The Evaluation of the Family Nurse Partnership Programme in Scotland: Phase 1 Report – Intake and Early Pregnancy

9 DISCUSSION

9.1 Introduction

In the previous chapters we have outlined the views and experiences of clients, Family Nurses and key stakeholders in relation to the early implementation, client recruitment and pregnancy phases of the programme. In this chapter, we discuss the key learning points for the wider implementation of the FNP in Scotland. We also briefly discuss some issues around transfer of learning from FNP to wider nursing and professional practice in Scotland.

9.2 Conclusions and key learning points

The early stages of the FNP programme in Edinburgh appear to have been particularly successful in terms of:

• The high degree of fidelity achieved in relation to both the Core Model Elements and fidelity 'stretch' goals. The Family Nurse recruitment process, the engagement and enrolment of eligible clients, training, supervision and programme delivery were all achieved with a high level of programme fidelity. The recruitment process attracted a team of Nurses reflecting extensive and varied professional experience.
• The level of acceptance of the programme by clients - with the proportion of eligible clients who agreed to participate exceeding the fidelity 'stretch' goal for acceptance.
• The development of good, trusting relationships between Family Nurses and clients, with their descriptions of 'agenda matching' in meetings and their views of their therapeutic relationships closely reflecting the central values and principles of the programme. The degree of trust and respect between clients and Family Nurses also highlights the benefits of the strengths-based approach which underpins FNP in working with vulnerable young women.
• The value clients placed on having support during, as well as after, the birth of their first child.
• The influence of the Family Nurses' own degree of comfort in discussing sensitive issues on clients' willingness to discuss topics like sexual health.
• The value clients placed on referrals to services specifically targeting younger women, and on the advice and help they received from their Family Nurse on issues beyond maternal and infant health - like housing benefits and money management.
• The involvement of user-recruiters in the recruitment process for Family Nurses - with users identifying the same preferred candidates as the panel.
• The value Family Nurses placed on the training delivered by the National Unit at the DHFNP National Unit - perceived to be of a higher quality than any previous professional training that they had received.
  
• The value Family Nurses placed on the individual and group supervision received.

In addition to these substantial successes, the early phase of the evaluation also identified a number of challenges experienced in implementing FNP in the first Scottish pilot site, which can be learned from as the programme is extended to other areas of Scotland (or, indeed, elsewhere). Key learning from these challenges includes:

• Giving careful consideration to any decision to front-load client engagement during the recruitment phase. Any front-loading will require careful management to ensure that Family Nurses have time to become familiar with the programme and to consolidate their learning before their number of cases increases significantly.
• The decision to front load using existing Maternity Trak cases also appeared to increase the proportion of clients who were already 16 weeks at enrolment (the one Core Model Element the programme appears to have missed during the recruitment phase). However, this also reflects the decision to offer FNP to all eligible women identified during the recruitment period. Given that most pregnant young women will be in contact with health professionals in advance of 16 weeks gestation, perhaps this element of FNP is less crucial to its success in the Scottish context - providing that clients are still enrolled sufficiently early in their pregnancy to allow for the full 'dosage' of FNP home visits to be delivered.
• The early stages of the programme appear particularly challenging to deliver within normal working hours. This highlights the central importance of ensuring that workloads are monitored on a continual and transparent basis, with supports in place to address excessive workloads, as well as the potential need to consider more formal ways of alleviating pressures on workloads early in the implementation of FNP.
• Considering the timing of master classes and additional training, to ensure that it is delivered close to the time when the Family Nurses are ready to use the skills covered.
• Ensuring there are sufficient opportunities for paced learning and consolidation of that learning can be challenging, particularly in the early stages of delivery. However, this is clearly viewed as extremely important to Family Nurses' development and should be considered and reviewed regularly.
• Having an appropriate and fully functional database in operation at inception is very important in terms of supporting effective supervision and avoiding unnecessary additional work for the Supervisor and local FNP Lead.
• The management structures for FNP were viewed as sometimes confusing for the professionals involved. Where multiple organisations are involved in managing and delivering FNP, management roles and lines of reporting need to be very clearly agreed and articulated to all those involved.

Subsequent reports will provide more detailed information about the entire pregnancy and infancy periods of the FNP programme in Edinburgh, and will consider the experiences of the programme through the eyes of the panel of 15 clients, their Family Nurses and members of their families.

9.3 Wider learning

In terms of learning beyond the FNP programme itself, strategic stakeholders and others suggested that the programme is in a position to inform the community nursing agenda and to influence practice in Scotland more widely. Indeed, the Scottish Government FNP team are contributing to the Modernising Nursing in the Community Programme. The key ways in which the FNP programme was perceived to be potentially influential included lessons relating to the implementation of change within the health service, engaging and supporting service users and, specifically, and offering a different approach to interacting with service users, particularly via the use of motivational interview techniques and a 'strength based approach' (reflected in an increasing interest in 'assets-based' approaches in health interventions more generally - see for example Assets Alliance Scotland, 2010). ²⁴

However, whilst taking into account that the FNP it still at a very early stage in Scotland, there would appear at this early stage to be some barriers to ensuring learning transfer of this kind. Stakeholder informants were very clear that a critical aspect of FNP (if not the critical aspect) is that it is a carefully prescribed, manualised programme with defined inputs (the Family Nurses, the training, supervision etc) and outputs (the prescribed number of visits, specified content of contacts, albeit within a context of agenda matching, and the materials that the Nurses use during the contacts with clients etc).

The dilemma for learning transfer is two-fold. First, those involved in the development and delivery of the programme were clear that, for example, motivational interviewing and strength-based approaches are elements of the evolving "therapeutic relationship" between clients and Family Nurses which could be learned from. However, the evidenced outcomes for FNP depend on meeting the stringent Core Model Elements and fidelity 'stretch' goals which extend beyond the use of specific techniques. The success of the programme is, put simply, more than the sum of its individual components. Second, the licensing agreement and copyright restrictions do not allow the materials to be used outwith the programme. So, however useful those materials are deemed to be (and the team did regard them highly), they cannot for Intellectual Property Right reasons (intended to prevent inappropriate or poor replication of the programme) be shared with, for example, community nurse colleagues. There are, therefore, some challenges relating to the extent to which experience of FNP can be effectively embraced more widely in the light of these dilemmas in relation to learning transfer.

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