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

6 PROFESSIONAL VIEWS AND EXPERIENCES OF DELIVERING THE PROGRAMME IN THE LATE PREGNANCY TO POSTPARTUM PERIOD

6.1 As the first FNP Team in Scotland, the experiences of the team in NHS Lothian, Edinburgh in delivering the programme are likely to be of substantial interest, particularly for newer FNP sites and Health Boards who may be considering establishing an FNP programme. Family Nurse views and experiences of delivering the programme to clients have already been discussed in some detail in Chapters 3 and 4. This chapter therefore focuses on other (non-client contact) aspects of the programme - particularly training and supervision. As both these issues were considered in some detail in the first Scotland evaluation report (Martin et al, 2011), discussion focuses on new issues or learning raised in interviews with the NHS Lothian, Edinburgh FNP team conducted in late 2011. The chapter starts, however, with a more general discussion of perceptions among the NHS Lothian, Edinburgh FNP team of their key achievements and of the key challenges associated with delivering the programme in the pregnancy and early post-partum period.

6.2 Key questions from the monitoring and evaluation framework relevant to this chapter include:

• Does the team receive the training and support intended, and develop the knowledge and skills required?
• How feasible/appropriate is the visiting schedule?
• Are FNP data entered into the FNP database in a timely fashion?

Key achievements

6.3 Family Nurses were asked what they viewed as the key achievements of FNP since they were first interviewed for the evaluation (in late 2010/early 2011). Unsurprisingly, impacts for and achievements of clients featured strongly. Family Nurses described themselves as 'walking alongside' their clients and were enthusiastic about the changes they perceived in clients' confidence levels and parenting ability, particularly in relation to those clients who were seen to be most vulnerable.

She (Supervisor) met one of our really quite vulnerable wee girls a few months ago when her baby was little, and then this girl came along to an FNP event the other day at half nine in the morning which is not her idea of fun … and she was really impressed with how this young woman presented, … you know sort of good eye contact, the big cheesy grin and … showing her baby off kind of thing. (Family Nurse 6)

6.4 The establishment of strong therapeutic relationships with clients was (as described in Chapter 3 and in the first Scotland evaluation report) viewed as key to the delivery of FNP. These relationships were evidently something the NHS Lothian, Edinburgh Family Nurse team were very proud of and (as discussed in Chapter 3) viewed as key to their high retention rates:

My personal achievement? … I feel … I've built up such a good strong therapeutic relationship with my clients that … I've not had any one who has left the programme … because of a breakdown in our relationship. (Family Nurse 3)

6.5 Increasing familiarity with, and confidence in using, both the programme materials and FNP's approaches to delivering these was also viewed as a key area of achievement since the first evaluation report. It was suggested that the team's initial confidence levels in delivering different elements of the programme varied in part with their particular professional backgrounds - those with a health visiting background might feel more familiar with the detailed content of the programme in the post-partum period, while those with midwifery experience reported finding the late pregnancy and birth stage relatively easier. Family Nurses thus reported having expanded their knowledge of areas that may not have been part of their original professional background as well as having gained in confidence using the specific facilitators and materials associated with FNP. The use of motivational interviewing and strengths-based approaches to delivering these materials, as well as the holistic focus of the programme (tackling social issues alongside health), was viewed as having led to significant shifts in professional practice and interactions with clients.

This is the lovely thing about, I think, the programme, is as a nurse, you want to 'fix, do, make things better' … Whereas what the programme has done is it's sort of freed that up a bit in the sense that, "OK. You've got a problem here. Let's look at it. What can you do to fix it? How can I help you find a solution to fix it?". And d'you know what? Most of the girls have got that now. (Family Nurse 4)

FNP covered, you know, the whole spectrum. It's not just about health practice ... It's about social practice as well, and it's about where all these social things actually interlink with health, and how everything links together for a better future for everybody. … So I guess it's probably the impact it's had on me is that, even if FNP didn't continue, or if .. if we chose to go back to our previous careers, I guess we would all … professionally visit in a very different way. (Family Nurse 1)

6.6 The potential achievements of FNP in terms of its perceived influence on wider services are covered in the next chapter.

Key challenges

Workload

6.7 The Scottish Government took a decision early on to fund a 1:6 ratio of Family Nurse Supervisors to Nurses, rather than the agreed maximum of 1:8. As this does increase the cost of the programme, it is important to monitor workload levels across sites. The findings below reflect the views of the NHS Lothian, Edinburgh Family Nurse team in late 2011, around half way through delivering the programme to their first cohort. Evidence from previous evaluations of FNP (e.g. Barnes et al, 2009, 2011) indicate that as Family Nurses' confidence and familiarity with the programme increase and the level of training reduces, workload pressures may reduce.

6.8 There was consensus among the Family Nurse team in NHS Lothian, Edinburgh that workloads remained a major challenge in delivering the programme. Issues around workloads were discussed in some detail in the first Scotland evaluation report (Martin et al, 2011). While workloads were believed to have eased somewhat since then, as of late 2011 delivering the programme within a standard working week (37.5 hours) was still seen as a significant challenge. The view that 'it's got marginally better, but it's not great' summed up opinion within the team.

6.9 The factors contributing to high workloads were, however, seen as changing depending on the stage of the programme. As discussed in Martin et al (2011), coping with the high volume of training at the same time as enrolling clients created challenges in the initial stages of delivery. Later, as clients started to deliver their babies, the need to visit them weekly in the 6 weeks post-partum could be difficult to accommodate in the hours available. Workload was also affected by the complexity of each Nurse's caseload. For example, cases where there were child protection issues often took up considerably more time (for attending case conferences, making referrals, etc) than others. The fact that NHS Lothian, Edinburgh was the first FNP site in Scotland was also seen as creating some additional pressures, relating to the volume of visitors to the project and the number of events team members were asked to host or attend, for example. Finally, other factors that contributed to workload pressures were less connected with FNP specifically and more related to the fact that the team is part of the wider NHS. An issue which the team felt had a significant impact on their workload in late 2011 was the requirement for them to move to electronic record keeping. Prior to this, Family Nurses had maintained hand-written records only, which they tended to write-up between visits. Being able to write up notes on a timely basis between visits was initially more difficult when the new system was introduced, leading to some duplication of effort (e.g. making hand written notes to type up later). At the time of writing, this had been resolved by providing the NHS Lothian, Edinburgh Family Nurse team with NHS laptops so that they could enter their notes directly between visits. Another issue arising out of the team's location within the wider NHS was the amount of time the Supervisor needed to spend on liaison with other NHS and non-NHS services. In general it was suggested that the requirements for UK-based Family Nurses to link with wider services, undergo standard NHS training, etc., might mean their workloads were heavier than those of their US counterparts.

6.10 In terms of strategies for managing workloads, as discussed in the first Scotland evaluation report, the Supervisor was viewed as being very supportive, including being firm about taking time back. In comparison with their first interviews, Family Nurses also reported putting more 'boundaries' themselves around their work to try and protect their work-life balance - for example, being stricter about the number of client visits they would try and fit into a single day and no longer trying to see every client in the week before annual leave. Other ways in which the NHS Lothian, Edinburgh team have tried to meet workload challenges include:

• Drawing on support from the Team Administrator in making up packs of materials, sending out client letters, setting up events, etc.
• Team discussions around ideas for time management
• Attempting to geographically 'cluster' visits, and
• Providing NHS laptops to facilitate record keeping in the field (as discussed above).

Other challenges

6.11 Other challenges to delivering the programme in 2011 included:

• Assimilating learning/gaining familiarity with materials - As reported above, the FNP Team felt they were becoming more familiar with FNP materials over time. However, the volume of materials associated with the programme was nonetheless seen as a lot to take in. It was suggested that they would feel much more confident about delivering the programme to the next cohort of clients.
• Gaining confidence with new approaches - Again, although using motivational interviewing and strengths-based approaches were areas where Family Nurses felt they had grown in confidence and skill, the move to using these approaches was viewed as involving a 'massive learning curve'.
• Challenges around keeping in touch with a mobile client group - As discussed in Chapter 3, the fact that FNP clients move house frequently and that some may have relatively complex or chaotic lives posed some challenges to meeting fidelity around visit numbers in pregnancy. While Family Nurses reported being extremely flexible and accommodating in their approaches with these clients, keeping them engaged was obviously challenging:

For example today I went out to see somebody and she wasn't around. I did text her this morning to remind her, I didn't hear from her. Went out, I texted her again, went out, not there, texted her again, she's in a new house painting the house and having, then having to rearrange. There's a lot of that kind of stuff (Family Nurse 2)

• Balancing necessary team changes with the requirements of a licensed programme. As noted in Chapter 1, there were several changes to the NHS Lothian, Edinburgh team in the last year, including the appointment of a new Family Nurse and the promotion of an existing team member to act up to supervisor two days a week. While these changes were discussed positively, they did create some challenges, particularly around balancing the desire to keep clients with the same Family Nurse (listed as one of the Core Model Elements) and training requirements for the new supervisor with the workloads of different team members.

Training

6.12 As described in Martin et al (2011), the formal training provided to Family Nurses in NHS Lothian, Edinburgh falls into three main categories:

• FNP programme specific training, delivered by the DH FNP National Unit. This covers the three main phases of FNP - pregnancy, infancy and toddler. Within each block, Family Nurses are trained on programme manuals, materials and facilitators.
• Master Classes relevant to Family Nurses. These cover approaches to delivering FNP, such as Motivational Interviewing, as well as specific topics (e.g. 'Perinatal Mental Health') and approaches to discussing these (e.g. PIPE, Partnership in Parenting Education, which focuses on practical approaches to supporting parent-child relationships).
• Mandatory NHS Lothian training, covering issues such as child and adult protection and NHS Lothian IT and records systems.

6.13 The FNP NHS Lothian, Edinburgh Team had already completed the mandatory 5 day residential pregnancy and infancy training courses at the time of their first evaluation interviews. Their views on this are reported in detail in Martin et al (2011). Reflecting back on the pregnancy and infancy phase training, Family Nurses again described the training as having been 'second to none', although challenges around finding time for absorbing and consolidating training (particularly for the infancy phase) were again noted. The only additional areas where, on reflection, Family Nurses suggested the National Learning Programme could have been improved were:

• Including more practical workshops. One view was that the programme was very focused on principles and delivery, and that it would have been helpful to spend more time on practical issues like understanding labour processes or on maternal mental health (also identified as a gap by Family Nurses interviewed in Barnes et al, 2008). Similarly, it was suggested that the PIPE training could have included more practical demonstrations. Understanding labour processes in more detail could be a particular issue for those who were not from a midwifery background. In Lothian, this was addressed by one of the team who did have a midwifery background running sessions on labour and delivery (described as 'hugely helpful' by other team members).
• Less reliance on self-directed learning for some topics. The decision to use self-directed learning for some FNP topics was made to support teams learning together locally and in response to the finding that pre-course work was required to maximise the effectiveness of some training. However, one Family Nurse view was that the PIPE and Smart Choices courses should both rely less on self-directed learning. Both these courses were seen as very valuable, but workload pressures could prevent Family Nurses from completing self-study and fully incorporating them into their practice until later in the programme. Expanding these courses and/or relying less on self-study were seen as ways of ensuring that Family Nurses are equipped to use this learning at the earliest opportunity.

6.14 Since completion of the FNP National Learning Programme, ongoing learning and development has been facilitated within the team via scheduled learning and consolidation days, and through the NHS Lothian, Edinburgh team's continued engagement with activities, workshops and conferences organised by the DH FNP National Unit. These include:

• Regional Learning Sets - which bring FNP Supervisors together in different venues in England on the same day for training.
• Supervisor Buddy Groups - the FNP Supervisor is currently 'buddyed' with supervisors in Sunderland and Durham. In addition to meeting for Supervisor peer support, these groups also organise joint learning sessions for their teams.
• Other workshops and events - for example a workshop on fathers' engagement with FNP.

6.15 Although the requirement to travel to England for these events was time consuming, there were perceived to be ongoing benefits to the NHS Lothian, Edinburgh team from being involved in learning activities with the English FNP sites, particularly from sites which are further on in implementing the programme than NHS Lothian, Edinburgh. There was therefore a concern that the NHS Lothian, Edinburgh team might miss out on valuable shared learning if these activities become more localised in the future (for example, Scotland-specific buddy groups once there are several FNP sites in Scotland).

6.16 Plans for further developing FNP training in Scotland include: the appointment of a new FNP Child Protection Lead within the FNP National Unit (Scotland) team; a new National Lead Psychologist; a National Lead Supervisor; and a DANCE trainer. The Child Protection Lead remit includes identifying specific learning needs relating to child protection in FNP in Scotland, and supporting the development of appropriate training to address these needs.

Supervision

6.17 Supervision is an integral part of the FNP programme. Perceptions of supervision among the NHS Lothian, Edinburgh Family Nurse Team were discussed in detail in the first Scotland evaluation report (Martin et al, 2011). The views and issues raised in Family Nurses' second interviews largely echoed those discussed there: Family Nurses commented on the priority attached to supervision within FNP, viewing this as 'invaluable' in supporting them with managing a challenging caseload and giving them the 'headspace' to reflect on and improve their practice. The fact that supervision is specified as part of the licensing conditions for the programme was viewed as key to enabling the team to prioritise it - without this, it might drop out of people's 'busy working week'. Additional points or developments in how supervision was approached raised in the second NHS Lothian, Edinburgh Family Nurse Team interviews included:

• The increase in frequency in Child Protection supervisions (from 6 monthly to quarterly). The Supervisor noted that this might mean that some cases that did not involve such issues received less attention in group sessions.
• The recent decision by the NHS Lothian, Edinburgh FNP Team to change their group supervision sessions from being completely 'open' (where Family Nurses only discussed those cases they felt they needed to talk about that week) to a more structured programme, with set clients to discuss at each meeting. This may be one way of ensuring that teams are able to learn from all their cases as a group, and not only those which raise specific kinds of concerns.
• The increasing perceived usefulness of supervisions with the team Psychologist, as Family Nurses have become more familiar and comfortable with these sessions.

6.18 While supervision within FNP was generally viewed extremely positively, there were a few suggestions from NHS Lothian, Edinburgh Family Nurses for changes to the way supervision was structured locally. These primarily related to the focus of FNP supervisions on specific clients as a way of learning from practice. One view was that while this was useful, it might also be valuable to spend more time talking about general clinical issues, or looking at programme delivery in general - for example, looking at materials and sharing views on ways of delivering that worked particularly well.

6.19 Finally, as discussed in the first Scotland evaluation report, the lack of a user-friendly database for FNP in Scotland, while not preventing effective supervision, nonetheless continued to be viewed as a significant limitation on the team's ability to creatively engage with the data Family Nurses collect within supervision meetings. It was also perceived as creating continued pressure on the Administrator's and Supervisor's workloads in relation to data checking and validation.

Key points

Does the team receive the training and support intended, and develop the knowledge and skills required?

• Family Nurses' views of the training they received remained extremely positive. The only ways in which it was felt training might be improved were including more practical sessions and relying less on self-learning (which could be difficult to find the time for).
• The ongoing opportunities FNP provides for learning and sharing practice - including with FNP teams in England - were appreciated by the team.
• The quality and level of supervision provided to the FNP team was viewed as 'invaluable', particularly in situations where the FNP manual materials were perhaps seen as relating less well to specific client needs. The fact that supervision was part of the license enabled the team to prioritise it.
• Supervisions with the team Psychologist were seen as increasing in value as the programme progressed and the team became more comfortable with these sessions.
• Suggestions for changes to supervision included spending more time talking about general clinical issues or looking at programme delivery in general.

How feasible/appropriate is the visiting schedule?

• General challenges in meeting the visiting schedule are discussed in Chapter 3. 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 the volume of visits and events associated with being the first FNP test site in Scotland) 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).

Are FNP data entered into the FNP database in a timely fashion?

• Although there were no reports of issues around the timeliness of data entry from the forms completed by Family Nurses at each visit, 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'.