4 What is the potential for FNP to impact on client outcomes relevant to Scotland?
As discussed in Chapter One, this evaluation was not designed to provide decisive evidence about the impacts FNP can have in a Scottish context in comparison to universal care. However, through interviews with clients, their significant others, and their Family Nurses, this evaluation has explored perceptions of the impacts FNP has for the young mothers who participate in it, and for their children. Although such accounts cannot be taken as conclusive evidence of FNP impacts (we cannot be sure that these outcomes would not have occurred in the absence of FNP), they nonetheless provide evidence of the potential or plausibility for FNP to achieve its target outcomes.
FNP aims to improve outcomes in three main areas - pregnancy outcomes, child health and development, and maternal health and self-efficacy. We address each of these in turn below.
Well I, to be honest I already knew about like drinking alcohol and taking drugs but I never knew about the smoking thing because my gran smoked with all her three kids while she was pregnant and my gran keeps on saying that later on they were fine.
I used to think that, 'oh, as soon as I'm not pregnant, I can have a wee drink'… but I've just like not anyway, I've just left it because I know it can make the baby more sleepy.
Describing the perceived impact of information from her Family Nurse about drinking while still breast feeding.
4.1 Improved pregnancy outcomes
4.1.1 Improved knowledge of health behaviours and impact on child
The early stages of the programme also focus strongly on client health behaviours around smoking, drinking, diet and exercise. However, in some cases clients reported having made decisions around giving up smoking when pregnant, for example, in advance of joining FNP. Nevertheless, there were also clear examples where clients reported a better understanding of the impact of their own health behaviours ( e.g. the risks of smoking and drinking) on their developing baby as a result of information received from FNP, and of clients changing their behaviour as a result.
Breastfeeding has been a particular focus of infant health promotion in Scotland and the UK for some years now. The experiences of delivering FNP to the first FNP cohort in Scotland highlighted the challenges involved in promoting breastfeeding to young mothers, whose rates of breastfeeding are known to be lower than those of mothers in general. There were examples of clients reporting positive impacts on breastfeeding decisions as a result of information received from FNP - for example, a client who reported being able to breastfeed longer because of information from her Family Nurse about supplements to help with milk flow. Based on quantitative figures collected by the NHS Lothian, Edinburgh FNP team, overall 46% of clients breast fed at least once, while 28% of those clients who were initially either undecided or did not intend to breastfeed when they joined the programme, went on to breastfeed at least once. However, clients interviewed for the evaluation who were not breastfeeding by their second evaluation interview (around 3 months after the birth of their child) identified familiar barriers to doing so, including feeling uncomfortable breastfeeding outside the home, soreness, and the baby not latching on well. As discussed in Chapter Three, there was also some evidence that FNP's outcomes may also be influenced by the support clients receive from other services at key points.
… [the Midwife] just keep going on and on about breastfeeding and how good it was, but with [Family Nurse] […] We sat and went over like the pros and cons of bottle feeding and breastfeeding, so I dinnae feel like the pressure that normally got from my midwife about it, so it was really good.
…it was very much about giving all the information … And some girls that I thought that were definitely going to breastfeed didn't, and other girls that I thought weren't even going to think about it at least gave it a bash. So I don't know if I got it right, but I was listening to where they were, their starting point, and trying to fit in with that.
(Family Nurse 4)
So then she (Family Nurse) said to me, 'If they say like "Don't you push just now" then just say "Well d'you want to give me another vaginal examination, because I'm really feeling the need to push?". So then I said that to the woman. I was like "Look, I really need to push". I was like, "You can even check." … And then (I) started pushing and then (Baby) came out!
4.1.2 More knowledgeable and confident about labour and delivery
Preparing for labour and birth is a key focus of FNP during the pregnancy phase. Clients interviewed for this evaluation described feeling better prepared for the birth itself as a result of discussion with their Family Nurse in terms of:
- Feeling clearer about the different stages of labour
- Feeling more confident when the delivery did not go completely to plan, and
- Feeling better able to assert their views with hospital staff during delivery.
There was also evidence that FNP had helped fathers feel better prepared for the birth by giving them information about what would happen and by discussing roles in the labour room with the family in advance.
4.2 Improved child health and development
4.2.1 Positive parenting practices including good parent-child bonding and attachment
'Attachment theory' is one of the key theories underpinning FNP. It acknowledges the critical importance of new born babies developing secure attachments to their mothers for their subsequent development (Karl et al, 2006). Clients interviewed for this evaluation had discussed a range of activities to support attachment with their Family Nurse, including: skin-to-skin contact; the benefits of breastfeeding and the best feeding positions to encourage bonding; and the benefits of hugging, playing with, talking and singing to babies. While one view among clients was that they would have done all these things anyway, another was that clients and their partners discovered or gained the confidence to try new things with their child as a result of discussions with their Family Nurse.
I found it good that she was advising me to do skin-to-skin. I knew about skin-to-skin and I was planning on doing it anyway, but I needed that wee bit of confidence boost for me to do skin-to-skin and stuff like that.
She showed me how to play and everything with her, the way that she would respond when she's old enough, and then she started responding.
(Significant other 2)
With the Family Nurse, she's given us confidence to do … to do things that we wouldn't normally think of doing … Yeah, some of them are scary. Some of them aren't so scary. But at the same time then we know that, if it happens, this is how you deal with it.
(Significant Other 1)
4.2.2 Clients understand how to keep their child safe and create a safe home environment
The FNP supported clients to assess their home for safety from the perspective of their child, and to access practical home safety equipment. Topics relating to child safety are threaded throughout FNP. Family Nurses reported that clients were often already very knowledgeable about child safety - which may mean that the impact of FNP on their behaviour in this area was sometimes limited. However, clients gave various examples of gaining new information from FNP and changing their approach as a result, including: adopting safe sleeping positions (positioning babies at the bottom of the cot); sterilising dummies; and being more aware of the changes to the home environment that were needed to keep their children safe as they start to crawl and walk. Clients also reported that without the support they received from their Family Nurses in accessing financial grants, they would not have been able to purchase essential safety equipment, like fire guards or safety gates.
4.2.3 Improved infant feeding practices
Clients and Family Nurses discussed the perceived influence of FNP on decisions and practices relating to weaning and their child's diet. Again, there were examples of clients reporting holding off weaning for longer as a result of the support they received from their Family Nurse (current NHS advice is not to begin weaning children until they are six months old in order to give their digestive system time to develop). However, there were also examples where clients appeared to follow family members' advice about when to wean (see discussion of 'intergenerational influences' in Chapter Three).
Clients reported receiving lots of information from their Family Nurses about toddler diet and nutrition. While some panel clients said they already felt confident about what to feed their child, others cited positive impacts from the advice received, in terms of helping them introduce new foods or putting into practice ideas for how to make their toddler's diets more healthy.
4.2.4 Enabling parenting practices to support child development
Supporting children's cognitive and physical development is another key topic for FNP throughout the programme. Again, while one client view was that they would have undertaken the kinds of development activities their Family Nurses suggested anyway, others reported learning new things or doing things differently because of the support their Family Nurse gave them. For example, clients reported:
- Talking to their child more to support their speech development
- Reading to their child
- Adapting play for their child to make it more stimulating to support cognitive and physical development, and
- Being encouraged to take their child to the library and to read and sing to them to aid speech and language development.
4.3 Improved maternal health and self-efficacy
Clients interviewed for the evaluation were very positive about the dual focus of FNP on both mother and baby. This was sometimes contrasted with the support clients believed other services would offer them.
It's not just your baby as well. She'll look after you.
4.3.1 Clients feel better supported in relation to their own mental and emotional health and wellbeing
There was evidence of the potential for FNP to support young mothers to feel better supported in relation their own mental health and wellbeing as well as, where needed, support in coping with stress to help assessing treatment.
In addition to promoting positive health outcomes for their children, FNP has a strong focus on maternal health and self-efficacy. It aims to ensure that young mothers (and their partners) feel better supported in relation to their own physical and mental health, are better equipped to address any issues they have in their key personal relationships, and make plans for the future.
It was helpful yeah but I already had my mind made up anyway
4.3.2 Clients making decisions about contraception (when they might not otherwise have pursued this)
In NHS Lothian, there were some examples of clients reporting making earlier decisions about contraception as a result of advice received from their Family Nurse. However, the NHS Lothian, Edinburgh FNP team felt that some of their first cohort of clients had been at a relatively early stage in their journey towards becoming 'self-efficacious' in relation to their health behaviours in the period after birth, and that they might have needed more directive input around contraception at this point. As a result of these discussions, the team put in place a 'passport' system for their second cohort of clients, so that they could access contraception more quickly and easily. 
I probably would have left it (…) And probably have been pregnant again if I did.
4.3.3 Resolve or manage relationship conflicts
FNP aims to support clients in building and maintaining strong networks to support them as parents. As such, 'Family and friends' is a key topic for the programme. Clients and their significant others interviewed for the evaluation identified various examples of positive impacts they felt their involvement with FNP had on their relationships with others, including:
- Improved communication - clients suggested that the help received from their Family Nurse around raising concerns without escalating conflict had improved (or even saved) relationships with partners, as well as helping to diffuse conflicts with their wider family.
- Improved confidence in dealing with disagreements with family members over how to raise their child - for example, resisting family pressure to wean early.
I spoke to (Family Nurse) about it and she obviously gave me like some ideas to try … and it's helped us. Now we're talking and we're getting on a bit better and it's thanks to the nurse that we are.
4.3.4 Greater access and use of community support/resources
There was evidence that FNP had the potential to support young mothers to link with appropriate community support to help them feel less isolated as well as navigate and access housing and benefit services and grants. Clients' comments indicated the scope for their Family Nurses to play an important role in supporting them to become more independent and self-reliant. Clients mentioned their Family Nurses helping them identify who to contact for housing or benefits advice, contacting other services ( e.g. Housing) on their behalf, supporting them in setting up or attending meetings and, providing information about different housing and benefits options. For some clients, this help around housing or benefits was viewed as the most useful element of FNP. Clients also reported that discussions with their Family Nurse had impacted on their thinking about spending and saving money, which they might not previously have considered.
4.3.5 Broadening the options clients considered around education or work
Finally, clients also discussed the impact FNP had in helping them to make decisions about their own future plans for work or education by supporting them to formulate goals and overcome barriers - for example, deciding to go back to college in the face of a lack of family support for that decision. Client, significant other and Family Nurse accounts indicated the potential for FNP to:
- help them to identify goals
- broaden the options clients consider in relation to work, training and education - for example, broadening the list of colleges they considered applying to, and
- support them to overcome barriers - for example, by providing information about the childcare and funding options available to them if they do decide to return to work or study.
She helped me out with the childcare as well, coz I didn't know they had nurseries or I'd get funding for it.
Clients and their children attending a Parenting Strategy Event
Clients and their children at a Family Nurse Partnership Graduation Event