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

Appendix E: FNP core model elements and fidelity ('stretch') goals

Taken from Family Nurse Partnership ( FNP) Management Manual November 2010.

Section 2 - Licensing Requirements - Guidance

Introduction

The University of Colorado owns the intellectual property rights of the Nurse-Family Partnership ( NFP). The Department of Health and SG, working jointly with the Department for Children Schools and Families ( DCSF) and SG Early Years Team, have negotiated that sites will be able to test the programme, known as the Family Nurse Partnership in Scotland and England.

The programme is licensed to make sure that the original research conditions are replicated so that we can be confident that the benefits to children and families are realised. We are testing the FNP because of its strong evidence base so it is important not to dilute or change the programme. Any adaptations need to be agreed with the SGFNP Team who will in turn work with FNP National Unit.

Fidelity

The Nurse-Family Partnership (known as the FNP in and Scotland England) is a licensed programme that has been developed, researched and refined over 30 years in the USA. The FNP programme can only be used under license and fidelity measures are used to monitor implementation.

There are 2 main systems for ensuring fidelity to the original research:-

1. The Core Model Elements of the programme cover the visiting regime, staffing requirements, client eligibility and the supporting organisational structures and processes needed. These are the core requirement of the licensing conditions.

2. The FNP Fidelity Goals relate to the delivery of the programme to clients and cover client retention, visit dosage and coverage of domains. These are stretch goals and give sites and the SGFNP Team and FNP National Unit a benchmark against which to assess delivery. In the testing phase it can be challenging to achieve these goals so the supervisor and the team use them to monitor their progress towards meeting them.

The FNP Core Model Elements

Core model elements are prescribed for 5 aspects of the programme:-

i. Client enrolment and engagement

ii. Family nurse recruitment, training and working practices

iii. Supervisor recruitment, training and working practices

iv. Administrative support

v. Interpreter support

FNP leads, supervisors and family nurses should be familiar with these requirements and ensure that they adhere to them.

i. Clients:

Enrolment and participation in the FNP is voluntary.

Eligible clients include first-time mothers only.

Eligible clients include high risk mothers only - during the testing phase this is 19 years and under at last LMP.

Sites enrol at least 60% of clients by the 16 ^th week of pregnancy and 100% no later than the 28 ^th week.

Each client enrolled is visited by the same family nurse throughout her pregnancy and the first 2 years of her child's life.

ii. Family Nurses:

Are registered with the Nursing and Midwifery Council ( NMC), are educated to degree level and meet the person specification for a family nurse.

Follow the FNP learning programme and attend all FNP specific essential training.

Follow the FNP Home Visit Guidelines 1) original visit schedule, which specifies the frequency and timing of home visits; and 2) the adapted programme guidelines, which specify the desired structure and content of each visit, and programme assessments and interventions to be used.

Apportion home visit time among content domains within the ranges specified.

Actively participate in FNP supervision as specified.

Be trained in specified approaches for establishing therapeutic relationship and motivating clients for positive behaviour changes.

Carry a caseload of no more than 25 families per full-time employee.

Work at least 3 days a week (20 hours per week) on the programme. Collect data about activity, visit content, mothers, and children according to the schedule and procedures specified by the international partner's data management team and approved by Professor David Olds.

Will work exclusively in this programme.

iii. Programme Supervisors:

Each programme supervisor will:-

Be registered with the NMC, at least equivalent in education and training to family nurses, preferably educated to masters level, and meet the person specification requirements.

Follow the FNP learning programme and attend all FNP essential training, as well as supervisor training and action learning sets.

Carry a supervisory load of no more than 8 family nurses (per full-time programme supervisor).

Carry a small clinical caseload (2-3 families).

Work at least 3 days (hours per week) on the programme.

Use programme reports to assess and manage areas where systems, organisational, or operational changes are needed in order to enhance the overall quality of programme operations and to inform reflective supervision with each family nurse.

Meet one-on-one with each family nurse at least weekly to provide supervision, preferably in person but by telephone where travel constraints limit family nurse or programme supervisor mobility.

Conduct at least 4 team meetings per month: 2 to discuss programme implementation and 2 case discussions to identify client problems and solutions.

Develop opportunities for learning within the team and invite experts from other disciplines to participate in case discussions whenever cases require such consultation.

Make a minimum of one home visit every 4 months with each family nurse.

iv. Administrative Support:

Each site will employ a person (at least 0.5 full-time equivalent per 100 mothers enrolled) to provide support to the family nurses and programme supervisor, including:-

Ensuring that data about family nurse activity, visit content, mothers, and children are submitted completely and accurately on a timely basis.

Providing general administrative support.

v. Interpreter Support:

In addition to the research-based core model elements, we have added a further element regarding requirements for working with non-English speaking clients within FNP. Sites may wish to offer eligible non-English speaking families the programme. If so trained interpreters will be needed to work with family nurses.

Where local demography indicates a predominant second language in the local community, sites will ensure that a consistent interpreter is available to support the programme. Where a number of languages are used, sites will work with local interpreting providers to ensure that wherever possible consistency of interpreter is achieved for each client.

The supervisor will be responsible for ensuring that the interpreters are given adequate training in FNP and use of interpreters will follow the FNP guidance (Ref 3.14).

Supervisors should discuss with interpreting providers responsibility for supervision and support of interpreters both within and outside of FNP.

FNP Fidelity Goals

The FNP fidelity goals have been set using the achievements of the NFP teams in the US research trials. In contrast to the core model elements, the fidelity goals are designed to be "stretch goals" in recognition that achievement of these fidelity goals is not solely under the control of the family nurse. However, the US research indicates that reaching these goals, or being close to them, will maximise the site's likelihood of achieving the same results as those found in the research trial. Supervisors will be sent regular reports detailing their team and individual family nurse achievements against these goals and will use these to learn about and reflect on their progress.

The stretch goals cover 4 main areas and some of the measures overlap with the core model elements:-

A. Recruitment

B. Retention of clients (measured by attrition rates)

C. Amount of programme received ("dosage" as measured by visits)

D. Appropriateness of programme content received (measured by the time spent of each domain).

A. Recruitment and Enrolment

The programme attains enrolment goals of:-

At least 60% enrolled before 16 weeks of pregnancy and 100% no later than the 28 weeks.

100% clients enrolled are first-time mothers, within the specified site age bracket.

75% of eligible clients who are offered the programme are enrolled.

Each family nurse enrols 25 families (or pro rata adjusted) within 9 months of recruitment commencing.

B. Attrition

Clients leave the programme at no more than these rates:-

Cumulative programme attrition is 40% or less through to the child's second birthday:-

ð 10% or less during the pregnancy phase.

ð 20% or less during infancy phase

ð 10% or less during toddlerhood

C. Dosage

Clients receive:-

80% or more of expected visits during pregnancy

65% or more of expected visits during infancy

60% or more of expected visits during toddlerhood

On average, length of home visits with participants is around 60 minutes.

D. Programme Content

It is expected that the content of home visits reflect variation in developmental needs of participants across the programme phases:-

Average Time Devoted to Content Domains during Pregnancy	35-40%
Environmental Health	5-7%
Life Course Development	10-15%
Maternal Role	23-25%
Family and Friends	10-15%

Average Time Devoted to Content Domains during Infancy
Personal Health	14-20%
Environmental Health	7-10%
Life Course Development	10-15%
Maternal Role	45-50%
Family and Friends	10-15%

Average Time Devoted to Content Domains during Toddlerhood
Personal Health	10-15%
Environmental Health	7-10%
Life Course Development	18-20%
Maternal Role	40-45%
Family and Friends	10-15%