Case Study : Fathers in the Family Nurse Partnership (FNP) Programme

22 July 2013

This article summarises the information about young fathers in the three evaluation reports that have been produced by BirkbeckCollege, University of London about the formative evaluation of the first 10 FNP test sites (see references below).

Background to the Family Nurse Partnership (FNP) Programme

The Family Nurse Partnership was developed in the USA by Professor David Olds.  It is a nurse home-visiting programme designed to improve the health, well-being and self-sufficiency of young first-time parents and their children.  It involves regular, structured home-visits by a specially trained nurse from early pregnancy until the child is 2 years old.  The programme is designed for low-income mothers who have had no previous live births and starts in the second trimester of pregnancy.

Through regular home visits and the development of a strong therapeutic relationship between nurse and mother, the programme has three main aims:

  • To improve the outcomes of pregnancy by helping young mothers improve their pre-natal health
  • To improve the child’s health and development by helping parents to provide more sensitive and competent care of the child
  • To improve parental life course by helping parents plan future pregnancies, complete their education and find work.

The curriculum that families take part in if they sign up to the programme is structured and has detailed plans for the number, timing and content of home-visits.

Research evidence from three randomised-control trials in the USA show positive effects from pregnancy through to the time children were 15 years old.  The most pervasive effects are those relating to maternal life course (such as fewer and more widely spaced pregnancies) and better financial status.  The likelihood of child accidents is reduced and the children are likely to have improved developmental outcomes as they reach school age.  The research also shows clear evidence for a reduction in antisocial behaviour in children when they reach their teens.

The 10 pilot sites in England

In 2006 the UK government announced that 10 pilot sites would test the Nurse Family Partnership in England.  The programme was initially funded for three years.  The selected sites vary in size and geography:
County Durham and Darlington, Manchester, Barnsley, DerbyCity, Walsall, South East Essex, Slough, Somerset, Southwark and Tower Hamlets.  A Family Nurse team in each pilot site consists of four Family Nurses and a supervisor.  Family Nurses are expected to have no more than 25 clients each.

The UK Programme

If the programme is completed in full each family will receive a set number of visits for each of the three stages:

  • Pregnancy: Visits are weekly the first 4 weeks and then fortnightly until the baby’s birth (a maximum of 14 visits)
  • Infancy: (birth-12 months), visits are offered weekly for 6 weeks after the baby’s birth and then fortnightly (a maximum of 28 visits)
  • Toddlerhood: (aged 12-24 months), visits are fortnightly for 9 months (12-21 months), and then monthly until 24 months, where the family graduates from the programme (a maximum of 22 visits)

Visits last at least 60 minutes and sometimes longer depending on individual circumstances.

The material used for each visit is pre-described by the programme, although Family Nurses are expected to be flexible in terms of how the material is presented.  The hand-outs or activities, for example, cover:

  • In pregnancy: smoking and diet, maternal exercise, dental care, safe sex, contraception, labour and danger signs, as well as breastfeeding
  • In Infancy: infant cues/understanding your baby, keeping baby safe/smoke free, maternal health, nutrition and infant feeding, and going back to work/education
  • In toddlerhood: children’s development, emerging language, choosing childcare and family planning

Home-visits focus on more than child health and development.  Family Nurses are expected to address different domains of family life in each visit, namely personal health; parental role; life course development; family and friends; and environmental health.

An essential part of the programme is also the number of standardised data forms Family Nurses use to record the length and frequency of visits and details of participants and their progress.

The Evaluation

The 3-year evaluation focused on the 1,303 families that were involved in the Family Nurse Partnership in the 10 pilot sites.  The main purpose of the evaluation was to find out whether this US programme was acceptable to families and staff in an English context; the experiences of Nurses and families; and the benefits to families.

Because many of the positive outcomes associated with the programme (fewer behavioural problems, less involvement in crime) do not take place until later in the children’s lives, the evaluation did not address these long term outcomes.  A separate randomised control trial has been set up to evidence this (led by CardiffUniversity, due to report in 2013).

Every year, the evaluators interviewed a sample of mothers involved in the programme, as well as a small number of mothers who had left the programme prematurely.  Family Nurses, supervisors and other key stakeholders were also interviewed yearly.  In the first year only, 30 fathers were also interviewed, as were a small number of maternal grandmothers.  An important part of the evaluation data, derived from the standardised data forms routinely completed by Family Nurses delivering the programme and detailed work diaries completed yearly over a two week period. T his resulted in three evaluation reports (Barnes et al. 2008, 2009 & 2011).

Evaluation findings

The evaluation suggests that the programme can be delivered successfully in England, families like it and think it is making a difference, and the potential for impacts looks good.

  • There are early signs that mothers now have aspirations for the future and cope better with pregnancy, labour and parenthood
  • Reduction in smoking during pregnancy – from 40% to 32%
  • The number of mothers who start breastfeeding is higher than national rates for the same age group
  • Mothers are returning to education and employment, making regular use of effective birth control methods and spacing subsequent pregnancies
  • The children appear to be developing in line with the population in general, which is promising as this group usually fare much worse
  • Mothers who have graduated from the programme are very positive about their parenting capability, reporting high levels of warm parenting, low levels of harsh discipline and levels of parenting stress similar to that in the normal population

Fathers and the Family Nurse Partnership

Although young first-time mothers were the main target for the programme, an important feature of the Family Nurse Partnership is to involve the ‘whole family’. In practice this meant that Family Nurses would seek to work with fathers and partners, as part of the programme delivery. The data relating to fathers is relatively limited, as fathers were only interviewed for the first evaluation report. However, the following section summaries the information available about fathers and partners, their involvement in the programme and their views about the Family Nurse Partnership.

Fathers’ presence for home-visits

As part of the documentation completed for the programme, Family Nurses kept records of when fathers were present during home-visits.

Fathers’ presence for visits

% of visits fathers were present for

% of fathers present for at least one visits

Pregnancy

23% 51%

Infancy

24% 75%

Toddlerhood

19% 56%

The evaluation shows that there were big variations in terms of how often fathers or partners were present for visits. A small number of fathers were present for all the Family Nurse’s visits, while many fathers didn’t participate in any. More than half of fathers were present for at least one visit during pregnancy and toddlerhood, a figure that rose to 75% in infancy.

Some fathers were unable to participate in the Family Nurse’ visits because of work commitments, living a distance away or imprisonment. Others saw the Family Nurse mainly as a resource for the young mother, a view that was more prominent among fathers during the pregnancy stage, when families were first recruited. As one father highlighted:

I did not expect to be involved I thought it would be more for my girlfriend’s benefit, but when I turned up she [the Family Nurse] said she would help me as well. I have learned about being a parent and that has helped a lot. I don’t mind the worksheets; I find them really useful (Father quoted in Barnes et al. 2008, 57)

It often took a few sessions before fathers became involved in the activities, as they came to know their Family Nurse better. A few fathers expected the visits to be intrusive, but were pleased when this was not the case:

When I first heard about it I thought it would have been all about [client] being a teenage mother, not giving information but trying to check up, prying onto our pregnancy, but it hasn’t been like that (Father quoted in Barnes et al. 2008, 57)

Comparing mothers where there was some presence of their partner at visits with those where there were none, there was a small but significant difference; when fathers were present the mother’s average involvement rating was higher. Or in other words, fathers’ involvement encourages mothers to be more involved with the Family Nurse Programme (Barnes et al. 2008, 114). In similar terms, ongoing lower involvement of fathers (and mothers) was an indicator of the possibility that the family might leave the programme (Barnes et al. 2009, 46).

Fathers and the programme material

Family Nurses rated both parents’ level of involvement, understanding and conflict with the programme material provided.  Fathers were rated relatively high by the Family Nurse, for both involvement and understanding of the material, and as having a low level of conflict with the programme hand-outs and activities.

Family Nurse’s average ratings of fathers’ and mothers’ (1=low, 5=high)

Involvement

Understanding

Conflict

Fathers

Mothers

Fathers

Mothers

Fathers

Mothers

Pregnancy

3.9 4.7 4.1 4.5 1.2 1.2

Infancy

3.8 4.7 4.1 4.6 1.2 1.1

Toddlerhood

3.8 4.6 4.1 4.5 1.1 1.1

The ratings for mothers are slightly higher for involvement and understanding, but show no difference in the level of conflict with the material.

The evaluation highlights that even when fathers were not present during visits, a quarter of mothers would ask for worksheets or handouts for their partner and Family Nurses would in one-third of cases review homework completed by fathers (Barnes et al. 2008).

The evaluation is unable to evidence how the home-visits and the Family Nurse may have influenced fathers’ knowledge and behaviour as parents.  However, the first report provides a few examples of fathers who are trying to give up smoking or have changed their smoking habits as a result of input by the Family Nurse:

I don’t smoke in the house anymore.  I’ve cut down to a couple but I don’t think I’ll stop (Father quoted in Barnes et al. 2008, 114)

Others said they felt less anxious about the birth, more confident about bringing up a child or encouraged in thinking about what is important for the baby, as a result of their interaction with the Family Nurse.

Involving Fathers

Because fathers were only interviewed in the first year of the pilot programme, the evaluation gives no account of fathers’ views later in the process.  However, through interviews with Family Nurses and the data forms collected by Family Nurses following each visit, the final evaluation is able to give some indication of fathers’ involvement with the programme.

According to Family Nurses, fathers were as involved with the programme in toddlerhood as in previous phases and perhaps even more so as they enjoy play and other activities with their toddlers.  Some also begin to be more involved in childcare as the child grows older.

Overall Family Nurses had mixed experiences in terms of involving fathers as ‘sometimes it occurred, more often it did not’ (Barnes et al. 2011: 48).  Fathers are described as ‘dipping in and out’ of the programme.  However, again there are big variations between individual fathers and families.  As one Family Nurse points out:

‘[this one dad was] absolutely fantastic from the beginning … some of the dads are really hard-working and focused on parenting and some of them are absent’ (Family Nurse quoted in Barnes et al. 2011: 47).

The evaluation highlights that where fathers had been involved from the start, some are still involved at the toddlerhood stage (especially if they are not in work or education), but those who had never been involved at all were not becoming so in toddlerhood (Barnes et al. 2011).

The final evaluation report also points out that it is in the description of fathers and partners that the complexity these families becomes evident:  Through stories of domestic violence, young men in gangs, mental health problems, disability, unemployment and being witness to murder.  However, Family Nurses also gave examples of individual cases that illustrate progress for young men, in their interest in the child and their understanding of their own important role in family life (Barnes et al. 2011).

References

Barnes, J et al (2008) Nurse-Family Partnership Programme: First Year Pilot Sites Implementation in England, London DCSF.

Barnes, J et al (2009) Nurse-Family Partnership Programme: Implementation in England – Second Year in 10 Pilot Sites: the infancy period. London DCSF.

Barnes J et al (2011) The Family-Nurse Partnership Programme in England: Wave 1 Implementation in toddlerhood and a comparison between Waves 1 and 2a implementation in pregnancy and infancy. London DH.

This article was written for the Young Fathers Network site developed and maintained (2007-11) by Young People in Focus (YPF – Registered charity No: 800223).  YPF has now ceased operating and has given this article to the Fatherhood Institute.

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