any resistance to Social Work involvement, and
• Being able to draw on their depth of knowledge of the client's circumstances to give a wider context in meetings with other professionals, highlighting the client's strengths while also acknowledging and discussing concerns. In some cases, this was felt by the FNP team to have led to better outcomes for the client.

I think FNP has allowed them to see a lot of this as support, and I have one family who very much felt that, "… these people have helped me", and began to work along with the children's panel and eventually came off the register.

(Family Nurse 3)

3.17 However, as discussed in earlier evaluation reports, the child protection process can also sometimes pose a challenge to Family Nurses' relationships with clients. In some instances, this may relate to additional roles Family Nurses might have in the process. For example, one Family Nurse recounted what happened when she became the chair of a planning meeting.

That became quite difficult because I was in the role of the family nurse at the same point chairing this quite formal child planning meeting, and I think one of my clients struggled with that. (…) I think my relationship with her improved (subsequently) (…) because I could go back to being her Family Nurse.

(Family Nurse 5)

This suggests a need to consider carefully how Family Nurses can best contribute to child protection proceedings, and how specific roles might impact on the client-Family Nurse relationship (which could, in turn, have consequences for client engagement with both FNP and child protection proceedings).

Graduation

3.18 The client-Family Nurse therapeutic relationship exists for a fixed period of time. As previously stated, clients graduate from the programme when their child is 24 months old (plus or minus two weeks). Withdrawing support of any kind can often be experienced as challenging for both professionals and service users. This section explores the experience of preparing for and managing graduation from the Family Nurse and client perspective.

How FNP prepares clients for graduation

3.19 Family Nurses reported that they start preparing their clients for graduation from the outset of FNP.

You start disengaging them from the moment you engage them, kind of thing. "You know we're working with you 'til your child is two", we say to them on the very first time you meet them, before they've even said yes to the programme (…)

(Family Nurse 6)

3.20 Graduation is then mentioned on a regular basis throughout the programme. However, from around six months prior to graduation, the programme materials begin to focus on graduation in a more structured way. Sessions focus on feelings around 'endings'. During this time, Family Nurses also report doing a lot of 'agenda matching' with clients about what they would like to cover in the last few months of the programme. Visits become less frequent, moving to monthly in the last three months, so that clients become accustomed to seeing their Family Nurses less often.

The facilitators start six months beforehand, and actually start off very, very generic about … What's it like to ... say goodbye to someone, full stop, regardless of who that is? How does that process work? How does that make them feel?' … Gradually, you just build upon that, right up until ... the day of it. Getting to 21 months however, going down to the monthly, it's a gradual process, so you're not just saying, "Right. OK. I've seen you fortnightly, and then it stops." It's that kind of gradual build.

(Family Nurse 3)

3.21 With every client, Family Nurses produce a 'testimonial' - covering where the Family Nurse feels they were when they first met and what the client has achieved since, highlighting all the future things they would like to achieve, and indicating how, using the strengths they have built, they can now go on and achieve these goals.

3.22 Clients and Family Nurses also start to plan what they will do for their 'last visit'. The idea behind the last visit is for the Family Nurse, client and child to do something as a way of celebrating their time together. Last visits usually take place within two weeks either side of the child's second birthday, although this can vary due to individual circumstances. Examples of last visits included going to soft play or a play park, baking together or bringing over a cake, finger painting, making child hand/foot prints, or going to a farm or zoo. Clients also attend a graduation event with their Family Nurses, other clients and children who have finished the programme at a similar time.

3.23 FNP clients have their Family Nurse instead of a Public Health Nurse/Health Visitor for the first two years of their child's life. However, as they get closer to graduation, Family Nurses liaise with the Public Health Nurses/Health Visitors to whom clients are being transferred. In NHS Lothian, the FNP team and Health Visiting service agreed to arrange a joint visit with the client's new Public Health Nurse/Health Visitor, to give the client an opportunity to meet the Public Health Nurse/Health Visitor and vice versa. Family Nurse perceptions of joint working with Public Health Nurses/Health Visitors around graduation from FNP are discussed in more detail in Chapter 7.

Family Nurse and client perceptions of graduation

3.24 In their final evaluation interviews, clients and Family Nurses were asked about their feelings about graduation. It is worth keeping in mind here that clients' final interviews took place before they had fully graduated from FNP, and therefore reflect how they anticipated graduating might be. As FNP develops in Scotland, further qualitative and quantitative work may be required to follow-up clients post-graduation and explore how the transition to universal services has actually worked in practice over the medium to longer-term.

3.25 The NHS Lothian, Edinburgh Family Nurse team expressed a range of emotions and views about their first cohort of clients graduating. Perhaps unsurprisingly, there was some sadness about these intense therapeutic relationships coming to an end. However, at the same time graduation was viewed as a celebration of what clients have achieved. One view was that the team were surprised at how confident clients had been about graduating, a fact they attributed at least in part to the work that the team had put in to building clients' strengths and preparing them for that point.

I think they've handled it very well. I'm not sure that I had expected (…) most of them to be as confident about it. I'm delighted that that's happened (…) But in saying that, it's possibly come because of all the work that we did put in.

(Family Nurse 3)

3.26 The team reported that preparation for graduation was 'woven through the relationship from day one' by the FNP programme. By talking about graduation from very early in the programme, Family Nurses believed that clients understood the boundaries of the relationship and the fact it was time limited. One Family Nurse recalled one of her clients demonstrating the benefits of this approach, reporting that the client had told her:

"I'm under no illusion that you're leaving and this relationship has been very positive, because the good thing is that whenever we started working together you told me very specifically you would be leaving me at two, so the boundaries were set".

(Family Nurse 1)

3.27 The joint visit with Public Health Nurses/Health Visitors was also believed by Family Nurses to have helped make graduation a positive process (discussed in more detail in Chapter 7).

3.28 However, the team also cited examples where they felt clients had been less ready for graduation from FNP. In particular, where the client was experiencing some kind of crisis at the time they needed to graduate, Family Nurses reported wishing they could keep them in the programme for a little longer, although they accepted that was not how FNP worked. Similarly, they also cited cases where clients appeared to have been less accepting of graduating. This could manifest in cancelled final visits, in order to postpone the end of their contact with their Family Nurse. Finally, Family Nurses noted that they could not always predict in advance how individual clients would react to the end of the programme.

There are some clients who absolutely, without a shadow of a doubt, are ready to go hop, skip and a jump into the next phase of their life and their child's life. But others ... there are occasions where you think, "Oh. It would be nice if I could just have another couple of months"

(Family Nurse 3)

(Client) was supposed to go to soft play and cancelled, and then we arranged to do something else and (she) texted to say her wee one wasn't well, and I eventually just had to go around to her house anyway. So it wasn't…it wasn't the ending that we had planned, and I think that's because (client) didn't want the relationship to end.

(Family Nurse 1)

Some clients I maybe thought it would be particularly challenging ending the relationship, they seem to have coped with it really well. And others I thought would be absolutely fine…I mean I had one girl recently just dissolved in front of me!

(Family Nurse 5)

3.29 Clients' own feelings about graduating from FNP paralleled those described by the Family Nurses above. Their views 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 who understood why the programme had to end; and those who reported not feeling quite ready to leave or who still thought they needed support.

I'm going to miss it because it's quite good having it there but…I think its time to move on. It's been two years (…) I think I'm fine now.

(Client 11)

I wish I could keep her forever, just put her in my pocket. She was like my wee doll of advice. I can understand why it's had to come to an end 'cause (child) is two and everything like that (…) I think it's time to let (Family Nurse) go and for her to do, do her magic on her other people that are having their kids. But it is upsetting. I know I do miss her.

(Client 1)

I'm panicking! I'll probably not get used to it and I'll end up texting her. I'll not be able to will I? I'll need to delete her number.

(Client 12)

3.30 Clients were also asked how they thought their Public Health Nurse/Health Visitor might differ from their Family Nurse. It should be kept in mind here that by the fourth evaluation interview most clients were either still to meet their Public Health Nurse/Health Visitor, or had only just met them (usually at the joint visit with their Family Nurse). Client views are therefore based on what they anticipated the difference between FNP and the Health Visiting service would be. However, the dominant view among clients was that while FNP had a dual focus on the mother and child, they believed that Public Health Nurses/Health Visitors would focus only on their child. Clients also thought there would be less time to get to know their Public Health Nurse/Health Visitor. As a result, they felt they would be less likely to build a trusting relationship, within which they could share their problems.

(My Family Nurse is) secure, safer, easier to go to with my problems, 'cos I knew she wouldn't judge me for it, 'cos she respected me as a person. Whereas people like… you know, other people - for example Health Visitors, midwives - they only know you for a limited amount of time, and they're just there to do their job, and then, as soon as the job's done, they leave. Whereas, with (Family Nurse)… she actually cared about me and my state of mind, as well as my children's.

(Client 8)

Relationship between FNP and the client's wider family

3.31 FNP is underpinned by 'human ecological theory', which highlights the importance of mothers' social, community and family context in influencing their decisions and the ways they care for their children. This is reflected both in the focus of the programme as delivered to clients (exploring their relationships with others and their support networks, for example) and in attempts by Family Nurses to involve other family members in visits where possible and appropriate. During the toddlerhood phase, clients' own parents were involved at some level in 10% of FNP visits; the client's partner, husband or the baby's father^[10] were involved in 20% of visits; and clients' friends or other family members in 3% of visits.

3.32 Family Nurses reported varying levels of involvement from clients' wider family with FNP. Some family members dipped in and out of the programme, 'they got sound bites'. With other families, Family Nurses delivered the programme to everyone in the house. In other cases, clients reported that their wider family was not involved in visits at all.

3.33 In general, significant others interviewed for the evaluation reported attending fewer visit as the programme progressed. They suggested that they felt it was important for the client and Family Nurse to have some time alone to allow the client to discuss things she might not feel comfortable talking about in front of family or friends.

I was normally here when (Family Nurse) came, and I would sit for 5, 10 minutes, then I would sort o' just disappear upstairs or into the kitchen (…) I think it was good for her as well, 'cos it gave her a chance to talk without anyone else here.

(Significant other 8, client's mother)

3.34 Where significant others had spoken to the Family Nurse, they reported feeling similarly comfortable to clients in discussing relationship issues or things to do with the child. Fathers interviewed for the evaluation gave examples where they felt the Family Nurse had helped improve their relationship with the client, while there were examples where clients felt FNP had helped their partner or the baby's father be more involved with looking after the child.

We got on a lot better, 'cos at the start we werenae really communicating on what we were doing, and we would just snap at each other. So we explained to (Family Nurse) about it and then she gave us... She was obviously a counsellor in a way if you want to say it like that, you know? (…) I realised what I was doing wrong, so I obviously corrected all that as well.

(Significant other 6, child's father)

3.35 Clients also reported that Family Nurses had encouraged them to rely more on close family and friends, while also helping clients stand up to any conflicting or unwanted advice from family (see examples discussed in earlier evaluation reports).