Case study: Intensive home visiting for young mums and dads

7 June 2009

The Family Nurse Partnership (FNP)

is an intensive prevention programme being tested in England.T he programme, which has been developed and researched over 30 years in the US with impressive results, is based on home visiting by the same Family Nurse to vulnerable, first time, young parents, from early pregnancy until the child is two years old. 

In England, it is jointly led by DH/DCSF and began in 2007 in 10 sites. Slow expansion with robust evaluation is the name of the game – and by 2011 there will be FNP teams in 70 areas.

Although the focus is the mothers, FNP is having considerable success engaging with fathers, around 80% of whom seem to be in a relationship with the mother during the pregnancy. The Year One Evaluation  revealed that, in the first cohort of 1000 families, one third of the couples lived together during pregnancy. In that first year, FNP engaged with half the fathers; and 58% of the mothers asked for materials to be left for fathers who couldn’t be present (for example, because they did not live with them or could not be there, and in a couple of instances were in prison). Fathers who were present were almost as involved in the activities as mothers, and appeared to understand and accept the materials.

Why the success with fathers?

An early start

Because the programme kicks in before the 28th week of pregnancy the fathers are more likely to be in the picture. And because the same Family Nurse visits weekly or fortnightly, both parents have the chance to develop individual relationships with her, as well as relate to her as a couple. One-on-one relationship building is the key to success in engaging disadvantaged fathers, as well as mothers.

Strengths based, solution focused – and an holistic approach

Young fathers, in particular, tend to be criticised (and fear being criticised) for having “got her pregnant”, so the FNP’s strengths-based, solution-focused approach is hugely engaging for them. One young father said to Derby Family Nurse and Supervisor Sue Perkins: “you are the very first person who has been positive about this baby.” FNP’s wide scope also draws the dads in, since the programme is concerned with far more than just the pregnant woman’s body and covers health, parental role, home, neighbourhood, family and friends, parenting, resources and community and other services.

The Nurses – and their training

The health professionals appointed as Family Nurses are excellent communicators and highly skilled at engaging clients who may find it difficult to relate to professionals. This puts them in strong position to engage well with dads. They are particularly skilled at ‘agenda matching’ as well as listening and responding to ‘change talk’ and picking up on subtle disengagement cues. In depth training along with excellent materials and facilitators equip them to raise and work on couple-issues including violence, communication, life goals and relationships. The nurses are able to guide mothers and fathers to understand the impact of good, bad and “absent” fathering on mother and infant – a vital motivator for engaging with the dads. In addition, each Nurse is expected to raise the issue of the father with the young mother early on – and to support his participation, where this is safe.

Programme materials

Many FNP materials address the couple relationship and communication issues, and/or can be worked on together by the couple. From 2009, duplicate materials have been produced for nurses to use with dads. Many activities are practical and involve playing with the child, which is very appealing to the fathers. Furthermore, the purpose of each visit is laid out clearly – and fathers are much more likely to participate if they know what to expect. Fathers are also more likely to take part when they understand the benefit to their child. The Nurse repeatedly focuses on this. For example, the materials describe the impact of maternal stress, of smoking (and passive smoking), alcohol etc. on the unborn baby’s developing brain. The young parents are also offered strategies to develop positive communication with each other, and are helped to set realistic step-by-step goals for behaviour change. Manageable behaviour change plus an understanding of why change matters to their child seems to be a winning combination for fathers: one expectant dad commented that he and his partner had stopped fighting because they now understood its impact on their baby in the womb.

Adjusting practice

The degree to which a Family Nurse will engage successfully with dads depends on nuanced changes in practice. Sue Perkins mentions timing one regular visit “after he’s got in from work and had a bit of tea” and demonstrates positive moves to include fathers: “If he says ‘I’ll buzz off’ we say – no, it’s for you as well, but in a way that doesn’t make them feel that they have to. I think it is quite a skill.”

As Supervisor, Sue does joint visits with some of the Nurses and mentions two moments of subtle inclusion by her colleagues that she observed. One father had been tinkering with his bike in the corner, and when the Nurse introduced baby massage, she turned and addressed him directly: ‘Mike – would you like to come and have a go?’ He came straight over. Another Nurse let a young father go downstairs but, when he’d been gone for a bit, went to the top of the stairs and called him – and he came up again immediately. Derby FNP have also been careful to make the fathers’ participation visible: including dads in extra things, like a visit from the Government Minister; and ensuring dads are on the interview panel for two new nurses. “We work with so many of the dads much more closely than we would have before – helping them get into education, linking them in with Connexions, with courses, with mental health services and so on – and not just because mum had told us, but because we have been talking to them ourselves.”

The future

However, it is early days and there is still lots to learn. Sue has noticed in Derby that as the babies are born and grow older, FNP connection with the dads can drop off. She doesn’t know why.  It may be related to trouble between the couple (other research has shown the months after the birth to be more of a “risk time” for the stability of the couple relationship than the months before it).  And other research has shown that positive attitudes to the pregnancy by young, disadvantaged fathers don’t necessarily translate into immediate heightened engagement afterwards, although if communication channels can be kept open, that may happen later – even after a spell in prison . . . 

AsKate Billingham (FNP Project Director) says herself: “We’re really just at the beginning of understanding how to meaningfully engage young dads in they become parents ”.

That’s true – but FNP have certainly made a very good start.

Contact

To find out more about the Family Nurse Partnership model, email nursefamilypartnership@dh.gsi.gov.uk

 

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