Evaluation of the Family Nurse Partnership Programme in NHS Lothian, Scotland - Late Pregnancy and Postpartum

8 CONCLUSIONS AND KEY LEARNING

8.1 This final chapter summarises the key conclusions and learning from this report in relation to each of the evaluation aims (discussed in Chapter 2).

Is the programme being implemented as intended?

8.2 This second report indicates that 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 pregnancy was well below the fidelity 'stretch' goal, while the proportion of clients receiving the target level of expected visits (80% or more) during pregnancy was 52%. The amount of time Family Nurses spent on different topics during pregnancy also came very close to the division suggested by the fidelity 'stretch' goals. The NHS Lothian, Edinburgh Family Nurse team continued to actively participate in all the training and supervision required by the programme.

8.3 The Family Nurse team in NHS Lothian, Edinburgh suggested that their low attrition rate during pregnancy was primarily a result of the strength and continuity of the relationships established between clients and Family Nurses. For the minority of clients who had disengaged, in retrospect Family Nurses suggested that a more flexible approach to meeting their needs in the early stages of the programme, focused on agenda-matching rather than closely following the suggested content, might possibly have helped.

8.4 Key factors that facilitated Family Nurses being able to meet the visiting schedule during pregnancy included: being able to be flexible about appointments; establishing strong client relationships (with clients motivated to keep appointments); and the perceived level of motivation clients had to discuss the birth and beyond with their Family Nurse. However, Family Nurses also identified a number of barriers to delivering the target number of visits for some clients during pregnancy. Some of these were external factors (such as weather), outwith the team's (or clients') control. Other factors related specifically to the fact that NHS Lothian, Edinburgh is still in a test phase - for example, the team should not face the same pressures around delivering home visits at the same time as receiving intensive mandatory training when the next cohort of clients are recruited. Similarly, if the team moved to small-scale permanence, they should not face the same pressures around delivering weekly visits to many of their clients while still engaging and enrolling the remainder. However, factors like client mobility and clients' preferences for seeing their own Family Nurses, in combination with the higher level of annual leave nurses in the UK are entitled to in comparison with nurses in the US, may continue to mitigate against delivering 80% of home visits for some clients.

How does the programme work in Lothian?

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

8.5 Clients continued to praise the impact of the FNP programme in supporting them both practically and emotionally. As discussed below, they identified a wide range of perceived benefits from their participation and appeared very happy both with the overall content of the programme and the scope for 'agenda-matching' with their own concerns. Cases where the programme appeared to be somewhat less successful in meeting clients' needs or expectations generally appeared to feature a lower level of contact between client and Family Nurse and/or specific challenging circumstances, like a child being taken into care. The NHS Lothian, Edinburgh Family Nurse team highlighted the particular challenges associated with supporting clients if their baby is taken into care, suggesting that the programme materials were not always very helpful in this scenario.

8.6 Family Nurses highlighted the impact of FNP not only for clients but also for their own professional development and practice. The level and quality of training and supervision both continued to receive high praise. Family Nurses also reported feeling increasingly confident in delivering both the programme materials and the new ways of working associated with FNP. Suggestions for further improvements to training included more practical sessions and less reliance on self-learning, while it was felt that supervision sessions might benefit from more general discussion around clinical issues or programme delivery, rather than always being structured around particular clients. Finally, it was noted that the programme content for the post-partum period was very full and suggested that some of the materials might benefit from being reduced, simplified or, in relation to contraception, revised for the UK context.

8.7 The evaluation has not yet included interviews with stakeholders from other services. However, the FNP team suggested that working relationships between FNP and key services like midwifery, health visiting, social work and housing had all improved since the start of the programme as they had become familiar with each other and with FNP's ways of working. Family Nurses suggested that they had started to see aspects of their own practice - for example, the use of strengths-based language - reflected back by some of the other services they were working with. Relationships with benefits services were reported to be more difficult. Building on experiences of working with other services, this may perhaps be addressed in the future through identifying opportunities for joint-working and shared learning around strengths-based approaches. It was also suggested that the establishment of FNP had encouraged NHS Lothian to think about their services for other teenagers, who are not eligible for FNP. Future evaluation reports will hopefully include the views of other services on FNP.

What are the implications for future nursing practice?

8.8 As discussed in Chapter 7, it is important not to draw too many conclusions about the success of FNP at this early stage, before the results of the English RCT are available and before the learning from NHS Lothian, Edinburgh and other test sites has been fully consolidated. However, the findings in this report nonetheless suggest a number of potential implications for wider nursing practice from the experience of delivering FNP in NHS Lothian, Edinburgh to date, including:

• The benefits of adopting a strengths-based approach in securing and maintaining the engagement of 'hard to reach' clients with services.
• The potential for motivational interviewing to encourage clients who are ambivalent or hostile to try or change particular behaviours, like breastfeeding or cutting down on smoking.
• Potential learning for midwifery and other services around young mothers' anxieties and learning needs in relation to infant feeding.
• The importance of agenda-matching services to clients' current needs and aspirations - particularly in relation to keeping the most vulnerable clients engaged.
• The potential for intensive, mandatory, structured supervision, which also reflects a strengths-based approach to staff management, to reduce turnover and maintain motivation and morale where nurses are working in high pressure roles.

What factors support or inhibit delivery of the programme?

8.9 Family Nurse and client accounts suggest that the key factor underpinning successful delivery of the programme is the quality of the client-Family Nurse relationship. The establishment of this therapeutic relationship was seen as having helped reduce attrition, motivated clients to keep appointments and facilitated the open discussion of potentially uncomfortable issues. The flip-side of this was that where Family Nurses and clients had less contact during pregnancy (for whatever reason), it could be more difficult and/or take longer to establish this therapeutic relationship, with consequences for engagement, clients' level of comfort discussing particular issues and perceptions of the quality of support received. Training and supervision were also key factors underpinning Family Nurses' ability to deliver the programme.

8.10 Workload remained a key challenge for the FNP team in delivering the programme. An important point here, which echoes findings from Barnes et al's evaluation of the Wave 1 England FNP test sites, is that workload pressures do not only reflect FNP programme requirements. They also reflect the requirements of being part of the wider NHS - attending mandatory training, engaging with and commenting on new developments, networking with universal services, etc. As FNP is rolled out further in Scotland - particularly if it moves from test phase to permanency - it may be worth carrying out further research to review Family Nurse workloads and the balance between the FNP-specific and NHS-generic requirements of their role. Monitoring future workloads is also important in the light of the additional costs associated with the Scottish Government's decision to support a lower Supervisor: Nurse ratio (1:6 rather than 1:8), which obviously has cost implications.

8.11 Finally, the lack of a user-friendly database, while not preventing effective supervision, continued to be viewed as a limitation on the team's ability to creatively engage with the monitoring data they collected as part of a 'reflective supervision' process.

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

8.12 As discussed in the introduction to this report, this evaluation is not a formal impact evaluation and cannot conclusively establish causal links between FNP and particular outcomes. The 'Building Blocks' RCT in England will provide this evidence. However, interviews with Family Nurses and clients conducted for this evaluation nonetheless highlight a wide range of areas where participation in FNP was perceived to have a positive impact, including:

• Young parents who are better prepared for labour and delivery, and feel more confident and in control.
• Improved parent-child attachment.
• Improved maternal health behaviours.
• Enhanced awareness of child health and safety issues.
• More confident parents.
• Mothers who feel better supported in dealing with mental health and emotional difficulties.

8.13 There was also some evidence of the potential for the approach used by FNP to have a positive impact on breastfeeding rates among younger mothers. However, this report also highlights the essential importance of the support mothers receive with breastfeeding in the first few days after birth, particularly in hospital. Without this support, positive intentions to breastfeed may easily be undermined, particularly where young mothers may have been ambivalent about this in the first place.