Family Nurse Partnership: 10 year analysis

The Importance of the Early Years

The earliest years of life, including during pregnancy, provide the greatest opportunity to influence a child's development^[1]. There is now a wide ranging evidence base from neuroscience, epigenetics, endocrinology, and the study of physiological systems and inflammatory disorders that shows how the experiences and environments in which children grow shape the developing brain, influence genes, and affect the health of the body's systems^[2].

The earliest years are also the most vulnerable for babies and children. The importance of positive and predictable caregiver interactions and experiences that are responsive and reliable cannot be over emphasised. These interactions and experiences help to build secure attachment^[3] and are crucial to shaping a child's brain architecture, and in turn key life skills^[4]. If responses are unreliable or inappropriate, the brain's architecture can be permanently altered, and this can have an impact on learning and behaviour and the ability to develop positive relationships, which are crucial for early development.

The evidence base on Adverse Childhood Experiences (ACEs), including neglect, abuse and parental substance use problems, also demonstrates the link between traumatic events in childhood and less positive outcomes over the life course, including physical health, mental health, education, and employment into adulthood^[5]. This is particularly true in the absence of protective factors in a child's life.

The 'social determinants of health' are the collective set of conditions in which people are born, grow up, live and work. These include housing, education, financial security and the built environment, as well as the health and social care systems. It is now widely accepted that these social determinants are responsible for significant levels of health 'inequalities'^[6].

The evidence, however, also indicates the importance of protective factors; the strengths that help to buffer and support families. They can also serve as safeguards, helping parents who otherwise might be at risk find resources, support, or coping strategies that allow them to parent effectively, even under stress^[7]

Investing in early years can be considered a 'life course prevention' approach. The return on investment from early years interventions is greater than spending at later stages of development^[8].

The Family Nurse Partnership Programme in Scotland

The Family Nurse Partnership programme (FNP) is an intensive, preventative, one-to-one home visiting programme developed in the United States of America (USA) by Professor David Olds and the University of Colorado, Denver (UCD).

FNP currently has a Level 4+ evidence rating from the Early Intervention Foundation (EIF)^[9]. This is the highest rating given to programmes with evidence of a long-term positive impact established through multiple rigorous evaluations^[10]. It is a highly intensive, complex clinical intervention, with the purpose of achieving three core outcomes:

• to improve pregnancy and birth outcomes, through improved prenatal health behaviours;
• to improve child health and development, through positive, responsive caregiving; and
• to improve the economic stability of the family, through developing their vision and realising their plans for the future.

FNP in Scotland focuses on supporting all young first-time mothers^[i] aged 19 or under and some older mothers under 25, where there is local capacity to reach them. The programme is delivered from early pregnancy until the child reaches two years old, recognising the important 'window of opportunity' and capacity to influence child development during early key life stages. This is a voluntary programme, in that it is the decision of the young mother as to whether they want to enrol onto FNP, which is offered once eligiblity is established.

The focus of FNP on the mother and child, and the wider relationships and environments in which they live, means it maps well onto the Scottish children and young people policy context. Key policy drivers that are embedded in FNP include:

• Getting it Right for Every Child (GIRFEC)^[11]
• Pregnancy and Parenthood in Young People Strategy (PPYP)^[12]
• Tackling Child Poverty Delivery Plan^[13]
• The Promise^[14]
• Trauma informed^[15]
• United Nations Convention on the Rights of the Child (UNCRC)^[16]

Implementation of FNP in Scotland

FNP began in Scotland in 2010. A focused evaluation was carried out on the early implementation of the programme in Scotland^[17]. The learning from this was used to implement the programme in other areas of Scotland, whilst increasing the reach of the programme within the existing sites.

The scale and spread of the programme in Scotland, to cover a whole country, is the first time this has been achieved anywhere in the world. This has been largely due to the dedication of the clinical nursing teams, strategic leadership in NHS Boards, supportive relationships with Professor David Olds and the University of Colorado (UCD), the continuing relevance to National policy drivers, and the families receiving the programme.

By September 2018, all areas delivering the FNP programme in Scotland had a continuous model of recruitment in place, which meant that all eligible first-time young mothers, aged 19 or under, have been offered the programme since that point.

The programme is currently being delivered in all 11 mainland NHS Board areas, with the latest area being brought onboard in 2018 (see Table 1 below):

Since the start of the FNP programme in Scotland, over 10,000 young women have enrolled and over 6,000 have graduated to date^[ii].

Further information regarding the evidence base, theories, models, core model elements and benchmarks/ fidelity measures can be found on the Child and Maternal Health Scottish Government webpages and on the FNP international website^[18].

The FNP Workforce

As part of the licensing conditions, the workforce model to deliver FNP consists of experienced, registered nurses or midwives, a supervisor (1WTE per 8 family nurses), and a data manager. In Scotland, there are also FNP Leads who provide strategic oversight for FNP within their local areas. To take on the role as a Family Nurse or Supervisor, extensive additional training at Masters level is delivered by NHS Education for Scotland (NES), as set out in the FNP education strategy^[19].

All Family Nurses must receive regular supervision, as an essential element of support for nurses^[20]. Family Nurses work in environments with high levels of risk and uncertainty, with complex and challenging circumstances, and are required to make autonomous decisions; at times, this can be physically and emotionally draining. Having a space to critically reflect is an important aspect of protecting the workforce, and building individual and team learning. Family nurses can experience the essence of a safe and trusting therapeutic relationship through role modelling with the supervisor.

Data gathered about FNP programmme delivery is essential to understanding the impact of the programme, and identifying areas of success and for improvement. The data manager works closely with the supervisor to ensure that the bespoke data, collected as part of the licensing conditions, is routinely and consistently collected, recorded and reported.

FNP Programme Delivery

FNP is a focused, preventative approach that seeks to enhance parents' understanding of their wider enviroment and influences, to promote and model sensitive, responsive care-giving and self-efficacy. The programme also supports clients^[iii] to develop their own coping skills and strategies to enable them to be the nuturing carer and protective factor for themselves and their children.

The FNP client group is complex and because of this, the changes they wish to make in their lives are diverse. Programme delivery, therefore, aims to be robust and yet dynamic. The FNP programme sets out a schedule of structured home visits, with guidance on content. Family Nurses are encouraged to match their schedule of visits and the content of these to individual clients' specific needs and goals.

Family Nurses are provided with an extensive suite of materials to support client engagement and the development of knowledge, skills and confidence. During each visit the Family Nurse considers six domains: Personal Health; Maternal Role; Life Course Development; Family/Friends; Environmental Health and Health and Human Services, with an aim to build on previous learning.

The COVID-19 pandemic has had a profound impact on health, economy and society, with damaging impacts on the way of life and wellbeing of people in Scotland. There is considerable uncertainty about long term impacts at present, as the pandemic itself and response to it continue to evolve^[21]. A recent Scottish Government report on FNP, which was commissioned to explore the experiences of the Family Nurses and clients in Scotland during the COVID-19 pandemic^[22], highlighted the importance of the face-to-face, in-home visiting structure of FNP and the therapeutic relationships built between nurses and clients. The data analysed within this report shows that during the pandemic, FNP continued to be delivered, new clients were enrolled, and clients continued to graduate without substantial variation in any of the benchmarks for programme delivery.

FNP Data In Scotland

The environment in which FNP is delivered has many intersecting factors that can impact on families health and wellbeing including socio-economic circumstances, geographic area, and access to services. The FNP programme is designed to be delivered flexibly and responsively to the individual needs of the parent and child, and understanding the environmental and individual circumstances enables the programme to be matched to the needs of the client.The use of qualitative and quantitative data sets in combination is fundamental to developing this understanding, to achieve successful programme implementation and beneficial outcomes for clients and their children. The data captured is more than management information, it is core clinical information used to inform the engagement between the client and the nurse. It also provides key insights about areas that are working well, and those for for local and national improvement, in both processes and outcomes, and continues to shape the FNP delivery model in the Scottish context.

FNP data requires to be captured on structured data forms and analysed in a specific way. As part of the scaling up of the programme in 2012, the use of the national Multi-Disciplinary Information System (MiDIS) was approved; this began routinely in 2014. As part of a Business Benefits Review in 2016, it was identified that the MiDIS system had some limitations and there was no scope to deliver improvements as the system itself was being decommisioned. A successful business case was put forward to develop a national bespoke FNP data system (Turas FNP) through NHS Education Scotland (NES).

Turas FNP, was launched in late 2019. The system was designed to reduce the data burden on Family Nurses and enhance the utility of the data at all levels of the programme. As part of the FNP quality improvement programme, the clinical experiences of stakeholders across Scotland are used to enhance the data systems usability. The additional benefits of this new system has been recognised across Scotland and FNP England have also adopted this system. The collaborative efforts used in its design and implementation continue to add value to the FNP programme impacts and effectiveness.

Alongside the development of robust IT systems, qualitative data continues to be gathered, to ensure that the client and nurse voice and experience is inherent in driving improvements to the programme. The most recent qualitative evaluation of FNP in Scotland, published in 2019, can be found on the Scottish Government website FNP Qualitative Evaluation 2019.

This Report

To mark the first ten years of FNP in Scotland, the Scottish Government has undertaken a review of FNP data over the 10 years of operation. This exercise was undertaken primarily to deepen understanding about the FNP programme as a whole and in particular to understand more fully who has received FNP, changes over the 10 years of operation, and to identify areas of success and for improvement.

The data drawn on in this report is based on the data of clients that have enrolled onto the FNP programme at some point between its inception and March 2021^[23]. The analysis uses the data of 9,177 clients in section 1: intake and client characteristics. The remaining sections 2 to 4 analyse data on clients who have completed the programme (5,006 up to 31 March 2021), to ensure full data over the duration of the programme could be analysed, with the exception of attrition data which included the 1,262 clients who left the programme before completion. However, the number of clients that data is analysed for at any given variable will depend on data completeness for that variable.

The statistics included in this report are descriptive, meaning that no hypotheses testing has been carried out on the datasets. This allows description of trends over time and between sub-groups of FNP clients, however no statements can be made about the the statistical significance or causation of differences.

Limitations

There are a number of limitations to this analysis, in that much of the data is sourced from the bespoke Turas FNP system. This means that while data is collected for FNP clients there is no real comparator group in administrative data that can be easily accessed.

The data held in Turas FNP is primarily self-reported data collected from clients by Family Nurses, therefore data reported here is not validated against any independent sources although data is compared to national datasets where possible.

The completion rate for each data form used for the analysis, and each question within data forms is variable. Therefore the number of clients that data is analysed for at any given measure will depend on data completeness for that measure. Percentages are expressed as a proportion of all clients or children for whom data was collected on a given measure, unless stated otherwise.

FNP clients will also be contained within different administrative datasets, however they cannot be identified within these datasets. This limits the analysis that can be conducted on such data, which would complement this analysis.

The Turas FNP IT system was implemented in October 2019. While there was the MiDIS database prior to the new system, the data collected has altered between the two systems. While much of the legacy data has been mapped to the new system to enable longer term comparisons, some data could not be migrated. This has substantially limited the outcome data that can be analysed.

As part of improving data quality, the Scottish Government and local sites continue to consider whether further modifications to data collection and analysis would be beneficial in the longer term.

The data from the pilot of FNP in NHS Lothian is not included in the majority of the analysis that follows, as this data was only held on a preliminary IT system and was never migrated to MiDIS. The pilot data is only included in Chart 4 – enrolment onto FNP over time and the overall number of enrolments and graduates in FNP since 2010 (page 16). Therefore the majority of the data commences in July 2011.