3 What factors supported or inhibited delivery of FNP in NHS Lothian?
Factors that have impacted - either positively or negatively - on the delivery of FNP in the first Scottish test site have been discussed extensively in the four previous evaluation reports. Rather than revisiting each individual factor that supported or inhibited delivery here, we instead explore the broad areas that appear key to successful implementation and which may influence outcomes. These areas are likely to be significant for other FNP sites in Scotland, and include: 3.1) Adapting to the wider policy context, 3.2) Working with key stakeholders, 3.3) Developing and supporting nurses to work with young parents and their children, and 3.4) Building successful therapeutic relationships.
3.1 Adapting to the wider policy context
FNP is not delivered in isolation. The reception it receives and the impact it is likely to have will be influenced by a range of wider contextual factors. For the NHS Lothian, Edinburgh test site, the current focus within the wider strategic and policy context in Scotland on (a) the early years (b) co-production and (c) reducing inequalities, assets-based approaches and person-centred working may well have helped to ensure that FNP found a receptive audience at a strategic level. FNP was introduced in Lothian shortly after the publication of Getting it Right for Every Child ( GIRFEC - the Scottish Government's strategy for ensuring that every child in Scotland is supported to have the best possible start in life)  and the Early Years Framework.  As such, its focus on supporting young parents and their children in the early years was clearly timely. The use of a 'strengths-based' approach in this way ( i.e. in a one-to-one relationship) was 'new' and diverged from the traditional 'deficits-based' approach. This new approach reflected wider interest in rethinking public services within Scotland using more 'assets-based' approaches, which seek to involve clients and communities in promoting their own health (see Burns, 2009 for example discussion  ).
The Family Nurse Team reflected on the ways in which they felt the first FNP test site in NHS Lothian, Edinburgh might have influenced thinking in the wider NHS and in other services. It was suggested that it may have had an influence in the following key areas:
- How to work with those less likely to access universal services
- How to support Nurses working in high pressure roles
- Specific approaches to assessing clients
- Thinking about services for teenage parents who are not eligible for FNP.
We're building these clients up to have… the confidence and the ability to go out and try and get themselves jobs and move on in the world, and as the recession is biting that's becoming more and more difficult… So we're trying to now think about … 'OK, let's try and think about part-time work… let's think about maybe doing some voluntary stuff, let's think about doing education and training' rather than… going straight into full-time work.
( Family Nurse 3)
In terms of the wider economic context, the FNP programme was implemented in Edinburgh against a backdrop of the UK-wide economic downturn. The Family Nurse team felt this had required them to think more creatively about how to support clients towards becoming more financially self-reliant in a context where there were fewer jobs available - perhaps by looking at voluntary work or education as alternative options to paid employment.
Finally, in relation to wider cultural factors that may impact on delivery and outcomes, the NHS Lothian, Edinburgh FNP team noted the potentially significant influence of clients' own parents' views on their parenting. Family Nurses described involving fathers and family members in visits and explaining changing advice about areas like infant feeding. However, comments from clients indicated that they might nonetheless find it difficult to favour/follow advice from their Family Nurses against these 'intergenerational influences'.
3.2 Working with key stakeholders
3.2.1 Embedding FNP as part of wider services
The NHS Lothian FNP team and FNP National Lead for Scotland were very keen to emphasise the importance of investing time in relationships with key stakeholders from universal and other specialist services with which FNP clients might come into contact ( e.g. Social Work, Children's services, Housing, Benefits, Voluntary organisations etc.). These relationships were considered essential to the successful implementation and delivery of the programme. While stakeholder relationships matter throughout FNP, they were perhaps particularly important at the outset of the programme in ensuring that other services were able and willing to work with FNP, and at the end of the programme in terms of ensuring that clients made a smooth transition to universal services.
She did advise me to wait till he was 6 months, but I couldnae do it. He was starving. (...) Like my mum said as well, me and my brother were on solids by about 3 months, so (…) There's nothing wrong with it.
( Client 6)
Factors that were believed to have supported good working relations between FNP and other services in the NHS Lothian, Edinburgh area included:
- Building on pre-existing working relationships
- Continuous and open communication by the FNP team, including attending meetings of other services
- Shared electronic records (between Midwifery and FNP)
- The quality of Family Nurses' work around shared clients
- Joint visits with Health Visitors prior to clients transitioning back to universal services at the end of FNP.
I think by the time our later clients were giving birth I think the midwives were beginning to come on board with understanding what it was we were trying to achieve and were able to see … the girls … were gaining knowledge etc. and were preparing well for their babies.
Family Nurse 5)
Key barriers (from the perspective of the FNP team) to building and maintaining these relationships related to:
- Communicating the underlying philosophy of FNP - in particular, conveying the rationale for and practice of a strengths-based approach and reassuring other services that this does not mean ignoring risk.
- The time demands involved when other services undergo staff changes or when new services/geographical areas need to be visited ( e.g. when clients move to other areas)
Early learning point
Finding ways of optimising the relationship between FNP and wider services is clearly critical to the success of the programme. Some of the suggestions for further improving communication between FNP and other services included: more and/or earlier sharing of the theoretical and research base for the programme and how it would work with particular services, and more regular meetings between Family Nurses and GP practices.
3.2.2 Linking to appropriate wider services
Referrals and signposting from Family Nurses to other services for both maternal and child health issues were clearly appreciated by clients and their significant others. It was suggested that without the support of the Family Nurse, maternal health issues might have gone undiagnosed or untreated for longer.
Clients also reported finding it helpful to have support with various aspects of housing, benefits and money management, particularly as for some obtaining housing benefit was perceived as causing more problems during pregnancy than anything else. Clients appreciated advice about benefits as they were often uncertain about what they were entitled to, where to go for help and what forms to complete.
It was that night (after the Family Nurse's visit) that (client) said to me, 'I need help', kinda thing … It was the first time she's actually asked for help properly, you know?
(Significant other 3)
However, the availability and appropriateness of additional services for young mothers, or indeed families in general, may impact on FNP outcomes. Examples discussed in the evaluation reports include:
- Clients feeling that the breastfeeding support while they were still in hospital was insufficient for their needs. In some cases, this was believed to have contributed to clients giving up breastfeeding before their first postnatal FNP visit.
- A lack of antenatal classes that cater specifically for young mothers. Clients reported being reluctant to attend universally available antenatal classes, which were viewed as being more for older women.
- Some clients reported a reluctance to attend postnatal mother and baby/toddler groups for similar reasons. Meanwhile, the NHS Lothian, Edinburgh FNP team felt that there was something of a gap in the provision of general services for young parents of two year-olds.
- The perceived affordability and appropriateness of available childcare options was cited by clients as a key barrier to realising their ultimate goals around work and education.
I think everybody at those groups would just be too old anyway. They'd be like twenty … mid-twenties or something.
Early learning point
While FNP is able to play a role in filling some important information and support gaps - for example, providing antenatal education to young mothers who may not otherwise engage with classes - it might be easier to achieve FNP outcomes ( e.g. around behaviour change and improved health etc.) if there was a greater range of services catering effectively for mothers in its target age group. The FNP team in NHS Lothian has shown how it can inform the development of such services in Edinburgh by supporting a number of FNP clients to train as 'peer supporters' as part of a 'best buddy' scheme (which includes breastfeeding) run by NHS Lothian's Infant Feeding team.
3.2.3 Managing risks within a strengths based approach (Child Protection)
Working relationships between FNP and key services like midwifery, health visiting, social work and housing had all improved since the start of the programme as they had become familiar with each other and with FNP's ways of working. However, as discussed in Chapter Two, some initial challenges were noted in communicating the FNP approach.
3.3 Developing and supporting nurses to work with young parents and their children
3.3.1 Recruitment of nurses
FNP attracted highly motivated and skilled health professionals, who are committed to the client group, and met the programme requirements as set out in the CMEs.
In addition to a formal interview process with a professional panel, potential service users - young mothers (under 20), and mothers to be, their partners and families - were invited to be involved in the recruitment of the FNP Team. This innovative approach was embraced by the service users who worked with the FNP lead and the Psychologist to define questions to ask of the candidates and was perceived by those involved as a very positive experience. It was a measure of the success of the approach that the service user-recruiters identified the same Nurses as the professional recruiters and in the same order of preference.
I think sometimes it was just seen as 'strengths-based approach, you don't see any of the risks'. And it's not that you don't see the risks, you maybe just deal with them in a slightly different manner. …so I think it was sometimes a challenge to just … get over the... perspective we were coming from. However, when people started to see the fruits of the labour, they actually then got the approach … they really got behind us.
(Family Nurse 5)
3.3.2 The Learning Programme
FNP involves extensive core mandatory training and ongoing learning. Before Nurses are permitted to deliver the programme to clients they must complete the pregnancy training. They attend three residential courses between 3-5 days duration covering each 'phase' of FNP (pregnancy, infancy and toddlerhood). They also attend 'master classes' covering specific tools and approaches used in FNP, like communication skills training or the Partnership in Parenting Education ( PIPE) materials. 
Family Nurses suggested that refresher training around these tools would be helpful to ensure Family Nurses are able to make the most effective use of them in visits. The NHS Lothian, Edinburgh FNP team were extremely enthusiastic about the training they had received for their role. They described it as ' phenomenal' in terms of quality and suggested that it was superior to any training they had previously received as nurses. Their experience indicates the value of investing in high quality training in order to ensure that nurses are prepared for working with key groups of patients like young families.
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.
Early learning point
While the learning programme for FNP as a whole was highly praised, the majority of the core mandatory training (which takes place after the pregnancy phase training) is delivered over the next 18 months, commencing during the period (9 months) in which Family Nurses were trying to recruit the first cohort. As a result, there was a perception among the NHS Lothian FNP team that some elements - such as the toddlerhood training and some of the masterclasses (like DANCE  training) - were delivered at a point at which it was difficult to apply the learning because of the age and stage of the children. While some time lag is perhaps always likely, according to Family Nurses, building in the opportunites to enable structured on sitelearning to consolidate training during the earlier stages of the programme would be useful. In order for the FNP learning programme in Scotland to continue to develop, the experiences of Family Nurses in the first site in NHS Lothian need to be considered alongside the experiences of those in subsequent sites  .
You couldn't do it without supervision or the level of supervision. You really need to have that reflective space just to look and analyse what you've actually done and what you've actually seen to plan ahead.
(Family Nurse 4)
…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)
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)
3.3.3 Supervision (supporting intensive interventions)
Supervision was viewed by Family Nurses as ' invaluable' in supporting them to manage a challenging caseload and giving them the ' headspace' to reflect on and improve their practice. Making supervision mandatory ( i.e. part of the licence) was viewed as key to ensuring that the team committed to attending sessions, and that it did not drop out of people's busy working week, instead it enabled the team to prioritise it.
Nurses felt that the supervision they received mirrored what they offered to their clients - reflecting the focus on 'parallel processing' as a key component of the FNP model.
The Family Nurses had various other forms of group support, including monthly clinical supervision with the team psychologist. The team psychologist provides both group supervision to encourage reflective practice among the FNP team, and individual supervision to the FNP supervisor.
3.3.4 Developing the FNP materials
The FNP materials themselves were viewed by the NHS Lothian FNP team (and by clients) as high quality and very helpful in supporting them to discuss sometimes challenging topics. This is one area where there is perhaps less scope for sharing learning between FNP and other services, since all FNP materials are under license and cannot be shared out with FNP teams.
There may perhaps be shared learning about the kinds of topics in which professionals working with families might find it particularly useful to have high quality supporting materials.
In terms of the future development materials for FNP in Scotland, the evaluation highlighted some areas that might need to be considered, including:
- Development of additional/alternative materials for use when a client's child is temporarily taken into care - FNP materials focusing on interactions with your child were viewed as sometimes inappropriate during this particularly sensitive period for clients.
- Development/tailoring of materials appropriate for the age and stage of the baby and mother. For example, depending on the needs of the client, this may include alcohol, new relationships and contraception.
Early learning point
Although the Family Nurses praised the training, supervision and materials associated with the programme, they identified a few areas which may require some further development depending on the age and stage of the child/mother and the needs and interests of the client. These include:
- Labour and delivery
- Sexual health
- New relationships
- Working with clients when they have a second pregnancy
- Working with clients when their baby is being looked after
- Binge drinking
3.3.5 Managing challenging workloads
The role of Family Nurses is undoubtedly challenging. Although their caseload is lower than that of most Public Health Nurses-Health Visitors ( FNP caseloads are capped at 25 clients per full time equivalent Family Nurse), the frequency of client contacts specified by the visiting schedule, the intensity of the relationships that develop, and the fact that their clients' young age can sometimes (though not always) be associated with particular vulnerabilities all contribute to a workload that can be heavy in terms of hours, as well as being emotionally challenging.
Workload was the key challenge discussed by the NHS Lothian, Edinburgh FNP team over the two and a half years of the evaluation. Heavy workload was believed to be a key factor impacting on the team's ability to deliver the required number of visits to all clients, particularly in the pregnancy and early infancy phases of the programme (see Chapter Two for figures on the proportion of expected visits actually achieved).
I mean, I think the entire programme we struggle with time. We really do. And annual leave always makes it difficult to keep up the fortnightly contact. And I mean just time in general - managing the conflicting priorities of … of all our clients and the different programme components can make it a challenge to fit the schedule.
(Family Nurse 5)
However, views and experiences of workloads shifted over the course of the evaluation, both in terms of the degree to which workload was believed to be a major issue for the team, and the factors thought to contribute to higher workloads. There remained divergent views on whether the Family Nurse workload as a whole was manageable within contracted hours. Meanwhile, the Supervisor workload was viewed as having been very challenging throughout the programme to date. The FNP Supervisor has worked closely with the nurses to develop strategies for addressing challenges. It was suggested that additional training around capacity planning and different electronic tools that could be used to support this might be helpful.
The factors believed to have contributed to high workloads and/or to difficulties achieving the target number of visits for every client can be divided into:
- Issues associated with being a test site - in particular, the need to complete the majority of the core mandatory training at the same time as recruiting clients. The NHS Lothian, Edinburgh FNP team also appeared to experience additional pressures as a result of being the first test site in Scotland, reporting large volumes of enquiries or requests for support from other sites, prospective Family Nurses, and the FNP National Unit (Scotland).
- FNP programme-related factors - the requirement for the NHS Lothian, Edinburgh team to recruit the first cohort of clients within nine months was believed to have caused considerable workload pressure. In addition, delivering the required weekly visits in the six weeks post-partum was viewed as particularly difficult to accommodate within normal working hours, during that period.
- Issues associated with being part of a wider service (the NHS) - in addition to attending mandatory FNP training, Family Nurses in the UK also need to attend mandatory NHS training. Moreover, local changes within the NHS and the number of cases which require more intensive support can contribute to workloads - for example, the introduction of a new system of record keeping in NHS Lothian was believed to have caused some initial additional work for the team.
- Client-related factors - the team reported that their clients were often highly mobile, moving frequently over the course of the programme. This created challenges in terms of being able to 'zone' clients geographically to enable visits to be carried out in a time-efficient manner.
- External factors - finally, external factors like an extended period of very poor weather and staff illness had also created additional workload pressures at specific points in time.
Early learning point
Some factors associated with being a test site should dissipate over time, and the recruitment period for further FNP sites (and for the second cohort of clients in Lothian) has already been extended to 12 months. However, other factors - like the requirements placed on teams as part of a wider service, client mobility, and the requirement to deliver weekly visits to all clients during the first six weeks post-partum - will not automatically change over time. While the NHS Lothian, Edinburgh FNP team reported feeling well supported in attempts to manage their workload, wider issues around the longer-term sustainability of the hours involved in delivering FNP in Scotland may need to be considered as the programme develops (see further discussion in Chapter Five).
3.4 Building successful therapeutic relationships
Perhaps the key factor believed - by clients and Family Nurses - to have supported effective delivery of the programme was the quality of the therapeutic relationships that developed between Family Nurses and their clients. Low attrition, client engagement with the visiting schedule, and positive client outcomes were all attributed by the Family Nurse team to these relationships. The development of these relationships was in turn supported by:
- The consistency of the Family Nurse's involvement with clients - clients indicated that the reliability and continuity of this relationship, and fact they had got to know their Family Nurse over an extended period of time (from pregnancy) was key to their feeling able to open up to them about any difficulties with which they needed help. This was contrasted with clients' views of other professionals, whose infrequent and time-limited involvement in their lives was seen as a barrier to building up the same level of trust.
- The use of strengths-based approaches - a key way in which clients felt their Family Nurses differed from other professionals they had encountered was the fact that they did not ' judge' them and that they offered them information that they could ' take .. on board if you want to'. In addition to underpinning client trust in their Family Nurses, the fact that the programme emphasises recognising clients' own strengths and knowledge appeared to have a significant impact on client confidence in their own capacity to be good parents.
- The visiting schedule - where Family Nurses had been able to see clients regularly, they generally reported a 'deepening' therapeutic relationship with them over time. In contrast, where contact with clients was less frequent, they tended to view the therapeutic relationship with clients as not as deep.
- The use of agenda-matching - the fact that Family Nurses are trained to 'flex' the programme to meet the clients' specific needs clearly contributed to clients' positive experiences of their relationship with their nurse: clients reported that they were always able to bring any issues or concerns they had to their meetings with their Family Nurse. Meanwhile, Family Nurses noted that if a particular topic was initially met with client resistance, the structure of FNP meant that they were able to reintroduce it and address it at a more appropriate point in time for that client.
- The team's commitment to their clients - finally, while the structure of the programme supports the development of therapeutic relationships, the high level of commitment the team had to their clients was also very evident throughout the evaluation. Building such strong relationships between a professional and client might be thought likely to lead to dependency difficulties at the point clients need to leave a programme. However, the experiences of the NHS Lothian, Edinburgh FNP team and their clients suggests that, by introducing transition from the programme to on-going support right from the start of the programme and by working in a structured way to prepare clients for this, it is possible to support effective transitions out of intensive services like FNP.
Probably at the start like when I started telling her I feel right down and depressed and everything like that, I probably felt like out of my comfort zone. Because she's here to … she's here to help and everything like that but I just … she's not family. And like I know I can trust her, but like that was really personal, so there was a doubt in the back of my head "what happens if she runs and then goes and tells somebody that's not meant to…like I dinnae want them to know." There was always that doubt. But I know I can trust her now. I've always been able to trust her, but like I know not to feel self conscious about it.
She's just advised me like on stuff …so it's not that we've disagreed. We've just got different opinions … She's very supportive … I think it was leaflets she gave me … what they're there for and all that, so she has gave me advice, and she knows that it is my choice.
I had a client who, at the beginning of pregnancy, the minute that smoking was mentioned in any shape or form clammed up … I tried to raise it a couple of times after that and I really did think 'If I talk about this again, she's going to stop me from coming', so I didn't raise it for a good while, and then she then mentioned it to me … and I went in very softly softly and she now has completely stopped.
(Family Nurse 3)
3.4.1 Working with the family (Involvement of fathers and family members)
Clients' family members gained new knowledge, confidence and skills from FNP. They appreciated the information Family Nurses gave them, and recognised this could be more up to date than their own knowledge.
Clients' and partners' accounts of the impact of involving partners in FNP focused on the benefits of their Family Nurses advice for their relationships and on their partner confidence about the birth, rather than practical childcare skills.
Early learning point
While, overall, the depth and strength of the relationships that developed between Family Nurses and clients was a key facilitator of successful delivery, it was also associated with some challenges in relation to the continuity of programme delivery. For example, comments from both Family Nurses and clients indicated the strong preference clients have for seeing their own Family Nurse - which meant that attempts to cover individual nurses' visits during any periods of leave were rarely successful. Meanwhile, attempts to 'hand over' clients of a Family Nurse to allow her to act up to supervisor on a part-time basis were met with similar resistance. Future implementation of FNP will need to acknowledge and anticipate this issue in terms of managing both staffing and client expectations.
(Family Nurse) has answered my questions and queries just as … as if I was the main sort of focus as client as well. I don't feel like the second person. I feel like we're together so (Family Nurse) sees us together.
(Significant Other 1)
It did actually help. Like sometimes if we were having an argument, I'd try and, like, say stuff she had told me … and most of the time it did actually work. Like it calmed the situation down.
Family Nurse home visits - covering topics such as child's brain development, reading and stimulation through play