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

1 BACKGROUND AND INTRODUCTION

About this report

1.1 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.

1.2 The evaluation of the Family Nurse Partnership (FNP) programme in Scotland 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.

1.3 This second evaluation report focuses on the delivery of the programme in the late pregnancy and post-partum period.¹ It follows a first report (Martin et al, 2011) about the early implementation of FNP in NHS Lothian, Edinburgh and its delivery in early pregnancy. Subsequent reports (due late 2012 and spring 2013) will discuss learning from the experiences of FNP in NHS Lothian, Edinburgh in delivering the programme in infancy and toddlerhood.

1.4 The remainder of this introductory chapter describes the FNP programme and its implementation in Scotland in more detail. Chapter 2 briefly presents the evaluation methods and aims, while chapters 3 to 7 discuss the main findings from this phase of the evaluation on:

• Relationships - Chapter 3 focuses on: the developing relationship between clients and Family Nurses; the relationship between Family Nurses and other family members; and the potential impact of participation in FNP on the relationships between clients and their family and friends.
• Programme content - Chapter 4 explores: the amount of time Family Nurses spend on different topics in the late pregnancy and post-partum period; client and Family Nurse perceptions of the appropriateness of the programme content; and their views of specific topics covered.
• Services, resources and referrals - Chapter 5 covers: the number and nature of referrals of FNP clients to other services; and client and professional views of how FNP compares to and works with other services.
• Professional experiences of delivering the project - Chapter 6 focuses on views of the key achievements and challenges in delivering the programme to clients during late pregnancy and in the weeks after birth, as well as Family Nurse views on workload and the training and supervision they receive.
• Implementing FNP in Lothian - Chapter 7 summarises perceptions of key learning, both for and from the Lothian site.

1.5 Finally, Chapter 8 summarises the conclusions and key learning from the report.

The Family Nurse Partnership (FNP) programme

1.6 The FNP programme was developed in the USA (where it is called the 'Nurse Family Partnership' (NFP) 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 and well-being of first time parents and their children, child development and families' economic self-sufficiency.

1.7 FNP is informed by three key theoretical approaches to supporting mothers and their infants:

• Attachment theory acknowledges the critical importance of new born babies developing secure attachments to their mothers in their subsequent development and the equally critical importance of mothers initiating a strong relationship with their baby to become 'good mothers' (Karl et al, 2006). Family Nurses aim to parallel the mother-infant relationship in the relationships they build with clients, and to provide opportunities for activities that maximise contact between mothers and babies and help mothers become more responsive to their newborn babies' cues.
• Self-efficacy theory provides a framework for Family Nurses to understand how women make decisions for themselves and their child by suggesting that people are most likely to choose behaviours not only on the basis that they will lead to a particular outcome, but also on the basis that they think they themselves can successfully carry out the behaviour (Olds, 2006). Family Nurses use techniques like motivational interviewing (Houston Miller, 2010) to improve participants' sense of 'self-efficacy' and their feelings of control over their lives and relationships.
• Human Ecological theory highlights the importance of mothers' social, community and family context in influencing their decisions and behaviour and the ways they care for their children. Family Nurses therefore work to involve other family members in visits and to link families with wider services in the local community.

1.8 FNP is a licensed programme, such that new sites are only permitted to run the programme and access the materials and training associated with it if they sign up to an agreement to implement it according to specified fidelity requirements. Referred to in the FNP Management Manual (Department of Health FNP National Unit, adapted for Scottish FNP sites, November 2010) as 'Core Model Elements', these licensing requirements cover:

• the visiting schedule (specifying the frequency of Family Nurse visits to clients throughout pregnancy until the child is two)
• staffing requirements (for example, as referred to in the national job description and personal specification for the professional and personal characteristics of Family Nurses)
• client eligibility (for example, relating to the point in pregnancy by which mothers should be enrolled), and
• the organisational structures and processes needed to support the programme (for example, requirements relating to training, supervision and administrative support).

1.9 In addition, the FNP Management Manual sets out various fidelity goals - described as 'stretch goals'². These are goals based on the research evidence which, if met, may help maximise the likelihood of the programme achieving the same results as the US sites. The fidelity 'stretch' goals cover client retention, visit 'dosage' (in terms of the numbers and length of visits to clients at different stages of their participation in the programme), and coverage of different 'domains' or topics during visits (see Annexes to Martin et al (2011) for a full list of the FNP Core Model Elements and Fidelity 'stretch' goals).

Testing FNP in the UK

1.10 The background to and history of FNP's introduction in the UK is described in Martin et al (2011). The first FNP test site in Scotland commenced in NHS Lothian, Edinburgh, with the first clients enrolled from 25 January 2010. Since then, Scottish FNP sites have been introduced in NHS Tayside in July 2011. At the time of writing, the Scottish Government was planning to increase FNP capacity to reach three times as many clients as now and recruiting five new Health Boards by the end of 2013. Boards have been invited to submit expressions of interest and self-assessments by one of three phased deadlines³ for assessing applications for participation in FNP roll-out. Regional information days are being delivered to assist Boards in considering whether or not they are ready to deliver FNP.⁴ Matched funding has also been secured to enable NHS Lothian to move to small scale permanency starting in summer 2012.

FNP in NHS Lothian, Edinburgh

1.11 The NHS Lothian, Edinburgh FNP test site is based in Edinburgh Community Health Partnership (CHP) and delivered by NHS Lothian. The NHS Lothian FNP Edinburgh delivery team was initially comprised of:

• One Supervisor
• 6 Family Nurses, and
• An Administrator/Data Manager.

1.12 Since the first evaluation report, key changes to this team include: the appointment of the Nurse Supervisor to a new role of Scottish National Lead Supervisor for one day a week, with an existing team member acting up to supervisor; the local FNP Lead in Lothian leaving at the end of their contract; and the departure of the team Administrator.

1.13 148 women who met the key criteria for participation (living within Edinburgh CHP, first time mothers, aged 19 or under at LMP, and under 28 weeks gestation) were enrolled with FNP in NHS Lothian, Edinburgh over a nine month period, from February to October 2010. The first clients delivered their babies in April 2010, so the first cohort of clients will start to 'graduate' from April 2012 (when their child turns two years-old), with the full cohort due to complete the programme by the end of April 2013.