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

EXECUTIVE SUMMARY

Background

1. This summary presents the key findings from the second report of the evaluation of the Family Nurse Partnership (FNP) programme in NHS Lothian, Scotland. FNP is a licensed preventative programme which aims to improve outcomes for young first time mothers and their children. It does this through a programme of structured home visits delivered by specially trained Family Nurses during early pregnancy and continuing until the child is two years old.

2. The evaluation focuses on learning from the experiences of implementing FNP in the first Scottish FNP test site, based in NHS Lothian, Edinburgh. It focuses on process and understanding how the programme works in a Scottish context, drawing on quantitative data collected and collated by the NHS Lothian, Edinburgh FNP team, and on qualitative interviews with clients, Family Nurses and key stakeholders. This second report focuses on experiences of the programme in the late pregnancy and post-partum period (first 6 weeks following birth).

Relationships

3. By the end of the pregnancy phase, 93% of clients remained engaged with the NHS Lothian, Edinburgh FNP programme. The percentage of clients leaving the programme or 'inactive' (no contact for 6 months) during the pregnancy phase ('attrition') was 6.8% - well below the 10% or less attrition target in the fidelity 'stretch' goal. The NHS Lothian, Edinburgh Family Nurse team attributed this very low attrition rate primarily to the strength and continuity of the relationships established between clients and Family Nurses during pregnancy. Where challenges or difficulties were reported in Family Nurse-client relationships, these tended to be seen as related to lower levels of contact and/or specific challenging circumstances (like a baby being taken into care).

4. The NHS Lothian, Edinburgh FNP test site achieved the fidelity 'stretch' goal for the proportion of expected visits delivered during pregnancy (80%) for 52% of clients. Factors that helped Family Nurses 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 level of motivation clients had to discuss the birth and beyond with their Family Nurse. Challenges to delivering the target number of visits for some clients during pregnancy included:

• Client related factors: client mobility and/or geographical spread; challenges making appointments with clients who were working or who had chaotic lives; and fitting around client appointments with other services.
• Nurse or programme-related factors: the amount of training Family Nurses attended during the pregnancy phase; nurse annual leave; and challenges delivering weekly visits at the same time as engaging and enrolling clients.
• External factors: an extended period of bad weather (resulting in cancelled visits) and changes in clients' delivery dates.

5. Partners were present for 32.8% of visits during the pregnancy phase. Where clients' partners were involved in FNP, there was evidence that participation helped support their involvement in the birth.

FNP programme content in the late pregnancy to post-partum phase

6. The average time Family Nurses in NHS Lothian, Edinburgh recorded spending on different topics during pregnancy was very close to the division suggested by the fidelity 'stretch' goals. In general, Family Nurses felt that the suggested programme content during pregnancy was well matched to clients' needs. The content for the post-partum period was viewed as very full, however. It was suggested that a degree of flexibility was required to create space to deliver other relevant activities and to agenda match.

7. In cases where a baby is taken into care, it was suggested that (where a final outcome has not yet been determined) the programme materials may not always lend themselves particularly well to supporting Family Nurse visits to mothers, since they focus on issues like attachment which can be very sensitive in this situation. Other aspects of the programme materials that Family Nurses felt could be improved or enhanced related to labour and delivery, sexual health and binge drinking.

8. Clients appeared to be very happy with the overall content of the programme and with their ability to raise additional issues with their Family Nurses as required. In terms of the perceived impacts of the programme in the late pregnancy and post-partum period:

• Both clients and their partners gave examples of the ways in which they felt more knowledgeable and confident about labour and delivery, including feeling clearer about the stages of labour, feeling better able to assert their views during delivery and feeling more confident when the delivery did not go completely to plan.
• Examples of positive health behaviours and knowledge clients' attributed to FNP in the late pregnancy/post-partum period included: breastfeeding for longer; resisting pressure to wean early; greater awareness of the risks of smoking and drinking during and after pregnancy; changes to eating habits during or after pregnancy; and awareness of a greater range of contraceptive options.
• In relation to bonding with their new baby, while one view was that clients and partners would have engaged in bonding activities without their Family Nurse, clients and partners also reported discovering or gaining confidence to try new activities to support attachment in the post-partum period.
• Similarly, while clients did not necessarily feel that the information they received from FNP around safety and hazards was new to them, there were also examples where they felt they had changed their approach because of their Family Nurse - for example, in relation to safe sleeping positions or sterilising dummies.
• Clients in the qualitative panel who had experienced issues around their emotional or mental health around the birth and post-partum period were positive about the support they had received from their Family Nurse, ranging from general advice about coping with stress to assessments and referrals to GPs for treatment for post-natal depression.

9. Exceptions to this generally very positive picture of the support received around the birth/post-partum period included comments that clients had not received elements of support they had expected or wanted (including specific information relating to birth) or that they preferred to go to other people for advice.

10. Quantitative evidence of outcomes was available for all FNP clients in relation to breastfeeding, gestation and birthweight. Some caution should be applied in interpreting these figures, given the lack of a control group. However, they nonetheless provide useful data on the experiences of the first FNP cohort in Scotland. Overall, 46% of NHS Lothian, Edinburgh FNP clients breastfed at least once. Among FNP clients who were hostile to or ambivalent about breastfeeding when they joined the programme, 28% went on to breastfeed at least once. There was some evidence that both clients and Family Nurses felt they were not always receiving either enough or appropriate support with breastfeeding in hospital, and that in some cases this might undermine clients' intentions to breastfeed. Average gestation of babies born to the first FNP cohort in Scotland was 40 weeks (well above the 37 week threshold for a birth to be considered full term). Average birthweight was 3,291g, with 7.2% having a low birthweight. None had a very low birthweight.

Services, resources and referrals

11. Family Nurses referred clients to a wide range of services during pregnancy. Referrals from Family Nurses for both maternal and child health issues were clearly appreciated by clients and significant others. It was suggested that without the support of the Family Nurse, maternal health issues might have gone undiagnosed or untreated for longer. Family Nurses also appeared to play an important role in giving clients confidence in their own judgement about when to contact their GP about their baby's health. The information and support Family Nurses provided in relation to accessing housing and benefits were highly valued. The nature of this support varied in terms of how involved Family Nurses were in actually liaising with other services on clients' behalf, or whether they adopted more of a sign-posting role. More active involvement in linking clients with services was sometimes considered necessary where clients lacked confidence or motivation to engage with other services, or where they were in particularly challenging situations.

12. In terms of perceived differences in the support received from FNP and other antenatal services, while some FNP clients reported good relationships with both their midwife and their Family Nurse, others reported more mixed relationships with their midwife. One client view was that they 'got a lot more' information from their Family Nurse. Another was that midwives were not always best placed to support young mothers in particular. FNP may play an important role in providing antenatal education for young mothers who may not otherwise engage with antenatal classes - perceived by clients and significant others as being more suited to older women. At the same time, there may be a need for more antenatal and postnatal groups aimed more specifically at young women.

13. Delivering FNP city-wide was seen as advantageous in terms of getting to know the range of services clients might be able to access, although at the same time gaining familiarity with all the services available across the whole city could be challenging. From the perspective of the NHS Lothian, Edinburgh Family Nurse team, 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. However, Family Nurses noted some initial challenges in communicating to social work what working with a 'strength-based approach' means. They commented that a lot of 'open communication' had been required to reassure social work that this did not mean ignoring risk. The number of social work teams across Edinburgh also meant it took time to build relationships with them all.

14. It was noted that FNP has had relatively less contact with public health nursing colleagues (health visitors) to date. Meanwhile, it was suggested that benefits services had been less helpful and that both Family Nurses and clients had often found them more difficult to deal with., .

Professional views and experiences of delivering the programme in the late pregnancy to post-partum period

15. Family Nurses' views of the training they received remained extremely positive. The ongoing opportunities FNP provides for learning and sharing practice across the UK were appreciated by the team. The quality and level of supervision provided to the FNP team was also viewed as 'invaluable', with the fact that supervision was part of the license enabling the team to prioritise it.

16. In terms of challenges in delivering the programme as a whole, including meeting the visiting schedule, workload continued to be viewed as a significant issue, although it was also suggested that this had eased a little since the first evaluation interviews. Issues contributing to high workloads in the late pregnancy and post-partum period included factors relating to FNP specifically (for example, the requirement to visit clients weekly in the 6 weeks post-partum) and factors stemming from the fact that the team is part of the wider NHS (for example, the move to an electronic child health record keeping system in Lothian in late 2011).

17. 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 FNP monitoring data to support 'reflective supervision'.

Implementing FNP in Lothian

18. Perceptions of key learning from the experience of delivering FNP in NHS Lothian, Edinburgh for other FNP sites include:

• The importance of early engagement with local stakeholders and services
• Learning that 'the programme will sell itself' as people see the changes it can effect, and
• Building in time for consolidating learning from FNP training from the start.

19. Perceptions of the potential influence the NHS Lothian, Edinburgh FNP programme may have had on the wider NHS and other services focused on learning about:

• How to work with those less likely to access universal services
• How to support Nurses working in high pressure roles
• Specific approaches to assessing clients, and
• Thinking about services for teenage parents who are not eligible for FNP.