Family Nurse Partnership - a family nurse's perspective: 10 year anniversary

WHAT impacts do family nurses have?

The differences family nurses make are about helping young people to develop parenting skills, increase their self-confidence and promote their resilience.

"Working with the clients over two and a half years gives them a real opportunity to look at how they can make changes to improve their quality of life," says a family nurse. "I see how the support given to my clients can help them believe in their ability to succeed and make positive changes for themselves and their children. Many started with low confidence and had never experienced achieving anything. They want to succeed as good parents and working with them in achieving their goals has been truly amazing."

Others have seen clients manage to achieve their potential at personal level and as parents, with improved self-efficacy and ability to plan and problem-solve, and increases in confidence that allow them to engage with GPs and other health professionals.

"Some are able constructively to challenge services," says one. "Many of the young women we work with find it difficult to engage with services and other people.

They may have been seen in their families as having nothing to say or worth listening to. Just listening to them can increase their self-confidence and enhance their sense of being important. As nurses, we may not see this fully, as the impact can be after we have left them on their journey."

Achievements have been made despite many of the clients coming from very disadvantaged backgrounds in which abuse may have been a feature. One of the nurses was able to recount stories of supporting clients to talk about and take action on their experiences of abuse.

"I supported a very vulnerable young woman to a point where she was able to disclose childhood sexual abuse. I directed her to voluntary sector help which she was able to accept and she is currently working well with them. She is also considering approaching the police to report the abuse. She has said that this is all due to the fact that when she disclosed, she could tell immediately that I believed her. She had tried previously on many occasions to tell her family members but felt she may not be believed.

"I also worked with a young woman who gave the impression of being in a happy stable relationship with a very attentive partner. Twelve months after first working with her she contacted me to say that she was in temporary accommodation and had left her partner, who was abusive and had been for the past two years. She said that the penny dropped for her during a visit from me 10 months earlier when we looked at power and control – she had been planning and preparing to leave since then. She had the confidence to do so as she had realised she was not responsible for her partner's behaviour."

Clients' vulnerability is often patently clear and needs to be addressed sensitively. Another family nurse recalls a young pregnant woman who cried down the phone when she first contacted her to offer a place on the programme.

"She told me that social work wanted her baby and she didn't care any more – they could just take her baby. At first, I was advised by her social worker that she could be difficult to engage with, but she responded well to a gentle telephone call, an informal chat in a café and time spent getting to know what she wanted from the services that were around to support her. The client joined the programme and now has her own tenancy and is successfully living at home with her baby and engaging with support. The impact you're having is not always obvious, but in small ways you can gradually see the positive effect of your relationship."

Although FNP can bring very positive rewards to young people and their children, there are also less positive outcomes for some vulnerable young women who are unable to overcome their previous trauma and have lost the care of their child.

Family nurses support families to remain together whenever possible, but there is a recognition that for some, and in the best interests of the child, the child should be accommodated.^[6]  Family nurses work hard to maintain a strong therapeutic relationship with their clients to help and support them, but the wellbeing of the child is paramount.

"There are several clients I still think about and wonder how their life course is developing," says a family nurse. "The baby of one client was accommodated into foster care from the hospital after birth – she never had the baby home with her on her own. There were concerns from early on in her pregnancy about her capacity to parent, her own learning needs, a violent relationship, a partner who had issues with drugs, alcohol and violence, and minimal support from her family. She had 120 supervised contacts with her baby until the baby was 22 months old, and she went to every one.

"The baby was adopted and was never returned to her care. She loved her baby very much and learned a lot about parenting, attachment and relationships through our work together, but understood her own limitations and the agencies' concerns.

"I have since met her by chance in the local area. She misses her baby every day but understands why her baby was adopted. She is still living in supported accommodation and considering returning to college or perhaps securing a job, despite limited support from her own family."

FNP nurses can feel a sense of failure when a baby is removed from their parents' care or is otherwise not allowed to have contact with its mother.

"It can feel like I've failed them somehow when children get removed," says one.

"But with support from the FNP team, psychologist and supervisor, I can now see the value to the client of being by their side. I once found that I was the only person one young woman could ask to be her birth partner, even though I had voiced my child protection concerns at a meeting that contributed to her baby being removed. She sincerely thanked me for supporting her and gave me a hug – this blew my mind!"

One family nurse recalls how three clients who graduated from a cohort believed their children would have been removed from their care if they hadn't had a family nurse.

"In one case, every child in generations of the family had been taken into care and the client's child was the first not to have been," she says. "The time available to spend with the clients and to explore their situations and the impacts on them and their child allows for understanding to be gained gradually and embedded. I've also managed to support clients to experience good endings when their children have been removed from their care. The flexibility of the programme allows me to continue working with them until legal processes are complete, offering ongoing care and support for as long as necessary."

Family nurses are having positive impacts in crucial areas of public health such as breastfeeding and smoking cessation.

One of the nurses has found her rates of breastfeeding are increasing.

"Statistics on initiating breastfeeding in the labour room now are much better than they were with the first cohort of clients," she says. "One young mother who tried to breastfeed had stopped by the time I visited after receiving advice from another professional. She wanted to feed and I supported her with that choice. She resumed feeding for three months despite difficulty maintaining her milk supply, but she fed for a whole year with her second child. She thanked me for being there and said it made all the difference."

"Almost all of the women I work with who were smokers have given up smoking in their pregnancy, either prior to enrolment on the programme or after," reports another. "And they have engaged very well in discussions around family planning, with most having a well-informed plan around postnatal contraception. My aim will be to support them in successfully accessing and maintaining this, and the nature of the programme delivery will allow me to do it."

Clients' families can be a source of support and help, or may present further challenges to the clients. Family nurses are having a big impact on the way families and clients interact.

"The clients' families become a huge part of our caseloads," a nurse states. "As they get to know me and understand my role, they become very interested and enjoy being part of the visits.

"The family of one of my clients has been known to social work throughout her life due to her parents' issues with domestic violence, alcohol misuse, criminal activity, neglect of the children and the children's poor attendance at school – my client hadn't attended school since second year. She agreed to enrol with FNP, but it took five visits before I had any eye contact with her – she would sit with a hoodie on throughout the visit, looking down."

The client appeared to be listening, however. She made huge improvements in her diet, stopped smoking and encouraged the rest of the family to start smoking outside the family home. The family's relationship, however, remained very volatile.

"They tended to resolve challenges with violence or arguments and shouting," the nurse continues. "I tried to model more positive behaviours of showing respect, kindness and appreciating that other people have an opinion. When I did a joint visit with a social worker who knew the family well, she was amazed at the changes she saw, such as the family welcoming her into the home and being prepared to discuss my concerns, not smoking in the home, the standard of cleanliness in the home, and the family wanting the best for the children and talking about the impact their behaviours will have on the baby."

FNP nurses take great pride in witnessing the achievements of families in their care.

"I feel proud of the progress that some of my clients have made since coming on the programme," one says. "One young woman in particular fully furnished a home over two months, with various types of community help. She hadn't managed this before and was avoiding the issue by staying with family and friends. She was at risk of losing her tenancy and being unable to provide an appropriate home environment for her baby.

"I was also extremely proud and touched to receive a phone call from a father, to give me the news that my client had delivered their baby three hours earlier. He sounded quite shell-shocked and emotional, and I felt he needed someone to comfort him while everyone else was focused on his partner.

It demonstrated the value that the young father placed on the support the programme offered."