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The Family Nurse Partnership Programme:enabling people to grow through emotional engagement
We are testing FNP because: • Between 2 and 5% of children in England experience multiple deprivation and poor outcomes, leading to high costs to tax payer and society • The experience of the unborn child and their early parental relationship has a determining role in their future life chances • Pregnancy and birth a key time for change • Robust evidence to show FNP can turn round life chances for most disadvantaged families, break intergenerational disadvantage and improve social mobility • Cost savings potentially substantial - recent US evidence showed Government saved cost of FNP through savings in welfare payments alone by time children aged 12 • International review by Lancet - one of only two programmes shown to prevent child maltreatment
FNP has consistent results in outcomes across 3 scientific trials in USA Improvements in women’s antenatal health and behaviours Reductions in children’s injuries, child abuse and neglect Fewer subsequent pregnancies Greater intervals between births Increases in fathers’ involvement Increases in maternal employment Reductions in welfare dependency Better parenting Improves children’s cognitive development, school readiness and academic achievement Improves children’s emotional and behavioural development Reduces children’s involvement in crime and anti-social behaviour later in life Reduced substance use initiation Substantial cost savings – up to $5 for every $1 invested by age 15
An intensive preventive programme through pregnancy until child is aged 2 • Benefits children and families who have the poorest outcomes • To improve antenatal heath, child health and development and parents economic self-sufficiency What families get: • Weekly, fortnightly, monthly home visits by Family Nurses • Each visit includes structured conversations and activities to improve self efficacy, change behaviour and build attachment • Voluntary and based on nurse/client relationship 7
FNP can turn round life chances and break intergenerational disadvantage • Parents envisage a different possibility – a new story of themselves and understanding of their lives and futures • To become a dependable figure for their baby and better able to meet their emotional, social and developmental needs • Better health related behaviours – pregnancy health, smoking, diet and nutrition, substance abuse, breastfeeding • A safe relationship with the family nurse so open to learning and emotional change • Improving mother’s life course – subsequent pregnancies, education, training and work • Improving relationships – with infant, partner/baby’s father, wider family • Accessing wider services
Client engagement • FNP is a voluntary programme. • Outcomes are achieved through changes in client behaviours • In order to change, clients need to engage with the programme : • Be at home for the FN visits • Develop a relationship with the nurse • Use the FN expertise and the FNP materials and activities to learn and grow • Commit to and undertake change
Client challenges to engagement • Distrust of services, often arising from experience • Adolescent brain – impulsive , challenged by planning • Adolescence – life transition • Difficulties of committing – challenged by close relationships • Content of programme, challenges of change • Results in testing out of nurses
Engaging fathers • Mother decides whether father is present for programme visits • Often new relationship, may be transient • Encouraged to engage father for benefit of child • Activities are both joint and separate e.g. monthly ‘Dad’s Days’ sheets • Programme goals and domains include understanding and developing positive relationships • Fathers, like mothers, have strengths and potential • Judging when a father is a ‘bad guy’ – if not engaged you won’t know • Fathers involved in interviewing supervisor and family nurses
Learning for universal services • Not all fathers want the same things, have different interests and needs from mothers • Involvement in services is not the same as involvement with one’s child • Same engagement principles apply • Some want to be more involved in our services than others • Importance of the provider role for fathers • Flexible hours • Specific, tailor made materials • Practical activities – beyond ‘sofa conversations’ • Respectful curiosity not making assumptions or judgements • Skills to communicate in a ‘triad’ rather than ‘diad’ • Matching agendas and balancing needs of child, mother and father
Principles of engagement in FNP • Not about why clients don’t engage with FNP but about why service fails to engage with client • Parallel process with the nurse modelling the relationship that we would want to see between the mother/father and child • Nurses align programme goals to client’s motivations • Initial strength based, sensitive but assertive engagement • Agenda matching – content and relationship to individual • Creating relevance and authenticity – respectful curiosity, exploring ambivalence, information exchange. • Modelling resilience – not taking behaviours personally –appreciating what is behind behaviours • 6 months for re-engagement
Supporting the emotional growth of clients in FNP • Based on a therapeutic relationship • Use of emotional language • Strength based approach • Increases understanding of emotional concepts e.g. attachment • Models behaviours which exhibit emotional stability e.g. trustworthiness, containment • Works to increase client self efficacy and material and social support structures
Supporting the emotional growth of children • The way in which parents respond to a child’s needs has a profound influence on the child’s development • Over time, the pattern of responses is assimilated by the child into their understanding of how the world works and becomes built into their neurological hardwiring • Sensitive and responsive care giving that promotes social, emotional and cognitive development provides security for the child and enables them to explore and develop • FNP enables clients to develop their understanding of, and skills in, sensitive, responsive care giving
Tools to support this work • Programme materials increase understanding and explore emotional concepts • Modelling of behaviours and positive relationships • Exploring and modelling responsive care giving through use of interactive materials and dolls • DANCE tool to observe caregiver/child interactions and use programme to address specific issues. • Motivational interviewing approaches to support changes in behaviours
Early evaluation suggests FNP can be successfully transferred to England • FNP can be implemented successfully in England - programme can be delivered with fidelity to the US model. • The materials work in this country and are well received by families. • The programme is welcomed by hard to reach families and reaches clients who are likely to benefit most. • Successfully engages with hard to reach families from early in their pregnancy - 87% of women offered programme enrol, high levels of retention through to end of programme. • Clients like and value the programme and have high regard for their family nurses. • Engagement with fathers is good. Almost half the fathers and partners had been present for at least one FNP visit. • The programme has the enthusiastic support of the nurses who are seeing changes take place in health behaviour, relationships, parental role and maternal well-being. 19
Promising early impacts • Many clients reported positive changes in their understanding of pregnancy, labour, delivery and their infant • Clients more confident as parents, doing activities with children likely to enhance cognitive and social development • Closer involvement of fathers with infants • Feel less judged and excluded, thinking about the future with more optimism, gives them an expectation that formal services could be helpful • There are early signs that clients now have aspirations for the future and cope better with pregnancy, labour and parenthood • Reduction in smokingduring pregnancy - 40% to 32% (20% relative reduction) • Breast feeding initiation rate higher than national rate for same age group (FNP = 63% UK under 20s=53% ) • Increased participation of mothers in education and employment • Improved self efficacy of mothers between start and end of programme • Early identification of safeguarding issues and better outcomes for families involved with child protection system 20