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

3 RELATIONSHIPS

3.1 The 'therapeutic relationship' between client and Family Nurse is at the heart of FNP's approach. The key aims of the programme - building clients' skills, self-efficacy and confidence as parents - underpin this client-Family Nurse relationship. The holistic focus of the programme - exploring the social, emotional and economic context of clients' lives - also means that Family Nurses often seek to involve other family members in the programme, with the aim of enhancing the wider support available to both mother and baby. This Chapter draws on both quantitative and qualitative data to explore the nature and quality of the relationships between, first, clients and Family Nurses and second, Family Nurses and other members of clients' families..

3.2 Key questions from the monitoring and evaluation framework addressed in this chapter include:

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

Relationships between clients and Family Nurses

Client retention and engagement

3.3 As Barnes (2010) notes, 'In a programme extending over 30 months, attrition will always be a major concern'. Evidence from the delivery of the programme in 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, and should not be greater than:

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

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

3.5 Programme attrition during the pregnancy phase of FNP in NHS Lothian, Edinburgh was 6.8% - well below the 10% maximum attrition fidelity 'stretch goal' suggested for this phase. This figure is comprised of 2.7% (4 clients) who left the programme during pregnancy, and 4.1% (6 clients) who were 'inactive' (disengaged) for over 6 months by the end of pregnancy.

3.6 In all 4 cases where clients left the programme, withdrawal was either because they had moved out of the area covered by FNP in Edinburgh, or because of pregnancy loss - factors which in fact mean they are no longer eligible to participate. In fact, one of these 4 clients had subsequently moved back into the FNP catchment area, and re-joined the programme in the infancy phase. No clients left the programme during the pregnancy phase because they no longer wished to take part.

3.7 FNP sites also monitor clients who have not left the programme, but are currently 'disengaged' (having not received a visit from their Family Nurse for more than 6 weeks) or 'inactive' (disengaged for 6 months or more - see Table 3.1). At the end of the pregnancy phase, 12 clients (8.1%) were classed as 'disengaged' - that is, they had not left the programme, but had not seen their Family Nurse for more than 6 weeks. Of these, 6 had not had any contact for more than 6 months.

3.8 The next evaluation report will include final attrition figures for the infancy phase. However, as of the end of November 2011, cumulative programme attrition was 11.5% (17/148), with 88.5% of clients remaining on the programme.⁷

Table 3.1: Attrition and disengagement (pregnancy phase), NHS Lothian, Edinburgh FNP test site

	Pregnancy phase
Left programme	2.7% (4/148)
Inactive (no contact for more than 6 months)*	6.8% (10/148)
Disengaged (no contact for more than 6 weeks)	8.1% (12/148)

* Inactive comprises those who have had no face-to-face contact for 6 months or more.

3.9 Clients who are disengaged or inactive can re-engage with the programme, and do not therefore count towards the attrition rate. The NHS Lothian, Edinburgh Family Nurse team commented on the fact that some clients' level of engagement does fluctuate. They cited examples of clients who appeared to be disengaging but subsequently fully re-engaged with the programme, either because 'their head has cleared', or perhaps because they were experiencing some kind of adversity and were looking for support from FNP. Where clients either cancelled visits or were out of the area for several weeks on holiday or visiting family, there was a perception that 6 weeks might easily pass without face-to-face contact. However, the team reported making considerable effort to keep in touch with clients who had disengaged by text and phone. In fact, one view was that the figures for clients who are 'disengaged' might be an overestimate as they may not include these non face-to-face contacts within the 6 week window before a client is classed as 'disengaged'.

3.10 The NHS Lothian, Edinburgh Family Nurse team attributed the very low attrition rate during pregnancy primarily to the strength and continuity of the relationships between clients and Family Nurses, discussed in more detail below. Levels of disengagement were also low and, as discussed, may not necessarily lead to attrition. However, the team did reflect on the reasons why some clients had disengaged (and in some cases subsequently left the programme during infancy) and on approaches that, with hindsight, might have helped prevent disengagement. Two main reasons why clients disengaged from FNP were identified by the NHS Lothian, Edinburgh Family Nurse Team:

• a belief on the client's part that they did not need the programme, and
• a perception that the nature of the programme had been difficult for the client to cope with at that point in time, for example because they found the programme too intense in terms of the time commitment or the topics covered, or (more exceptionally) because they found the strengths-based approach 'overwhelming' (because it was so unfamiliar to them).

3.11 Family Nurses reflected on things they might have done differently to keep these clients engaged. Their suggestions focused on agenda matching⁸ the programme to the clients' specific needs from an earlier stage, including:

• using a reduced visiting schedule for a period of time if the client appeared to be finding the programme too demanding and there was a concern they might disengage
• keeping the programme 'lighter' in the earlier stages and delving less deeply into emotional issues where clients appear to be struggling with this, and
• moderating use of 'strengths-based' language in the case where the client seemed to be reacting against this.

3.12 In part, these comments may reflect the fact that Family Nurses in Edinburgh were still at a relatively early stage of delivering the programme during the pregnancy period. As discussed in Chapter 4, Family Nurses felt that their ability to agenda match their approach to the needs of different clients was improving with time and experience. Family Nurses' suggestions also indicate that for the most vulnerable clients, a highly flexible approach to meeting their needs may be the best way of keeping them engaged. This reflects findings from the US research on the programme, which shows that nurses with the highest retention rates tended to emphasise tailoring and adapting the programme to the needs and interests of clients, while those with lower retention rates had a more directive approach, emphasising the programme's 'perks' and the positive outcomes of completion (Ingoldsby et al, 2009, discussed in Barnes, 2010).

3.13 A final suggestion from the Family Nurse interviews in relation to engagement and retention was that Family Nurses should avoid enrolling new clients in the week before they go on annual leave, as visits in the immediate weeks after enrolment were considered particularly important in terms of both establishing a relationship and addressing any concerns clients might have about participation.

Level of contact between clients and Family Nurses

3.14 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 the 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.

3.15 The fidelity 'stretch' goals also specify the content of the programme to be delivered in each phase of the programme.

3.16 The visit schedule varies depending on the stage of the programme. The aim is for clients to receive weekly visits for the first 4 weeks after enrolment, and then fortnightly visits until the baby is born. In the post-partum period, clients are visited weekly for the first 6 weeks after the birth and then fortnightly until the child is aged 21 months and monthly for the last 3 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.

3.17 The NHS Lothian, Edinburgh FNP site met the fidelity 'stretch' goal (80% of expected visits) during pregnancy for 52% (77/148) of all clients who enrolled in the programme. The average dosage during pregnancy was very close to 80% (79%). The average number of visits delivered during pregnancy was 9.6 for all clients.⁹

3.18 The Family Nurse team in NHS Lothian, Edinburgh identified a number of factors that they felt helped with meeting the visiting schedule during pregnancy, including: flexibility in terms of allowing clients to change appointments and being contactable by them by phone or text; the relationships they had with their clients which meant clients were motivated to keep to appointments; and the level of motivation they felt clients had during pregnancy to engage with the programme and to discuss the birth and beyond. However, Family Nurses also identified a number of issues they felt had been barriers to delivering the target number of visits for more clients during the pregnancy phase. These issues can be divided between client-related factors, programme or nurse-related factors and external factors, outwith the control of nurse or client. Client-related factors identified by Family Nurses included:

• Client mobility and/or geographical location - the fact that Family Nurses had clients across NHS Lothian and that clients tended to move frequently was seen as presenting practical challenges in getting round all the visits they needed to carry out within a particular week.
• Challenges around making/keeping appointments for clients who were working and whose time might be more limited as a result.
• Client life course - where clients were perceived to have relatively chaotic lives, this was sometimes viewed as mitigating against keeping regular appointments with them.
• Clients' appointments with other services, which were sometimes perceived to take up a lot of time and/or mean that clients had to cancel appointments with their Family Nurse.

3.19 Programme/nurse-related factors included:

• Nurse annual leave also sometimes preventing the team delivering weekly or fortnightly visits. Although clients have the option of contacting another member of the team when their Family Nurse is not available, the NHS Lothian Family Nurse team noted that in practice clients rarely did so. This preference for only contacting their own Family Nurse is reflected in client comments too:

I would prefer to speak to my nurse that I have. Like if there was a problem, I probably would feel a bit uncomfortable phoning someone else and asking them to come out 'cos I've been dealing with the same person, so I'd probably just look somewhere else instead of getting someone I don't know out. (Client 9)

• Challenges around the recruitment window and around balancing the need to learn the programme and attend training with caseloads (discussed in Martin et al, 2011).

3.20 Finally, external factors affecting the team's ability to deliver planned visits included:

• The bad weather experienced towards the end of 2010 and early 2011, which had resulted in a large number of cancelled visits (82 in total).
• Changes in clients' delivery dates, which sometimes created difficulties in delivering the last few weeks of planned content for the pregnancy phase (though this would not be reflected in lower dosage figures, since these take account of the eventual delivery date).

3.21 The clients interviewed for the evaluation appeared aware of some of the barriers Family Nurses experienced in meeting every scheduled visit, mentioning the snow and their Family Nurse being on holiday or ill as reasons for gaps in visits. Client views on the duration and frequency of visits were generally positive though, with clients describing the level of contact during pregnancy and the post-partum period as 'just enough' and stating that they were able to get in touch with their Family Nurse between appointments by text or phone in any case if they needed additional support. More negative comments, however, included a view that home visits were sometimes too long and took up too much of the client's time and complaints about Family Nurses being late or cancelling appointments with short notice.

3.22 A specific issue also emerged from interviews with clients and the NHS Lothian, Edinburgh Family Nurse team about the level of support clients receive when a baby is taken into care. As long as the mother is engaged, the mother continues to receive visits from their Family Nurse. At the same time, unless there has been a clear decision that the baby will not be reunited with the mother, Family Nurses also continue to visit the baby, sometimes separately from visits with the mother when they are living apart. Interviews highlighted the continuing desire of mothers in this situation to receive support from their Family Nurse, but also the challenges for Family Nurses in delivering the programme in this scenario, which could lead to a client perception that the Family Nurse was supporting the baby more than the mother. The process for working with clients where a baby is taken into care is complex and the level of contact between Family Nurse and client may depend on a large number of variables including: whether the baby was taken into care with the mother's consent or whether he or she was removed; whether the arrangement is temporary or permanent (in most cases babies will be taken into care on a temporary basis initially, and this arrangement may or may not become permanent); the reasons for the baby being taken into care (which in some cases might create safety issues for Family Nurses around continuing with home visits - for example, if there were concerns violence in the home - as well as issues around criminal proceedings); the amount of time the mother has available for Family Nurse visits alongside supervised visits to the baby; and the mother's reaction to any involvement of the Family Nurse in the decision to take the baby into care. Interviews with the NHS Lothian, Edinburgh Family Nurse team also identified some challenges around delivering the content of the programme when a baby is taken into care (discussed further in Chapter 4).

Nature of the relationship between clients and Family Nurses

3.23 As discussed above, the nature and strength of the relationship between client and Family Nurse was considered key to maintaining engagement with the programme and to being able to agenda match the content effectively (see Chapter 4 for further discussion of this). In the second wave of evaluation interviews, conducted around 3 months after clients had delivered their babies, both clients and Family Nurses reflected on the ways in which their relationships with each other had developed during the pregnancy and post-partum period. While some relationships had taken longer to establish than others, Family Nurses suggested that in general their relationships with their clients were now deeper and that the 'therapeutic' aspect had become more prominent. These views were echoed in comments from clients, who described feeling more comfortable talking to their Family Nurses about a wide range of issues once they had got to know them better.

I think now I'm getting to know her better, we're getting on a lot better … I feel … more comfortable like speaking about anything, so I just let it all go basically. Just talk about anything! (Client 12)

3.24 Clients also clearly valued both their Family Nurse's professional knowledge, while the ways in which they acknowledged and recognised clients' own knowledge and strengths could have a significant impact on client confidence.

She's someone easy to talk to … She's like a friend to talk to, and then she's like … a professional as well. (Client 3)

There is a lot of folk actually out there that are like, 'Right, you're a young mum. You're not very good. How are you meant to cope with a child when you're basically a child yourself?' And it kinda does put you down and that. And … they do build you up 'No you're not. You're a brilliant mum. You're doing fabulous.' … So it just makes you feel like 'Maybe I'm not, ken, a young mum. Maybe I'm not daft and can't bring him up … Maybe I'm actually a good mum and I can do this.' (Client 16, paired interview)

3.25 Where clients and Family Nurses reported challenges or difficulties in their relationship, this tended to relate to lower levels of contact between them at particular points (reasons for which are discussed above) and/or to specific challenging circumstances (such as a baby being taken into care, discussed above).

Relationships between Family Nurses and the client's wider family

3.26 FNP is underpinned by 'human ecological theory', which highlights the importance of mothers' social, community and family context in influencing their decisions and behaviour and the ways in which they care for their children. Family Nurses therefore attempt to involve the wider family in visits where it is possible and appropriate to do so. The NHS Lothian, Edinburgh FNP site recorded that clients' husbands or partners were present for 32.8% of visits during the pregnancy phase.

3.27 Family Nurses reported that they encouraged clients to involve their partner and/or the baby's father with FNP. However, Family Nurse's and client's accounts of the level of involvement fathers/partners have in practice reflects a wide range, from little or no contact, to dipping in and out of sessions, to fathers who are very engaged and attend most sessions. Clients reported that where partners did not attend sessions, they nonetheless sometimes completed worksheets or read information left by the Family Nurse. Family Nurses' views on the relationship between the stage of the programme and fathers' levels of involvement varied - one view was that they saw more of them antenatally, while another was that fathers often became more engaged after the baby was born when they wanted to get more involved in the baby's care.

3.28 Barriers to involving fathers/partners included:

• Practical barriers around arranging visits to suit both client and father/partner, particularly where fathers/partners were working or studying full time. Family Nurses noted that they sometimes arrange later visits so that fathers/partners can attend.
• Client-related barriers - for example, Family Nurses reported that clients sometimes did not want their partner to be very involved as they felt their Family Nurse was 'theirs'.
• Father/partner-related barriers - both Family Nurses and clients reported that sometimes partners just elected not to be involved.

3.29 Clients' and partners' accounts of the impact of involving partners in FNP in the pregnancy and post-partum phase tended to focus on the benefits of their Family Nurses advice for their relationships (discussed below) and on their partners' confidence about the birth, rather than on practical childcare skills. Comments from Family Nurses, clients and partners suggested that Family Nurses could help give partners a better understanding of the birth itself and help them to feel more comfortable and confident about their role in this.

Certainly one of them was delighted to share with me that he actually managed to cut the cord in the end, because that was something he hadn't been sure about and we'd spoke about it beforehand, that he wasn't under pressure but if he wanted to this is what it would look like, this is what it would feel like and … he was quite delighted that he had been able to do that. (Family Nurse 5)

3.30 Although only a small number of partners were interviewed for this evaluation, and these are likely to be among those who were more involved with FNP, their comments nonetheless highlight the value they placed on their involvement and on being able to use the Family Nurse as a source of information when they had questions and concerns.

(Family Nurse) has answered my questions and queries just as … as if I was the main sort of focus as client as well. I don't feel like the second person. I feel like we're together so (Family Nurse) sees us together. (Significant Other 1)

3.31 While figures on the involvement of other family members in visits are not collected as part of FNP monitoring data, Family Nurses report that clients' mothers are often present for visits. While the involvement of clients' wider support network was welcomed, on occasion it could also be challenging, particularly where grandmothers appeared to consider that they knew as much or more about childcare compared with the Family Nurse. Family Nurses again described using a strength-based approach to address any potential conflict with other family members - by acknowledging their experience and wisdom and the support they can offer to the baby's parents, but at the same time recognising that good practice and advice about looking after babies might have moved on since they had their children. Where their Family Nurse had met either their mother or their wider family, clients reported that they got on well and that their family appreciated having someone to ask questions of.

Impact of FNP on clients' wider relationships

3.32 'Family and friends' is one of the key topic domains for FNP, which aims to support clients in identifying and building or maintaining strong networks to support them as parents. The explicit focus of the programme on clients' wider relationships, as well as the immediate health needs of mothers and their babies, is something that arguably distinguishes it from universal health services. Family Nurses noted that discussing clients' relationships could be challenging, particularly where the client was experiencing problems. Examples of strategies for encouraging clients to open up about their relationships included asking them to reflect on other relationships (not their current one) as a way of helping them to put their current relationship into perspective, and asking clients to reflect on why they thought a partner or family member was reacting in a particular way.

3.33 Clients interviewed for the evaluation gave a range of examples of positive impacts they felt their Family Nurse had on their relationships with others, including:

• Improved communication. Clients described their Family Nurse doing practical communication exercises with them, giving them ideas for ways of framing concerns without escalating conflict, and helping them think about how their actions or words might affect others. These kinds of activities and discussions were viewed as having helped them communicate in a more helpful, mature fashion and to share feelings more openly. Clients suggested that this help had improved (or even saved) relationships with partners, as well as helping diffuse conflicts within their wider family:

It did actually help. Like sometimes if we were having an argument, I'd try and, like, say stuff she had told me … and most of the time it did actually work. Like it calmed the situation down. (Client 13)

• Improved self-efficacy/confidence. Where clients were experiencing difficulties with other family members giving unwelcome advice about looking after their baby, they described their Family Nurse helping them with strategies for disagreeing with them while avoiding major conflict. This advice was seen as having both practical impacts - for example, being able to resist pressure from other family members to wean early - and emotional impacts in terms of improving their confidence in their ability and rights as parents.

3.34 More generally, clients also reported their Family Nurses checking in with them regularly to make sure that they do have enough support - for example, by helping them map their support network, checking that they are getting to see their friends, and asking about their relationships with wider family. In some cases, clients reported feeling quite isolated after they became pregnant - highlighting the importance of their social networks for young mothers.

Key points

Does the programme meet the fidelity targets for attrition?

• The percentage of clients leaving the NHS Lothian, Edinburgh FNP programme or 'inactive' (no contact for 6 months) during the pregnancy phase ('attrition') was 6.8% - well below the 10% maximum 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. Both clients and Family Nurses felt their relationships had developed and strengthened during the pregnancy and post-partum periods.
• Reflecting on approaches that might have prevented a minority of clients from disengaging during pregnancy, Family Nurses' comments suggest that, for the most vulnerable clients a highly flexible approach to meeting their needs might be required.

Do the Family Nurses carry out the intended number of visits? How feasible/appropriate is the visiting schedule?

• 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

How involved are fathers in the FNP process/visits? Is the FNP seen to engender fathers' involvement?

• 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.

Do clients mobilise support within personal networks?

• Clients reported that their Family Nurses had supported them to communicate more effectively and to feel more confident about disagreeing (where appropriate) with their partners and wider family, with a positive impact on both their relationships and on their sense of control as parents.

Other findings

• Challenges or difficulties in Family Nurse-client relationships tended to be seen as related to lower levels of contact and/or specific challenging circumstances (like a baby being taken into care).