The Family Nurse Partnership programme in Scotland: improving outcomes for child, parents, and society

Being a parent is a challenge for most people, but being a teenage parent brings with it even greater challenges. NHS Tayside has the highest teenage pregnancy rate in Europe and is one of several areas being supported by the Family Nurse Partnership (FNP) programme in Scotland. The approach was first developed by Professor David Olds at the University of Colorado and is based on strong scientific evidence. The Scottish Government have included FNP as part of the manifesto commitment to ‘roll out FNP across Scotland’ and plan to support almost 1200 young families by 2013.

Seeking to provide early and effective intervention FNP seeks to move away from the traditional approach for supporting families, being directive to working alongside families. It aims to introduce a different approach where nurses engage with young parents early on in pregnancy building a therapeutic relationship with them to enable them to build their parenting skills and resources, whilst also developing and realising their own aspirations.

The aims of FNP is to support first time teenage parents to improve child and maternal health, improve school readiness and educational achievement  and  help parents become economically self sufficient i.e.  help parents to find meaningful employment or return to education. The importance of nurturing families was highlighted by Sir Harry Burns, Chief Medical Officer for Scotland, when he said consistent parenting can reduce sickness and increase life expectancy – with inconsistent parenting potentially adversely affecting children in later life.

FNP is aimed at first time pregnant teenagers (19-years and under). The are required to be resident for the 2.5 years that the programme is delivered, with no plans to relinquish the baby ( as it is an attachment programme)  It is optional for clients and those not wishing to be supported by FNP will receive the support from a Public Health Nurse/ Health Visitor. It is an intensive home visiting programme that focuses on the ambitions of the young parents; agenda matches with them and uses a variety of methods to work with them in a respectful and meaningful way.

The FNP is delivered by highly trained family nurses who hold a caseload of 25 clients open whole time equivalent. The partnership begins during very early pregnancy, ideally about 16 weeks and at the latest before the mother reaches 28 weeks, and lasts until the child’s second birthday. This is based upon the premise that pregnancy and the birth represent an opportunity when parents are especially open to receiving support and help (even if they have normally rejected help from public services). It works on a mother’s intrinsic desire to care for her baby and pregnancy offers a wonderful window to do just this. In the antenatal period, maternity care (screening and core antenatal appointments) is delivered by midwives, whilst the family nurse delivers the home visiting programme to the client. Family nurse visits are regular – initially every week and then a fortnight, the number of visits decreases as the young parent’s confidence develops towards the end of the programme - The programme is manualised but is adapted to meet the family needs. Each visit usually last for around an hour.

The FNP is a strengths-based approach and recognises the skills and resources that parents possess and that can contribute to improve their and their child’s outcomes. The role of the family  nurse is to ensure those skills come to the fore and develop confidence in the young parents .FNP focuses on an expecting mother’s natural motivation to do the best for their child, respecting that the parents are the experts of their own lives, and working to develop achievable goals for the family.

There are three theories that underpin the programme. They are:

• Human ecology; The importance of understanding the context in which people live their lives;
• Attachment; The formation of the bonds between parent and child as basis for subsequent positive child development, and the child’s learning from the responses it gets from its parents (be they negative or positive);
• Self efficacy; a belief that people can be supported to take control of their own lives and are the only ones who can really bring about change for themselves.

This premise requires a one-to-one alliance with the Family Nurse. This strong partnership aids the parents to change their behaviour to healthier habits (for more on behaviour change click here) and deal with the emotional problems that can prevent parents providing good care and forming a positive relationship with their child.

The capabilities of the mothers and fathers are realised through structured home visits in which the nurse will work with the parents to identify the resources they have and where needed signpost to further support that  the mother needs. Each of the visits is designed to provide guidance and support to the parents so that they are aware of how best to look after their child and how they can change their behaviour accordingly. These conversations also serve to allow first-time mothers to bring up the many questions that arise during pregnancy – ‘How do I know if my baby’s healthy?’, ‘what do I need to change in our house to make it best for my baby?’, ‘how big will my stomach get?’, ‘how does breast feeding work?’. The Family Nurse is able to address these questions and concerns to enable to the mother to take the healthiest route possible and prepare them for childbirth. The Family Nurse is also able to coach the mother and father about how they can realise their own goals and give them the confidence to do so. Watch this video which will give you an overview of the FNP and a illustration of what home visits are like.

The Scottish Government holds the license with University of Colorado, Denver to implement the FNP. Implementation is supported by a consultancy agreement with the Department of Health FNP National Unit, which provides training, access to expertise and support.

The first Scottish FNP programme was funded £1.6 million by the Scottish Government and is being delivered by NHS Lothian during a three-year period. A second cohort of FNP families will be supported in Lothian later this year, with Scottish Government match funding NHS Lothian’s contribution to delivering the programme (approximately 800K). The NHS Lothian team consists of a supervisor, six family nurses, and an administrator/data manager. The delivery team is supported by a full-time local FNP lead to implement the programme locally and ensure that it is integrated with other services within Lothian and NHS Lothian. 

Over a nine month period beginning on 25 January 2010 148 clients who were eligible to be included on the programme were recruited.  Issues such as gender-based violence have been included in the FNP programmes delivery in Lothian. This included hosting an event to raise awareness of the issue during the ’16 Days of Action Opposing Violence against Women’ campaign.

A second pilot site for the FNP was established in January 2011 in NHS Tayside and its surrounding area. NHS Tayside’s area has the highest teenage pregnancy rate in Europe. The project received financial support of £3.2 million over three years from the Scottish Government and a contribution of £600,000 from NHS Tayside.  This pilot was staffed with 12 family nurses, supported by two supervisors –forming two teams. NHS Tayside is aiming to reach in excess of 300 families by summer 2012.

These two examples below provide real life cases of how the Family Nurse Partnership helps young parents.

Client story 1 (By a Family Nurse)

Moira was 18 years old when recruited onto the programme.  She had left school at age 15 years with no qualifications.  She had a history of being a looked after child and was in a relationship currently with an abusive partner.  Both Moira and her partner had a criminal history and were addicted to heroin and other street drugs.  Moira was mistrusting of professionals and had limited support from family and friends.

The family nurse worked to build a therapeutic relationship with Moira.  The strength-based approach worked well and in time a trusting relationship has been established.  It was evident to the family nurse that part of the mistrust Moira had of services was related to her belief that they were negative about her ability to become a good parent.  Due to the level of concerns identified in the life of Moira and potential risk for her baby, the unborn baby’s name was placed on the Child Protection Register. The family nurse worked with Moira to help her recognise her own self-belief and how she could demonstrate this to the other services involved.  The family nurse respected that Moira was on a difficult journey with many demands being placed upon her and aimed to not judge her when things went wrong.  The family nurse continued to work with Moira to achieve her ‘heart’s desire’ to become a good mum.  Using the FNP materials and a variety of approaches including motivational interviewing Moira began to flourish.  She no longer takes illegal substances and has maintained this through working with the support of an addiction service.

Moira was able to recognise the importance of relationships in her life and worked hard to re-establish the support of her parents and siblings.  During this period she separated from her partner and was able to reflect that this was a good decision for her and her baby as he could be influential in her return to an adverse lifestyle.

Having found her inner confidence Moira has began to look forward in her life with her baby.  She recently moved home and independently cares for her baby.  She   continues to actively participate in the Family Nurse Partnership Programme.  Moira is excited about her future life with her child who is enjoying a secure attachment with his mum.  Moira has set up child care for her son on a part-time basis as she herself has successfully registered to start at college. She is keen to do the basic qualifications which she feels she was unable to do due to leaving school at such a young age.  The motivation and drive for success demonstrated by Moira has been recognised by support agencies.  Moira’s child was removed from the child protection register and Social Work is no longer involved.  Moira openly describes herself as a good mum and is proud of what she has achieved.

Anonymous

Client story 2

The family nurse contacted me when I was still coming to terms with being pregnant. Her approach was the first thing I noticed.  I remember how she never offered any comments and seemed to listen to what I had to say.  I wondered if this meant she was no good and that she knew nothing.  I found myself testing her by trying to shock a reaction out of her. She was kind of warm and made me feel good about myself.

Age 18 and pregnant had not been my plan and the father of the baby was less than supportive. Before I knew what was happening I found myself involved with Social Work and worried that I would not be allowed to keep my baby after the birth. The family nurse “helped me to believe in myself” and to plan for how I could manage the baby as a single parent.  I know now that I was really frightened and would find myself “behaving badly by shouting at the professionals who were only doing their job.” The family nurse helped me to recognise why I felt angry and in time I have got better at managing to “think before I speak.” I have even managed to change my behaviour with people in the street.  Being tough was what I believed was the best approach and I would fight in the street if I just didn’t like someone.

By the time my baby was born I wanted to show everyone how I could manage and could rely on the visits from my family nurse who was working to support me with what I felt was important in the life of my baby.

I am a good parent for my daughter and have been able to enjoy every minute of her life, well almost because it is okay to say it is tough and hard work.  People doubted that I could keep her safe but my family nurse got me to see that I was really doing well.  I love my daughter and the time we spend together.  It is different being a mother than what I imagined or seen with my pals.  My daughter is my main focus in life but I have been able to return to work and move to a suitable home for us to live in.  My family nurse has helped me to recognise that I can achieve whatever I put my mind to and guess what I believe her.

The programme will come to an end for me soon. My child is no longer on the child protection register and I am managing well to raise her on my own.  I hoped she would be a happy child who I could feel proud of, and she is.

My family nurse asked if I could give her any advice about when she starts to recruit new clients.  I told her how I would never have accepted seeing her if in the beginning she had not just kept coming back to see me.   I worry that others could do the same so have told her to tell them about me and that I truly believe that this programme has helped me with every single aspect of my life as well as allowing me to be a really great mum for my daughter.  Having a family nurse is different to what anyone could imagine and is the best thing I ever agreed to be involved with.

Anonymous, age 19

A wide range of data is collected about the programme in Scotland including an externally commissioned evaluation looking at the transferability of the model into the Scottish context early signs are promising. The programme is seeing high uptake of the programme, low attrition, good fidelity to the model and nurses feeling empowered and well supervised  to support vulnerable families  – click here for more. The Department of Health has also commissioned a randomized control trail due to report next year. The findings of the trial will have significant impact on FNP in UK.

The FNP model improves pregnancy outcomes, child health and development and mother's life course in the short, medium and longer-term. In the US research, FNP children and mothers, mainly those who were high risk with low psychological resources, compared to children and mothers in the comparison group had (http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/nursing/ModernisingCommunityNursi/MNCBoardMeetings/FNPClick here for more information):

Improved Pregnancy Outcomes

• 79% reduction in premature birth amongst mothers who smoked
• Fewer pregnancy related complications and infections
• 31% fewer closely spaced subsequently pregnancies

Improved Child Health and Development

Increase in Children's School Readiness

• 50% reduction in language delays at 21 months;
• 67% reduction in behavioural/intellectual problems at age 6

Increase in Academic Achievement

• 26% higher scores on school reading and maths achievement in Grades 1-3

Better Mental Health and Risk Taking Behaviour

• Lower rates of anxiety and depression at age 12
• Less use of tobacco, alcohol and marijuana at age 12
• Girls had had fewer pregnancies by age 19

Reduction in Criminal Activity

• 59% reduction in child arrests at age 15
• 90% reduction in PINS (US equivalent of supervision orders)

Reduced Child Abuse and Maltreatment

• 39% fewer injuries
• 56% reduction in emergency room visits for accidents and poisonings
• 48% reduction in child abuse and neglect

Improved Maternal Self Sufficiency and Life Course Development

Fewer Unintended Subsequent Pregnancies

• 23% fewer subsequent pregnancies by child age 2
• 32% fewer subsequent pregnancies

Increase in Labour Force Participation by the Mother

• 83% increase by the child's fourth birthday

Reduction in Welfare Use

• 20% reduction in months on welfare
• Saved the government over $12,300 per family in welfare payments alone by time children aged 12 , greater than the programme cost of $11,511

Increase in Father Involvement

• 46% increase in father's presence in household

More Sustained Relationships with Partner

• 18% longer with current partner
• Longer time with an employed partner

Reduction in Criminal Activity

• 60% fewer arrests
• 72% fewer convictions

The information above is drawn from three different NFP trials, each of which has followed families up at different points in time and measured different factors which is why different outcomes are evident at different ages. This list sets outs the main benefits observed. There were also a number of measures that showed no significant differences between the FNP group and the comparison groups, again these varied between the trials and time points.

The first Scottish FNP programme in Edinburgh was funded by the Scottish Government £1.6 million and is being delivered by NHS Lothian during a three-year period. The second pilot received financial support of £3.2 million over three years from the Scottish Government and a contribution of £600,000 from NHS Tayside. It is estimated to cost approximately £3,000 per annum per client who completed the programme.

The economic benefits of FNP are being reviewed as part of recently commissioned work in England. Current estimates suggest that for every £1 invested, £3-5 is saved.

The recently reported work of ‘Modernising Nursing in The Community’, Chaired by Chief Nurse Scotland, Ros Moore is looking at learning from FNP. In particular, models of supervision for nurses, use of data, education and training support for nurses as well as looking at the success factors in engaging people often considered ‘hard to reach’.

Scotland’s Early Years Framework - http://www.scotland.gov.uk/Topics/People/Young-People/Early-Years-and-Family/Early-Years-Framework.

USA Nurse Family Partnership website - www.nursefamilypartnership.org

Article by NS World 'Nurse Family Partnership Co-Produces Results in the US' - http://www.nsworld.org/discoveries/nurse-family-partnership-co-produces-results-us
 
BBC News article on the Family Nurse Partnership – ‘Family nurses offer young mothers a bright future’ - http://www.bbc.co.uk/news/education-11062614.

1.Olds, D.L., (2006). The Nurse-Family Partnership: an evidence-based preventive intervention. Infant Mental Health Journal, 27 (1), 5-25.