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

4 Overall delivery and views of programme content during the Toddlerhood phase

Key questions

• Do Family Nurses conduct visits in line with fidelity criteria?
• How is the FNP structure experienced by clients and Family Nurses?^[11]

Key findings

• The average time Family Nurses in NHS Lothian, Edinburgh, spent on different topics during toddlerhood came very close to the breakdown of coverage of different content domains suggested in the fidelity 'stretch' goals.
• Family Nurses and clients reported that the programme covered issues of relevance to clients during the toddlerhood phase, while also enabling clients and Nurses to 'agenda match' visits to address clients' specific needs.
• By toddlerhood, the strength of client and Family Nurse relationships meant that clients were more comfortable raising 'difficult' topics and that Nurses felt more able to be frank and direct in addressing these issues. However, some clients continued to find it difficult to discuss their own feelings and mental health, even two years into the programme.
• The FNP materials were viewed as particularly helpful in supporting discussion around graduation (by introducing it as a theme from early on) and relationships (both by providing different ways into raising this topic, and by 'normalising' its discussion as part of the programme).

Introduction

4.1 FNP combines a detailed manualised programme, including worksheets and materials for each visit, with an active focus on 'agenda matching' to clients' particular needs. Thus while each stage of the programme includes 'stretch goals' around the balance of coverage of specific topics, Family Nurses are also expected to 'flex' the programme to fit individual clients.

4.2 This is the first of three chapters that focus on programme content during toddlerhood. This chapter briefly reviews the overall delivery of FNP content to the first cohort of clients in NHS Lothian, Edinburgh during the toddlerhood phase of the programme. In addition to comparing the balance of time Family Nurses spent on different topics with FNP fidelity criteria and highlighting the topics that clients considered to be of most use to them in toddlerhood, it summarises Family Nurses' and clients' overall views of programme content in this period, and their perceptions of any topics they found particularly challenging to address. This chapter also sets the scene for and introduces some of the topics that will be covered in the next two chapters.

Visit content figures

4.3 Fidelity 'stretch' goals around the suggested division of topic coverage within FNP are intended to reflect variation in the developmental needs of parents and infants at different stages. For example, the amount of time allocated to personal health is highest during pregnancy, while during toddlerhood (12-24 months), more time is allocated to life course development, as parents are supported to plan for their and their child's future. As shown in Table 4.1, the average time Family Nurses in NHS Lothian, Edinburgh, recorded spending on different topics during toddlerhood came very close to the fidelity 'stretch' goals for this period. The times recorded for each content domain were all within one to three percentage points of the suggested range.

Table 4.1: Visit content figures, NHS Lothian, Edinburgh FNP site, toddlerhood

	Toddlerhood
Average Time Devoted to Content Domains	Fidelity 'stretch' goal	NHS Lothian, Edinburgh site average
Personal Health	10-15%	17%
Environmental Health	7-10%	13%
Life Course Development	18-20%	15%
Maternal Role	40-45%	39%
Family and Friends	10-15%	16%

Overall views of programme content in Toddlerhood

4.4 FNP topics in toddlerhood were similarly wide ranging to those covered in earlier phases of the programme, reflecting the variation across and within the FNP domains listed in Table 4.1, above. Within these domains, new topics were covered as they became relevant during toddlerhood - for example, potty training, moving from bottle to cup, and child dental health - while other topics were revisited or expanded upon. Family Nurses commented that the toddlerhood period provided greater opportunities for reflection on clients' development as parents, which served to further increase clients' confidence in their own abilities as young parents. Client and Family Nurse views relating to these topics will be discussed in more detail in Chapter 5 which focuses on delivery of programme content relating to parenting, child health and development.

4.5 As discussed in Chapter 3, discussion of graduation is threaded throughout the programme, but becomes a more specific focus from around six months into toddlerhood. While in general the structure of the FNP programme and many of the materials were viewed by Family Nurses as extremely effective in supporting graduation, however there was some feeling that the materials might slightly overplay the difficulty of 'endings'. It was suggested that the team might benefit from some further group reflection on how to use these materials in future.

4.6 As noted above, there is a greater focus on life course during the toddlerhood phase. In chapter 6 of the report, we will discuss in more details client and Family Nurse experiences of the programme content relating to maternal health, wellbeing and future plans. Family Nurses suggested that by Year Two of the programme, clients themselves often felt more confident about topics around parenting and child development and more able to look at themselves and what they want from life. However, the exact focus of the programme continued to depend heavily on the needs of individual clients.

That's the beauty of the Family Nurse Partnership, is you have the ability to agenda match, so for some in that stage there was a much greater focus on employment, or education, and moving that forward. But others…they're not at that stage yet so…for some there is a continued emphasis on parenting.

(Family Nurse 5)

4.7 Family Nurses commented that by this stage they felt much more adept at tailoring the FNP materials to clients' needs. The programme was seen to work best when Family Nurses were able to combine agenda matching with creative use of the materials - for example, using a facilitator around the client-nurse relationship to broach issues around a client's relationship with their partner, or using a facilitator on diet to prompt wider discussion of a client's health.

4.8 Clients' views on the topics they found most useful in toddlerhood were again diverse, including: potty training; how to deal with their child's behaviour; money issues and benefits; managing their relationships with others; (re)establishing sleeping routines; child diet and nutrition; their own mental health and stress; support around the client or their partner moving into education or employment; and help arranging nursery places. However, clients reported that they were always able to cover any issues they particularly wanted to discuss, suggesting that the NHS Lothian, Edinburgh FNP team were continuing to successfully agenda match during toddlerhood.

Challenging topics

4.9 As discussed in the Infancy phase report (Ormston and McConville, 2012), clients' and Family Nurses' perceptions of 'difficult' topics and the ease with which they were able to discuss these changed over time as their relationships developed. By the end of the programme, three main client experiences in relation to discussing 'challenging topics' with their Family Nurse were apparent:

• Some clients reported finding it easy to speak to their Family Nurses from very early on (during pregnancy) and continued to feel comfortable talking to their Family Nurse about any topic.

She was just really like…really friendly and easy to get on with from the start so it's probably just been good the whole time.

(Client 13)

• Others reported that their confidence in discussing 'challenging' topics - in particular their own feelings and mental health - had improved over the course of the programme as their relationship with their Family Nurse developed:

I think just at the beginning I was quite shy, but then once I personally know someone for so long, I kinda build up my .. don't know what you call it .. my trust maybe? (…) But now she comes in and we just chat. I just tell her everything, so I think it's actually really good now than it was at the beginning!

(Client 2)

• Finally, other clients reported that they continued to find it difficult to talk about specific topics, notably their own feelings. However, where they had felt able to broach these issues with their Family Nurse, they reported that it had helped them.

Client: I just don't really talk to anybody about that.

(…)

Interviewer: OK. So have you ever talked about any of your own feelings or worries with (Family Nurse)?

Client: Yeah. (…) like I had anxiety and stuff, so I spoke to her about that, but that's the only thing. (…) She gave me kinda some stress relief things to do, and it has actually helped.

(Client 10)

4.10 Family Nurses similarly reflected on the ways in which their deepening relationships with clients had impacted on their ability to raise 'difficult' issues during visits. One view was that by toddlerhood, the strength of this relationship made it easier both for clients to feel comfortable raising issues and for Family Nurses to be more frank and direct with them about 'challenging' areas. As discussed in Chapter 3 and in earlier reports, there was a clear view among the Family Nurse team that the therapeutic relationship made it both easier to raise issues around child protection and possible to sustain clients' involvement with FNP during ongoing child protection processes.

4.11 Family Nurses also noted that the FNP materials were extremely helpful in supporting the introduction of topics that might be perceived as 'challenging', either by the Nurse or the client. Being able to show the client a facilitator and say that the issue is being covered with everyone on FNP was viewed as making it 'so much easier' to discuss areas like domestic abuse, relationships and finances - all areas that Family Nurses felt clients could find 'emotionally' challenging to talk about. It was reported that it could be difficult to find an appropriate time to talk about clients' relationships with others if a partner or family member regularly attended sessions with the client. One Family Nurse suggested that with their second cohort of clients, they would be clearer from the start that they needed to see clients at least once on their own during each phase of the programme, to ensure they had space to discuss such issues.