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

1 SUMMARY OF KEY FINDINGS

This section summarises the key findings from the first year of the evaluation of the Family Nurse Partnership ( FNP) programme in Scotland. It focuses on the early implementation and pregnancy ¹ period of the programme. Future reports will include findings on the birth and postpartum, infancy and toddler periods of the programme.

1.1 Summary of progress towards Core Model Elements and fidelity 'stretch' goals

Table 1-A summarises the progress of the first Scottish FNPtest site in Edinburgh towards the Core Model Elements during the first year of the programme. Fidelity 'stretch' goals for which data was available for this report are also shown in italics. Core Model Elements and fidelity 'stretch' goals for which final data is not yet available will be reported on in subsequent reports.

Table 1 A Progress towards Core Model Elements and fidelity 'stretch' goals in the first year of FNPEdinburgh

	Progress in year 1	Commentary
Clients
Enrolment and participation is voluntary	Achieved	Family Nurses engaged with potential clients to introduce the programme and allowed them time to make a decision about whether or not to enrol.
Eligible clients include first-time mothers only	Achieved
Eligible clients include high risk mothers only	Achieved	For the test site, this was defined as mothers aged 19 and under at LMP. All enrolled clients were in this age range.
60% of clients enrolled by 16 th week of pregnancy	Not achieved	Several main factors appear to have created challenges to meeting this CME: first, the decision to offer the programme to all eligible women during the recruitment period, rather than focusing engagement on those under 16 weeks; second, the decision to approach all eligible women on Maternity Trak at the start of the recruitment period, which meant the average gestational age at enrolment was higher in the early months (since Maternity Trak included women already further along with their pregnancies); and third, the time taken to engage some women with the programme and to support them to make a voluntary decisions, which sometimes meant that while they were engaged prior to 16 weeks, they did not enrol until after this point.
100% of clients enrolled no later than the 28 th week	Achieved

	Progress in year 1	Commentary
Family Nurses
Each client enrolled is visited by the same FN throughout her pregnancy and the first 2 years of her child's life	TO BE ASSESSED IN SUBSEQUENT REPORTS	This CME appears to have been met to date, but it is too early to assess whether it has been fully achieved.
75% of eligible clients who are offered the programme are enrolled	Achieved	80% of those offered the programme enrolled with it.
Family Nurses are registered with the NMC, educated to degree level and meet the person specification	Achieved
Family Nurses follow the FNPlearning programme and attend all FNPspecific essential training	Achieved
Follow the FNPHome Visit Guidelines	TO BE ASSESSED IN SUBSEQUENT REPORTS	Data on 'dosage' and fidelity to the Home Visit Guidelines are not included in this report, given the focus on the early pregnancy period.
Apportion home visit time among content domains within the ranges specified	TO BE ASSESSED IN SUBSEQUENT REPORTS	Data on 'dosage' and fidelity to the Home Visit Guidelines are not included in this report, given the focus on the early pregnancy period.
Actively participate in FNPsupervision as specified	Achieved (to date)
Be trained in specified approaches for establishing therapeutic relationship and motivating clients for positive behaviour change	Achieved	Nurses were trained in both the use of strengths-based approaches and in motivational interviewing.
Carry a caseload of no more than 25 families per full-time employee	Achieved	Each full-time Family Nurse had a caseload of 25

	Progress in year 1	Commentary
Family Nurses cont.
Each nurse enrols 25 families (or pro rata adjusted) within 9 months of recruitment commencing	Achieved	Recruitment commenced at the end of January 2010 and was complete by the end of October 2010 (9 months).
Work at least 3 days a week on the programme.	Achieved to date
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 David Olds.	TO BE ASSESSED IN SUBSEQUENT REPORTS	Although evidence to date suggests that Nurses were collecting all the data as required, further monitoring data and evidence will be required to assess whether this has been fully achieved.
Work exclusively in this programme	Achieved	Family Nurses were recruited specifically to work on the FNPEdinburgh programme.

	Progress in year 1	Commentary
Programme supervisors
Be registered with NMC, at least equivalent in education and training to the family nurses, preferably educated to masters level and meet the person specifications	Achieved
Follow the FNPlearning programme and attend all FNPessential training, as well as supervisor training and action learning sets	Achieved
Carry a supervisory load of no more than 8 family nurses	Achieved	The Edinburgh Supervisor is responsible for 6 Family Nurses.
Carry a small clinical caseload	Achieved to date	The Edinburgh FNPSupervisor has a caseload of 2 families
Work at least 3 days a week on the programme	Achieved to date
Use programme reports to assess and manage areas where systems, organisational or operational changes are needed in order to enhance the overall quality of the programme operations and to inform reflective supervision with each family nurse	Partially achieved	The lack of a tailored database designed for extracting data for use in supervisions created some obstacles to running programme reports that were as up to date or useful as ideally required to inform reflective supervision. Although the local FNPLead in NHSLothian worked with the Supervisor to provide working solutions to support supervision, this was nonetheless viewed as falling short of the ideal.
Meet one-to-one with each family nurse at least weekly to provide supervision	Achieved to date

	Progress in year 1	Commentary
Programme Supervisors cont.
Conduct at least 4 team meetings per month: 2 to discuss programme implementation and 2 case discussions to identify client problems and solutions	TO BE ASSESSED IN SUBSEQUENT REPORTS	The accounts of Family Nurses and the supervisor suggest that group supervisions were happening regularly and were highly valued. Subsequent reports will clarify the extent to which it has been possible to stick to the group supervision schedule in different phases of the programme.
Develop opportunities for learning within the team and invite experts from other disciplines to participate in case discussions whenever cases require such consultation	TO BE ASSESSED IN SUBSEQUENT REPORTS	A clinical psychologist and child protection advisor were involved in group supervisions with the FNPteam in Edinburgh. The role played by these and other experts will be explored in more detail in subsequent reports.
Make a minimum of one home visit every 4 months with each family nurse	Achieved to date	Family Nurses reported being accompanied by their supervisor on two client visits every 16 weeks.
Administrative support
Each site will employ someone to provide support to the family nurses, including ensuring that data about family nurse activity, visit content, mothers and children are submitted completely and accurately on a timely basis and providing general administrative support	Achieved	The administrator has played a central role in supporting the delivery team and in managing inputting data from Nurse visits. It's perhaps worth noting though that although the FNPadministrator inputs the initial data from Nurse Home Visit forms, this work has needed to be verified by either the Supervisor or local FNPLead in NHSLothian, due to the lack of automated verification and checking functions on the temporary database.

1.2 Eligibility and enrolment

1.2.1 The acceptability of the programme

The programme fidelity requirements for enrolment in FNP were achieved in all respects but one. One hundred and forty-eight young women were successfully enrolled with FNP in Edinburgh. As well as achieving the fidelity 'stretch' goal of enrolling 25 families per Nurse (plus 2 families for the supervisor) within nine months of recruitment commencing, this figure also represents 80% of all eligible clients who were offered the programme, surpassing the 75% fidelity 'stretch' goal for programme acceptance. Fidelity was also achieved in the following respects: all of those enrolled were aged 19 years or less at conception, all lived within Edinburgh CHP, all were first-time mothers and all were enrolled before the 28 ^th week of pregnancy.

Fidelity was not achieved for the proportion of mothers who were enrolled at less than 16 weeks gestation - 32% of clients were enrolled by this stage in the pregnancy, short of the 60% specified in the Core Model Elements. Sixty per cent of clients were recruited by 18.5 weeks of pregnancy, however. It is worth noting that a number of the first 10 pilot sites in England were also unable to achieve the 60% target (Barnes et al, 2008). The overall proportion of clients recruited by 16 weeks across the first year of the English pilot sites was 51%, ranging from 28% to 73% across different sites. In the first Scottish FNP pilot site, several factors appeared to have influenced ability to recruit 60% of clients prior to 16 weeks. First, the programme was offered to all eligible women who became known to the delivery team during the recruitment period - both in order to meet the required number of participants and because of the test site's philosophy of providing an equitable service. Second, the front-loading of client engagement and enrolment using Maternity Trak data for all women eligible for FNP at the start of the recruitment phase (including those closer to 28 weeks at that time) meant that the average gestational age of clients recruited at the start of the programme was somewhat higher than it might otherwise have been. Third, the time required to engage with clients and support them in making an informed decisions meant that for some clients, although Family Nurses were engaging with them prior to 16 weeks of pregnancy, they did not make a final decision about enrolment until after this point.

A key reason clients gave for enrolling with FNP was the frequency and timing of visits - clients appreciated being offered a number of visits before as well as after the birth, and this was contrasted with the more limited (and primarily post-natal) support available from Health Visitors.

Only two clients left the programme during the early pregnancy phase (final figures for the pregnancy period will be available in the next report).

1.2.2 Identifying eligible women

Eligible women were identified using the NHSLothian database "Maternity Trak", which records information about all pregnancies to women in Lothian as soon as they are known to health professionals. As a result, there was a group of potentially eligible women, who were already known to services and who could be offered a Family Nurse very quickly at the start of the recruitment phase. The use of Maternity Trak also meant that the team would not have to rely solely on midwives to access potentially eligible young women. This, in turn, allowed the Family Nurses to present the programme to women without the filter of other professionals who, however supportive of FNP, may not (yet) have the same investment and commitment to the programme.

However, while there were clear advantages to using Maternity Trak, it also became clear that the information recorded on this database was not always completely accurate. First, as pregnancies might be included on the database before the due date was confirmed by ultrasound, young women may be further advanced in their pregnancies than initially assumed and, hence, may not be eligible for FNP or were enrolled at a later stage in their pregnancy. Second, pregnancies may have been included on the database which were then subject to maternity loss through miscarriage or termination.

1.3 Experiences of the (early) pregnancy phase of the programme

1.3.1 Establishing the client-nurse working relationship

The visiting schedule can include up to 14 contact visits during pregnancy, each intended to last approximately 60-90 minutes. Clients' accounts suggest that there were times when visits were longer and, moreover, that there were often contacts between Nurse and client by telephone (calls and text) between visits. Clients appreciated the frequency of contacts during pregnancy and the time that their Family Nurse spent with them; they valued the relationship of trust that evolved between them and felt respected and acknowledged by their Family Nurse. This was based on a strong sense that their Family Nurse talked with them in a non-judgemental way, respected their confidentiality and supported them to make their own decisions - highlighting the benefits of using a strengths-based approach in working with potentially vulnerable young women. While clients initially found some topics - such as sexual health - difficult to discuss, the Nurses' own level of comfort in raising these issues encouraged clients to participate on potentially sensitive topics. Clients clearly recognised that, although there was a structured programme being delivered, there was also flexibility. Although they did not use the term "agenda matching", they experienced the process in a positive way and perceived the Family Nurses as willing to be guided by the clients' needs and interests. In other words, clients' accounts suggest they experienced the programme in ways that reflected the FNP values and approach and pointed to a growing 'therapeutic alliance' with their Family Nurses.

Not only did clients value and appreciate their Family Nurses' time and approach to them, there was evidence of shifts in clients' knowledge, attitudes and some behaviours which they attributed to their involvement in the programme. Clients interviewed for the evaluation all reported that they had discussed health behaviours with their Family Nurse and that they had become aware of risks that they had not hitherto known about. Further, they indicated that their Family Nurse had supported their access to and understanding of ante-natal services. Clients particularly appreciated referrals to classes designed specifically for younger mothers. The support Family Nurses provided with non-health issues - for example, housing and benefits - was also appreciated, particularly since one view was that obtaining housing benefits could cause more problems in pregnancy than anything else. Clients reported that discussions with their Family Nurses had impacted on their thinking about spending and saving money, which they might not previously have considered.

1.3.2 Involving others

There was evidence from clients and Family Nurses of fathers' involvement in FNP visits, although the extent to which this happened varied widely among those clients interviewed for the evaluation. Postpartum interviews with a client's "significant other" will include a number of fathers. As such, the next report will be able to explore this issue in greater detail and from the fathers' perspectives. Suffice to say, from the clients' perspectives, their partners were included by the Family Nurse and were given opportunities to participate in visits, or through materials left for them after visits. There were accounts too of other family members feeling that they had gained from the programme in terms of their own knowledge and understanding of - for example - the risks of passive smoking in pregnancy.

1.4 Recruitment, training and supervision of Family Nurses

1.4.1 Recruitment of the Family Nurse team

Programme fidelity includes closely specified requirements in relation to Family Nurse recruitment, training, supervision, and the collection of monitoring data. The team of six Family Nurses, all of whom met the requirements set out in the Core Model Elements, was appointed following a national recruitment initiative. It was very clear that the programme attracted highly motivated and skilled health professionals, who are committed to the FNP and who met the programme specifications. Those involved in the recruitment process commented that it was an enormous advantage to be in a position to recruit an entire team at the same time: this allowed the selection of Family Nurses with a range of complementary skills, and attributes, reflecting extensive and varied professional experience.

Potential service users, including teenage mothers or mothers-to-be, their partners and families, were invited to be involved in the recruitment of the Family Nurse team. This innovation was embraced by the service users who worked with FNP lead and the Psychologist to define questions to ask of the candidates and was perceived by stakeholders as a very positive experience. The user-recruiters identified the same preferred candidates as the professionals involved in the recruitment process.

1.4.2 Training

Training of the Family Nurses and Supervisor was delivered by the DH FNP National Unit via a consultancy agreement with Scottish Government. The Family Nurse team were, without fail, enthusiastic about the range and quality of the training that they had received. There was great respect for the "excellent" training provided by DH FNP National Unit, even if the team found the travelling to attend training to be an additional pressure. It was acknowledged by all that would not currently be feasible to provide the training without the expertise and resources in England. Moreover, there were perceived benefits for the team beyond the actual training itself in terms of peer support and networking. It was very clear, for everyone involved, that the training provided not only formal inputs, but also provided opportunities for informal peer learning and exchange, which were seen as being of almost equal importance to the formal learning opportunities. The need to travel to England for peer learning and exchange may, of course, change as more sites are developed in Scotland.

However, while the training was clearly very highly valued, it was also clear that the Family Nurses felt, at times, overwhelmed by the need to complete the training while enrolling clients at - what they perceived to be - a fast rate. Not only did this place pressure on them, with an additional burden of having to travel to England to receive the training, but it was felt that it gave them little or no time to consolidate their learning within the FNP Edinburgh team - a finding that closely reflects the experiences of the pilot sites in England in their first year (Barnes et al, 2008). Finding ways to make space for consolidation was viewed as a key way in which training and learning would be enhanced. There was also a view that some elements were delivered too soon and that, in hindsight, the training programme did not necessarily need to be as compressed into a 12 month period. It was suggested that certain master classes, and DANCE training, would have been better delivered at a time when they were ready to use those specific skills.

1.4.3 Supervision

Supervision is integral to FNP. It was clear that the Family Nurses greatly valued the supervision model and felt themselves to be well supported by both the Supervisor within one-to-one weekly sessions and the group sessions with the Team Psychologist. Individual supervision sessions gave Nurses the opportunity to focus on specific clients, and to work through challenges they experience from a client-based perspective. Although there were concerns that these sessions might have been better informed if more detailed monitoring data had been available, there was a very clear view among the Family Nurses that they had never been so supported in their professional work.

1.5 Challenges in implementing FNP in Scotland

1.5.1 Factors affecting Nurse workloads

The Family Nurses' commitment to the programme was evidenced by their attendance at all training, their preparation for client visits, their ability and willingness to embrace the programme in all its complexity, their availability to their clients and their faithful delivery of the programme. Initial anxieties about delivering the programme appear to have been successfully overcome through training and support. The monitoring data also show that fidelity was achieved in key respects in relation to client enrolment and programme delivery. The Family Nurses, supported by the Supervisor, worked hard to deliver the programme in terms of the intended number of visits and - insofar as we can ascertain at this stage - in terms of delivering the required "dosages".

However, although fidelity was achieved for most elements, the first test site in Scotland nonetheless experienced some significant challenges relating to workloads in the first year of the programme. These included front-loading of enrolment in the early stages in combination with staff sickness which resulted in Family Nurses having larger than originally anticipated caseloads at an earlier stage of delivery, geographical challenges, and the need to combine the already heavy workload with travel to training. The fact that clients enrolled early on were further on in their pregnancies on average also meant that the first births occurred sooner in the programme than anticipated, at a point when the Nurses had only just completed the infancy training.

While the Family Nurses' clinical contacts did not usually exceed the normal working week or usual working hours, it was clear that travel to training and preparation time for client contacts could not necessarily be contained within normal working hours. It was also the case that the long hours cited by Family Nurses reflected, to some extent, personal decisions on their part to manage their travel to England for training in particular ways or to work after returning from training. This, in turn, was again a reflection of their commitment to their clients.

However, these findings reflect evidence from evaluation of the first 10 pilot sites in England which strongly indicated that Family Nurses are not able to deliver the early stages of the programme within their normal working hours. Indeed, on the basis of a specified recording of their hours, it appeared to be the case that Nurses in the first 10 pilot sites in England were working 20% above their standard hours (Barnes et al, 2008). Future sites may wish to consider how this issue is addressed - for example, by extending the recruitment period beyond 9 months, considering carefully how any front-loading of recruitment is managed, and perhaps examining the timetable for some aspects of training.

1.5.2 Management issues

There are distinct and clear line management and professional supervision structures within NHS Lothian for programme delivery. However, stakeholders in all sectors voiced the opinion that the management structure for the programme was confusing at times due to the number and the relatively high status of those involved in the Edinburgh site. This had led to some stakeholders perceiving the management structures to be top heavy.

1.5.3FNP Database

It became clear at a relatively early stage - before the first clients were enrolled - that Scotland would not be able to use the database developed for the FNP sites in England. Although a database was commissioned at the end of 2010 with options hopefully available by April/May 2011, the lack of a National FNP database created some significant challenges for the FNP Edinburgh team during the first year of the programme. These challenges related particularly to the time and complexity involved in extracting data from a database initially set up as a short-term measure simply to store the data until a more tailored database became available. The lack of a user-friendly interface also limited the usefulness of the database in individual and group supervision meetings. While the local FNP Lead in NHS Lothian was able to extract some data for the Nurse supervisor, there was a strong perception that this was neither as easy to do, as up to date, nor as useful as it should be (and as it hopefully will be once the National database is available). There was also a strong perception that the significance and importance of the database for supporting the work of the FNP team was perhaps not fully recognised at the beginning.

Moving forward, it is hoped that the new National database will be available for all new FNP sites from the start, in order to avoid these difficulties and additional work for the implementation teams. The national solution must allow for the existing data from Edinburgh CHP to be imported, to ensure that all data collected since implementation can be drawn on for site monitoring and analysis.