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

7 RECRUITMENT, TRAINING AND SUPERVISION OF NURSES

This chapter considers the programme start-up from the perspective of stakeholders, Family Nurses and others involved in the implementation of the first FNP programme in Scotland. The focus is on the recruitment of the Family Nurses, and on their training and supervision, all of which are key elements of the FNP programme approach.

7.1 Recruitment of the Family Nurse team

In order to adhere to the Core Model Elements for FNP, Family Nurses are required to be registered with the Nursing and Midwifery Council ( NMC), be educated to degree level and to meet the person specification for a Family Nurse. The Family Nurse supervisor, who is also required to be registered with the NMC, and to be at least equivalent in education and training to Family Nurses, preferably educated to masters level, was recruited in advance of the Family Nurses. This was in order to allow time for their own training and development, for building the local infrastructure, and so that they could be involved in recruiting the rest of the FNP Edinburgh team.

The Family Nurse job description was agreed nationally and the Family Nurses in Scotland were recruited through a national advertising campaign. ²¹ The selected Family Nurses were all qualified and experienced nurses, with professional backgrounds which included health visiting/public health nursing, midwifery and sexual health nursing. Individually and as a group the Nurses reflected extensive and varied professional experience.

The articulation of the necessary qualities for Family Nurses was shared by all of those involved in the programme. Namely, beyond their formal qualifications and experience, a good Family Nurse was seen as someone who is: committed to the client group, flexible, willing to work with a manualised programme, has a good understanding of the complex needs of the client age group, is clinically competent and understands their own deficits, has a capacity for learning and is enthusiastic about working in a different way. 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, experience and attributes.

….we were in a privileged position to be recruiting six people at once [ ] your recruitment process is very tight, and you are not allowed to cherry pick in anyway, shape of form. [ ] … at the end of the process we managed from the criteria that we had, from the applicants that we got, to get a very good mix of staff. So I feel…that we have successfully recruited a team with a vast array of strengths between them, that are complimentary to one another.

[Stakeholder interviewee]

In addition to a formal interview process with a professional panel, service users - teen mothers or mothers-to-be, their partners and families - were invited to be involved in the recruitment process. This was an innovative step, but one which was deemed to be very successful with the users able to ask candidates a series of questions that tapped into their own perceptions of the necessary Family Nurse characteristics. The user group were provided with brief training on the process by the FNP Nurse Supervisor and were supported by the recruitment team (including a Clinical Psychologist), to identify appropriate questions on a range of matters salient to potential clients ( see Section 7.3.4) for further discussion of the Clinical Psychologist role on FNP). It was a measure of the success of the approach that that the user-recruiters identified the same Nurses as the professional recruiters and in the same order of preference.

7.2 Training

We explored with the Nurses the range of training courses that they had received throughout their first year in post (a summary of the FNP National Learning Programme is included in Appendix F). There were three main categories of training received: first was the mandatory NHS Lothian training that included a number of study days, covering issues such as 'Child Protection', 'Adults that are at Risk' and 'Maternity Trak'. Second, there was the programme-specific training delivered by the DHFNP National Unit, which covered the three main phases of the programme - the pregnancy, infancy and toddler stages. Within these blocks of programme-specific training, Family Nurses received training on the programme manuals, materials and facilitators. Third, there was training was in the form of master classes: Nurses undertook a variety of courses such as 'Motivational Interviewing', ' DANCE' (Dyadic and Naturalistic Caregiver Experiences), ' PIPE' (Partnership in Parenting Education), 'Perinatal Mental Health' and 'Compassionate Minds'.

Family Nurses came into post at the end of November 2009. Following team building and local learning, they attended an intensive, mandatory, residential 5 day course in England in mid-January 2010 focused on the pregnancy phase of the programme, using the facilitators and learning about strengths-based approaches and motivational interviewing. In the following months, Family Nurses participated in a range of training courses and master classes relating to, for example, perinatal mental health and motivational interviewing, while the 5 day mandatory residential infancy training course fell around half way through the nine-month recruitment phase (4 months after the pregnancy training).

In addition to training for the Family Nurses, the supervisor (who, as noted above, was recruited in advance of the Family Nurses) has to undergo specific training for their role, including a 3 day residential course two months prior to the 5 day pregnancy training course (which the supervisor also attended). The supervisor also has regular monthly support meetings and 'learn and change' sets to support her development, facilitated by the Department of Health.

Family Nurses were unequivocal that the content and delivery of their training was outstanding and, indeed, of a higher quality than they had ever expected. It was felt that training had been delivered by dynamic individuals who lived and breathed FNP. Experienced Family Nurse practitioners were also on-hand throughout training sessions, which gave the Family Nurses access to advice and information. Nurses said that they felt privileged to have received such high quality training and, in turn, felt that they would in all likelihood be disappointed with the delivery and course content of any training outwith FNP that they may receive in the future.

I'd say [ FNP training's] been very very good. Very good; so much so that when I've gone on local training … this is gonna sound terrible ... when I've gone then on local training - not FNP - it's been really disappointing … Really disappointing. There is such a vast difference in quality of training that we've had.

[Family Nurse 5]

It was, nevertheless, clear that the Family Nurses experienced the sheer volume of training as considerable and sometimes onerous in the first year of the programme. As a result, Nurses felt, at times, overwhelmed in terms of their ability to absorb and retain information while simultaneously engaging and enrolling clients and adapting into their new roles. However, Nurses also felt that the training they have received had stimulated and stretched them and allowed them to adopt a very different approach to working with clients. In particular, adopting motivational interviewing techniques and working from a strengths-based approach were very new skills which the training supported.

Family Nurses' accounts indicate that they were exceptionally motivated and eager to start working with clients, but had understandable concerns about how well prepared they felt themselves to be after their initial pregnancy training. Family Nurses described three main anxieties that they experienced in the initial stages of the programme. First, there were concerns about their ability to deliver the programme which stemmed from their move from being highly skilled and experienced in their previous roles, to "novices" in their new capacity as a Family Nurse.

… you think to yourself, "Oh, I'll never be able to pull that off"

[Family Nurse 3]

…you've got this kind of conscious incompetence and unconscious incompetence … and the idea behind training is that you're learning things and then you have to apply them, and it's … hard in a way to go back to being kind of almost a novice at something…

[Family Nurse 2]

Second, Nurses described anxiety about engaging clients. As discussed in Chapter 4, Family Nurses mentioned their initial fears that clients would not want to take part in the programme.

Finally, Nurses described anxiety about their ability to digest the wealth of information that they had received. There was a general feeling of being overwhelmed by the amount and number of new materials, while also feeling under pressure to perform as well as other FNP sites. They commented that there were some aspects of the programme that they had felt more comfortable with from the start than others. For example, they described feeling more familiar with materials on personal health or maternal role as opposed to environmental health and life course development, possibly reflecting their prior professional roles.

However, the Nurses also recognised that while they may have felt overwhelmed or daunted to begin with, over time, there would be a process of consolidation and learning through practice. Certainly, the Family Nurses suggested that throwing themselves into practice was the only way to consolidate their initial learning. On-the§job learning and shared learning among the team was highly valued and something that could not be taught within the classroom setting. Nurses also acknowledged that they had to allow themselves a degree of professional patience. There was the view that becoming familiar and comfortable with the programme and its contents would be a gradual process and that they had to accept that consolidation of learning would take time and that they should not doubt their professional skills. That said, there were also some suggestions that the timing of some elements of the training and the structuring of the recruitment phase could be improved for future sites to ensure that Family Nurses have more time to consolidate their learning in this way. This is discussed in more detail in the following sections.

Nurses were aware when they came into post that there would be a substantial amount of travelling involved for the mandatory training. While the mandatory 5 day pregnancy training course commenced prior to the client recruitment phase, as noted above the Nurses attended a range of training courses and master classes in the following months (see Appendix F for a summary of content and timings of the National Learning Programme for FNP). The fact that training took place in England had advantages and disadvantages from the Family Nurses' perspective: on the one hand, the fact that training involved FNP teams in England afforded the positive and motivating chance to meet other site teams, while in the other hand, the time involved in travelling to training impacted on their busy working schedules and/or their personal lives.

The travelling for training was described as "exhausting". There was consensus that it would be preferable to hold training further north, but this was tempered by recognition that, at that time, they were still the only Scottish site ²². There was optimism, however, that when there were other Scottish sites the issue may be resolved via the provision of training in Scotland or the north of England.

In relation to timing of the training elements, the Nurses generally felt that these had been well spaced and delivered at an appropriate point in relation to the delivery of the programme with, for example, infancy training occurring just before the birth of any babies. The delivery of training in stage-specific blocks was seen as helpful, enabling retention of the information.

However, because of the actual and perceived pressures experienced by the Nurses during the recruitment phase in terms of engaging and enrolling clients and delivering the programme to their current caseload while simultaneously undergoing training, there was a view that aspects of the training programme could have been delivered at a later stage. While the initial pregnancy training was not viewed as problematic as, at that point, Family Nurses did not yet have any clients, pressures were seen as mounting when they became involved in engaging clients, delivering the programme with fidelity, receiving supervision and attending training.

The issue for the team at the moment is the capacity of them to carry on recruiting when they are struggling to meet the dosage of the people that they've actually got on board.

[Stakeholder interviewee]

Nurses reported that they often found it difficult to take time out from their caseloads in order to 'clear their headspace' to then fully engage with the training. It was also suggested that in some cases they felt they had little opportunity to consolidate learning before having to put training into practice. Given these considerations, it was felt that certain master classes, and DANCE training, would have been better delivered at a time when they were ready to use those newly acquired skills. Moreover, there was also a view that it may not have been necessary to deliver the training programme over a 12 month period and that a longer timeframe of, for example, 18 months may have been preferable and less pressured.

However, there was also an expectation that overall workloads should become more manageable once the mandatory training was complete. This expectation does appear to reflect the experiences of the first 10 pilot sites in England - Barnes et al (2009) noted that the diaries kept by a sample of Family Nurses included fewer comments about excessive hours and stress in the second year of the programme in comparison with the first (though they attribute this to relationships with clients settling down and nurses becoming more expert in managing their time, rather than the completion of training).

While the Nurses praised the training that they had received in relation to FNP, there were three key areas where they felt it could be improved.

First, the Nurses felt that they would benefit enormously from observing experienced practitioners delivering the programme. There was a view that they did not have the opportunity to observe the programme being delivered before they started their clinical practice. Observing a mock session or pairing up with an experienced practitioner to observe them delivering the programme materials were two ways in which the Nurses felt they could have benefited. In particular, it was felt that this would have provided an opportunity observe ways in which they could apply the theoretical content of the programme to their clinical practice.

Second, while the Nurses welcomed the opportunity to meet colleagues from other sites, training held further north would reduce the amount of time that they had to take out of both their clinical practice and their own free-time to travel to courses.

Third, although in general the timing of training was seen as appropriate, as discussed above, due to the pressures of work, it was suggested that certain aspects of the programme might better be placed later on in the programme.

In addition to suggestions for improving the training itself, the Nurses felt that the speed with which clients were enrolled onto the programme had an impact on them in terms of the consolidation of their training and learning. There was a view that there might have been benefits to enrolling a small number of clients to whom they could then deliver the programme in terms of allowing the Family Nurses to consolidate their learning before continuing with the engagement and enrolment process. However, as a result of front-loading in the recruitment phase (described in Chapter 4) the Nurses felt themselves to be under huge pressure to enrol clients while simultaneously learning and delivering the programme materials. Moreover, the fact that clients enrolled early on were further on in their pregnancies on average (as a result of the decision to engage with eligible women already registered on Maternity Trak in early 2010, rather than engaging with women as they registered) also meant that the first births occurred sooner in the programme than anticipated (and this was compounded by the premature birth of the first FNP baby) at a point when the Nurses had only just completed the infancy training. Although dates for consolidation of learning were scheduled, these were sometimes removed from diaries due to competing priorities. Finding ways to make space for that consolidation of learning was viewed as a key way in which training and learning would be enhanced.

7.3 Supervision

Supervision is an integral function of FNP and is intended to be delivered within a structured format. Supervision was experienced in a number of ways:

• Individual supervision on a weekly basis
• Four group supervisions per month (two clinical and two operational)
• Supervision visit with one client every 16 weeks
• Group supervision clinical meeting attended monthly by psychologist
• Group supervision clinical meeting attended by Child Protection Advisor quarterly

Nurses perceived two key functions for supervision. Firstly, supervision was seen as providing a space for them to think through their caseloads and was an opportunity for them and their supervisor to 'bounce ideas' off of one another. Secondly, supervision was seen as providing an opportunity for Nurses to ask questions and to seek advice. It was suggested that having the opportunity to work through challenging caseloads with their supervisor enabled them to deepen their understandings of their clients and their clients' situations. Overall, Family Nurses were very positive about the supervision they received on FNP - they said that they had never before, in their professional careers, felt so supported. Indeed, although the support and supervision structures in place reflect the Core Model Elements of the programme, the Family Nurses nevertheless considered that this professional support and supervision felt like "a luxury", especially compared with their prior professional experiences.

Family Nurses, together with the Supervisor, determined the content of weekly individual supervision sessions. Discussions focus on issues that are particularly relevant or currently salient for the individual Family Nurse at that point in time. Initially, individual supervisions were driven by a fairly structured format whereby the Nurses were encouraged to discuss their challenges, their achievements, their progress plans and their clients. However, it became apparent that this approach led to difficulties moving discussions beyond individuals' challenges and this led to a shift of approach to a more of a client-based focus. Nurses felt they were better able to work through their challenges using a client-based perspective.

The opportunity to focus on specific clients and, in turn, Nurses' approach to working with clients was highly valued by the Family Nurses. There was a feeling that without supervision, they would have struggled with their caseloads, particularly where they had a high proportion of clients with particular vulnerabilities and/or child protection issues. There was a view, therefore, that the role of the Supervisor was to help Nurses prioritise and manage their caseloads as well as individual client needs. Essentially, Nurses felt that the supervision that they received mirrored what they offered to their clients - reflecting the focus on 'parallel processing' as a key component of the FNP model:

…it's a … definitely a parallel to what we're giving to the clients. It's our space to clear our head. It's our space to think things through. It's our place to be able to ask a few questions and say, 'What do you think o' this? (…) Can you help me with this problem?' (...) but mainly a support person, but very much is somebody you can bounce ideas off of and say, 'What do you think of ..?' or 'Listen. I'm stumped. Can you help me out here?'

[Family Nurse 3]

In addition to discussing clients, Nurses felt that they were able to bring any issue to their supervisor session and further felt that, if required, they would be able to arrange extra support from their supervisor.

Group supervision sessions took place every two weeks and mostly focused on clinical or operational practice. Sessions lasted around 2.5 hours and were seen as an opportunity to bring a case study to the group in order to discuss potential challenges. The group, therefore, provided a means to work through how best to approach client-specific issues. Group sessions also provided an opportunity to discuss programme implementation issues.

Family Nurses found group supervision sessions to be a great form of support and an opportunity for them to talk about any worries or concerns and how they were managing generally. It was commented that it was only by talking their worries through that Family Nurses realised that they shared similar concerns.

… individually, each of us have got challenges or worries or concerns, and you think, I'm the only one thinking this, and then somebody'll mention it in the office, and "Oh right. Oh. So you find the same. Oh, you're worried about the same things".

[Family Nurse 5]

Within group sessions, Family Nurses shared learning and discussed their approach to delivering the programme materials with clients. This was another aspect of the group sessions that was highly valued, particularly as they felt that they had not had the opportunity to observe programme materials being delivered by other Nurses in advance of delivering them themselves.

Nonetheless, despite the opportunity to share learning within group supervisions, there was a feeling that, as a team, they did not have enough opportunities to share learning or discuss styles of delivery. There was the concern that due to the nature of their work, they were often out the office visiting clients, which meant that the opportunity to discuss general issues with colleagues was often missed.

In addition to individual supervision sessions, Family Nurses were also accompanied by their Supervisor to client visits (two clients every 16 weeks). It was hoped that by the end of the programme, the Supervisor would have observed each Family Nurse with all of their clients. Supervision visits were felt to be somewhat 'anxiety provoking' but, nevertheless extremely useful in terms of obtaining feedback on their style of delivery and use of specific techniques with clients.

7.3.4 Other support

Various other forms of group support were experienced by the Family Nurses. These included monthly clinical supervision with the team psychologist, clinical supervision with the team's child protection advisor every six months and, last but not least, peer support both within the FNP team and from Family Nurse colleagues across other sites.

The Team Psychologist provides both group supervision to encourage reflective practice among the Family Nurse team and individual supervision to the FNP supervisor. Initially, Nurses described feeling nervous about supervision sessions with the Team Psychologist. However, over time, these concerns dissipated and they valued her role in helping them to think through client issues from a different perspective. The Team Psychologist was also said to help the Nurses think about how they were performing as a team. They were encouraged to think through their challenges and discuss how each of them as individuals were managing those challenges.

[Psychologist] helps us kind of just think about how … how things are from other people's perspectives, how the … kind of how our approach differs from other people's and, you know, it helps us understand other people's approaches as well…Also helps us kind of think about where the girl had come in from, what their challenges are …

And [Psychologist] is also quite good at helping us think about 'Where are we as a team? What are the challenges? … How's everybody kind of managing with those challenges?

[Family Nurse 5]

Clinical sessions with the team's Child Protection Advisor were also viewed as an essential component of the supervision "package". Nurses brought cases to the sessions that had been identified as being vulnerable or 'families in need' and found that this forum also provided an opportunity to manage and identify methods of working with those often complex families.

Informal support was derived from peers within the Edinburgh team and also from colleagues in the English sites. Within the Edinburgh team, Nurses discussed their ability as a team to provide support, advice and encouragement for one another. Where they had been in contact with Nurses at other sites, their experiences were overwhelmingly positive. There was a sense of colleagues going out of their way to help.

Individual supervision sessions are intended to be based on information about each Family Nurse's casework for the previous week. This allows the Supervisor to review clients in a timely fashion with the Nurse, but also to seek comparable or relevant information for other sites which might help them to understand if there are - for example - comparisons which might throw light on a particular case or situation. This information should be accessible from the FNP database, which contains a record of all the data that Family Nurses gather about their contacts with clients for the purposes of both assessing fidelity requirements, and informing weekly supervisions.

However, a number of challenges have meant that, at the time of writing, a user-friendly database for FNP in Scotland was not yet available. It became apparent 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, due to the complex technical infrastructure used. This meant that a bespoke database would have to be developed for Scotland. A number of solutions were considered: first, an in-house solution with Scottish Government (not possible due to the data protocols around NHS data); next a bespoke solution, built by Scottish Government but housed within NHS Lothian; then a local solution, within NHS Lothian, using an existing application. Finally, following issues relating to capacity and access, it was agreed to nationally commission an FNP database through e-Health. This work was commissioned in December 2010 with options available in April/May 2011.

In the absence of a national FNP database at the start of the programme, an interim database was developed by the FNP implementation team in NHS Lothian. This was a fairly basic, DOS-base system, initially designed as a short-term measure to 'store' data from the forms Family Nurses fill in for each client contact until a more sophisticated database became available.

That database was never set up to do any data analysis. [ ] at the time of setting that up, it was a holding database [ ] it's easy enough to put it all in, but (…) it was never designed to pull it all out

[Stakeholder interviewee]

Although as noted in the quote it was not originally designed to be used for analysis purposes, it has been possible, although not straightforward, for the local FNP Lead in NHS Lothian to extract some data in advance for use in supervision sessions. As the local FNP Lead has acquired greater proficiency accessing and downloading information from the interim database, this has provided a working solution. However, it was apparent that this was not ideal - it is not, for example, possible at present for the Supervisor to use the database to explore the data for an individual nurse or client during a supervision session. As the data for supervisions needs to be extracted in advance, it is not always completely up to date in terms of very recent visits. Moreover, the basic nature of the database has created barriers to extracting detailed information on whether nurses are achieving fidelity in terms of dosage for the purposes of weekly supervisions. Finally, extracting data has proved both complicated and time consuming, and has meant that the local FNP Lead in NHS Lothian in particular has had to devote much of their time not only to the maintenance and management of the database but also to the analysis and reporting of the data. Given the limited functionality of the temporary database as regards 'validation checks', this has also included double-checking data entry for accuracy, while the nurse supervisor and administrator have also had to check paper forms for errors in advance of data entry.

As a result of these limitations, an element of supervision that, at the time of their initial interviews, Family Nurses felt was missing from supervision sessions was regular, detailed, formal feedback on their performance in terms of fidelity of dosage and how this related to performance of the group or of other nurses, including nurses in England. The nurses thus felt a slight sense of frustration due to the fact that collecting the data was a requirement of their post but they felt they were missing out on the opportunity to monitor or compare their progress:

I've seen it, and how it's used elsewhere yeah (…) I think from a team point of view it's a bit of a miss ( SIC), you know, because we could have used the data to say, 'Well, you know, some of you seem to be delivering more of this. Some are less. What .. what are people finding easy? What are people finding difficult?' Given the ... the data, not only individually, but from a team perspective. You know? Some people are managing fidelity. Some people aren't, you know? How is that? How are they doing it? You know? Is it because some people are working more hours? Is it some people are managing their time more effectively in the visits? What can we learn from each other? ...So ... yeah. I think it's a bit of a gap.

[Family Nurse 5]

There was a feeling that if they were to receive more structured fidelity feedback on frequency, length of visits and dosage, the Nurses and their Supervisor would be able to disentangle reasons why certain aspects of the programme may be easier to deliver than others. This learning was perceived as an important potential mechanism for individual and group learning.