2 Was FNP implemented as intended in NHS Lothian?
As discussed in the introduction to this report, FNP is a licensed programme. In order to ensure that the elements of the programme most strongly correlated with success (as evidenced by the US RCTs to date) are replicated, Professor Olds and his team have specified detailed core model elements which new sites must follow in order to implement the programme. A key aim of the evaluation of FNP in NHS Lothian, Edinburgh was to explore whether or not it was possible to implement the programme according to these core model elements within a Scottish context. It also explored barriers and enablers to implementing the FNP model in Scotland, to inform policy and practice around its future development. We discuss the first of these (whether FNP was implemented with fidelity) in this chapter, and the second (barriers and enablers to implementation) in Chapter Three.
Implementing with fidelity means adhering to the 'Core Model Elements' (CMEs) of the programme. These are requirements of the FNP license that ensure that the original research conditions are replicated in order for the benefits to children and families to be realised (FNP Management Manual, 2010).
Fidelity 'stretch' goals relate to the delivery of the programme to clients. They are based on the US research and are believed to be optimum delivery goals for maximising the success of the programme. However, in contrast to the CMEs, the fidelity goals are design to be "stretch goals" as it is recognised that they may be challenging to achieve when first implementing the programme (FNP Management Manual, 2010). They cover four main areas and sometimes overlap with the core model elements (recruitment, retention of clients, amount of programme received and appropriateness of programme content).
Here, we summarise key aspects of performance against the quality of fidelity for the NHS Lothian, Edinburgh site during the period of delivery to their first cohort of clients.
The full CMEs and fidelity 'stretch goals are listed in Appendix E of the first evaluation report (Martin et al, 2011) http://www.scotland.gov.uk/Resource/Doc/355013/0119868.pdf
2.1 Core Model Elements
The FNP CMEs include various criteria relating to client eligibility and recruitment, including that:
- enrolment and participation is voluntary
- only first time-mothers are eligible
- only high risk mothers are eligible - in Scotland, the decision has been to offer the programme to all first time young mothers (19 or under at conception), as age at first pregnancy is considered a risk factor for poor outcomes regardless of the presence of other risks
- sites enrol 100% of clients no later than the 28th week of pregnancy, and
- sites enrol at least 60% of clients during pregnancy by 16 weeks and 6 days (in order to maximise the chances of being able to deliver pregnancy content and establish a relationship before the birth of the child).
NHS Lothian, Edinburgh achieved all of these goals with their first cohort of clients except the final one. Forty two per cent of clients were enrolled by 16 weeks and 6 days gestation, short of the 60% specified in the CMEs.
2.2 Fidelity 'Stretch' goals
The programme met the 'stretch' goal around enrolling 75% of clients to whom the programme is offered - 80% of all eligible clients offered the programme in NHS Lothian agreed to enrol.
2.2.2 Client retention and attrition
Client retention and attrition are key issues for evaluating the success of any publicly-funded programme - clearly if many clients leave before the end of a programme like FNP, the scope for it to deliver its target outcomes, in particular - its population level impact, will be severely constrained. Evidence from the US has informed fidelity 'stretch' goals relating to attrition across the programme as a whole (no more than 40%) and within specific phases of delivery:
- No more than 10% during pregnancy
- No more than 20% during infancy (when the child is 0-12 months old), and
- No more than 10% during the toddlerhood phase (when the child is 12-24 months old).
The NHS Lothian, Edinburgh FNP team experienced attrition rates considerably below these levels with their first cohort of clients. Just 3% of clients left the programme during pregnancy, 12% during infancy and 6% during toddlerhood. Cumulative attrition by the time all clients were due to graduate was 19%.
See the fourth evaluation report (Ormston and McConville, 2013) for a table illustrating client retention and attrition in, NHS Lothian, Edinburgh FNP test site. http://www.scotland.gov.uk/Resource/0043/00435628.pdf
2.2.3 Delivery of expected number of visits
Delivering the programme according to the visit schedule is associated with stronger outcomes. The fidelity 'stretch' goals therefore include targets for the proportion of scheduled visits to be achieved for clients at different stages of the programme:
- 80% or more of expected visits during pregnancy
- 65% or more of expected visits during infancy
- 60% or more of expected visits during toddlerhood.
The 'stretch' goals do not include further guidance on what proportion of clients a site might expect to meet these goals for, but the expectation is that it applies to all clients. In NHS Lothian, they were met for 52% of clients during pregnancy, 55% during infancy and 83% in toddlerhood. The mean proportion of expected visits delivered was 79% in pregnancy, 65% in infancy and 75% in toddlerhood.
2.2.4 Time spent on key topics
FNP also has fidelity 'stretch' goals around the proportion of time spent with clients which is dedicated to different topics. The programme covers five broad topic 'domains' - personal health, environmental health, life course development, maternal role and family and friends. The suggested balance between these domains varies depending on the stage of the programme - for example, Family Nurses spend more time talking about the client's personal health during pregnancy, and more on life course development in toddlerhood. Overall, the time the NHS Lothian, Edinburgh FNP team recorded spending on these domains was very close to the stretch goals.
See the Second: http://www.scotland.gov.uk/Resource/0039/00396377.pdf
And Fourth: http://www.scotland.gov.uk/Resource/0043/00435628.pdf
Evaluation reports for tables illustrating the time spend on key topics across all phases of FNP.
2.3 Family Nurse recruitment, training and supervision
The CMEs for FNP specify a variety of requirements around Family Nurse qualifications, recruitment, caseload, contracted hours, training and supervision. These are intended to ensure not only that Family Nurses are qualified and prepared for the role, but also that they are able to dedicate sufficient time to delivering the programme to individual clients.
The NHS Lothian, Edinburgh site reported meeting all requirements around the qualifications, recruitment and caseload of nurses - all were registered with the Nursing and Midwifery Council, educated to degree level, worked for at least 3 days a week, worked exclusively in FNP, and carried a caseload of no more than 25 clients. The team attended all the training required, and while the evaluation did not monitor detailed compliance with the supervision regime, they all reported actively participating in the different elements of supervision (group, one-to-one, and shadowed home visits - see further discussion in Chapter Three).
2.4 Recording and using FNP data
As an evidence based programme, FNP as a whole is informed by ongoing research and evaluation, and the work of individual FNP teams is also informed by a systematic process of reflecting on data about clients and Family Nurses' contacts with them. The CMEs require Family Nurses to collect data about activity, visit content, mothers and children according to the original visit schedule. Each team's supervisor is then required to 'use programme reports to assess and manage areas where systems, organisational, or operational changes are needed in order to enhance the overall quality of programme operations and to inform reflective supervision with each Family Nurse'.
The interviews with the NHS Lothian, Edinburgh FNP team (i.e. self-reported data) suggested that the team had complied with all data collection requirements. However, due to the delay to the delivery of a national database for FNP in Scotland, the NHS Lothian, Edinburgh FNP team used a database developed in-house to store data from their visits. While this was not viewed as a suitable long-term solution, because of the significant manual intervention required to develop meaningful reports, it did allow the data to be interrogated, for effective supervision and gave the FNP team the opportunity to apply an early intervention to improve client and child outcomes.
Overall, it appears possible to implement the FNP model with a high degree of fidelity to the core model elements in a Scottish context. In the next chapter, we discuss barriers to meeting these two goals, as part of a wider discussion of barriers and enablers to implementing FNP in NHS Lothian more generally.
Parents with their newborn baby
Family Nurse home visit - Playing with baby