The family nurse partnership programme in Cumbria: Overview of initial outcomes Ann Grace, Lindsay Wright, Ellie Healey, Christine Martin, Sara Lyons, Sue Clunie & Sarah Cooper CITATION Grace, A.; Wright, L.; Healey, E.; Martin, C.; Lyons, S.; Clunie, S.; Cooper, S. (2011). The family nurse partnership programme in Cumbria: Overview of initial outcomes. Cumbria Partnership Journal of Research Practice and Learning, 1(2), 24-27.
Effective communication key to implementation and development of Assistant Practitioner role QUALITY/ORGANISATIONAL CHANGE The family nurse partnership programme in Cumbria: Overview of initial outcomes Ann Grace, Lindsay Wright, Ellie Healey, Christine Martin, Sara Lyons, Sue Clunie & Sarah Cooper Abstract This paper provides an overview of initial outcomes achieved in a Cumbria-wide family nurse partnership programme established in January 2009. Keywords family nurse partnership programme; child protection; teenage pregnancy; outcomes; therapeutic relationship Introduction The Family Nurse Partnership Programme (FNP) is an intensive home visiting programme to first-time teenage parents and their babies and is based on 30 years of scientific research in three pilot sites in the USA (Olds, 2002). Cumbria is part of a large-scale randomised control trial commissioned by the Department of Health to determine if the programme can be effectively delivered in England and produce the same beneficial outcomes as has been demonstrated in the USA. The programme provides an intensive home visiting service to vulnerable firsttime teenage mothers from the second trimester of pregnancy until the child is two years old. It has been shown to improve health, education and social outcomes for both the young mother and the child, with improved outcomes lasting into adolescence. It has also demonstrated large-scale cost savings; for example, the cumulative costs to public services for a child with troubled behaviour is 15,000 per year; the estimated cost of an FNP client is 3,000 per year (http://fnp.dh.gov.uk/how-can-i-get-fnp-in-my-area/). In addition to the randomised control trial there has been an evaluation by Birkbeck College London of the programme delivered in earlier sites around the UK. Birkbeck has produced its third year evaluation (http://www.iscfsi.bbk.ac.uk/projects/files/third_year. pdf) and this is demonstrating that the programme is accepted by teenage parents and indicating positive outcomes for children and their teenage mothers. The FNP programme is guided by the theories of human ecology, attachment and self efficacy. These principles are reflected in the five programme domains of personal health, environmental health, life course, maternal role and friends and family. These five domains are therefore explored and discussed in client visits using a combination of teenage friendly facilitating materials, work sheets and resources. Key to the delivery of the programme is the warm therapeutic relationship that the nurse builds with the young mother and where possible her partner. The FNP visiting schedule consists of weekly or fortnightly contacts, which can start from 16 weeks of pregnancy, and is in addition to midwifery care antenatally. The family nurse replaces the health visitor role for FNP clients for the duration of the programme, at the end of which the family is transferred on to the health visiting service when their child is two years of age. The young mother and partner are encouraged to engage with other services such as Sure Start and the nurse will support them to access education and training. Thus liaison and engagement with other support services is an important component of care. Child protection is at the forefront of the programme with the baby at the centre of all care. The Cumbria FNP Team The Family Nurse Partnership Programme started in Cumbria in January 2009. The team includes four family nurses (FN), a team supervisor (who also sees clients) and a team administrator. Clients have been recruited to the FNP programme across Cumbria s 2,613 square miles. The family nurses are based in two offices, one in Carlisle and one in Ulverston, and therefore cover considerable miles in their day-to-day work. Cumbria data early emerging indicators There are currently 72 teenage mothers and their partners and extended family engaged on the programme. The programme is delivered across the whole of the county but the majority of families live in 24 The Cumbria Partnership Journal of Research, Practice and Learning 1(2)
Carlisle, Allerdale, Copeland and Furness. Currently there are 25 clients in Carlisle, 13 in Furness, 11 in Allerdale, 11 in Copeland, six in Eden and six in South Lakes. At recruitment 2% of clients were 14, 2% were 15, 21% were 16, 23% were 17, 33% were 18, 17% were 19 and 2% were over 19; all clients were White British. The following information is subset of the core data which is collected in the five FNP intervention domains. Maternal role Birth weight National rates for infant mortality for infants born to mothers aged less than 20 years are around 60% higher than rates for infants born to mothers aged 20 to 39 years (Department of Children, Schools and Families, DCSF, 2007). There have been no infant deaths for clients recruited to Cumbria FNP. Children born to teenage mothers are also more likely to be born pre-term, with a 25% higher risk of low birth weight (DCSF, 2007). Low birth weight is defined as those weighing less than 2.5kg. Children who have a birth weight of less than 2.5kgs (5lbs 8ozs) are more prone to anxiety, aggression, poorer attention spans. Low birth weight has been linked to depression amongst school children (Bohnert & Breslau, 2008). Only one infant on the FNP programme has been born at 26 weeks gestation. One has been born at 36 weeks and all other infants born at term. Of these only one infant weighed less than 2.5kg. Therefore of the 72 clients on the FNP programme, only one was of low birth weight and pre-term. Breastfeeding The Cumbria Breastfeeding Insight Report (NHS Cumbria, 2009) surveyed 116 respondents, 72% (84) were aged 20 to 25 years and 28% (32) were aged 19 years and under. Of the under 19 years group, only 10 % (12) were currently breastfeeding or intending to. Of the 74 clients originally enrolled on the 6-monthly FNP data report as of 6 September 2010, it showed that 73% (54) of clients had now had their baby and that 54% (29) of these clients, aged 19 and under, had then initiated breastfeeding, which is a higher proportion than in the wider population. Environmental health Housing Housing issues are often complex for FNP clients and it may take considerable work by the family nurse in order to help the client improve their housing situation. Clients under 18 years of age do not qualify for council housing and rarely have the resources to rent privately. Of the 72 clients on the FNP programme, 32 clients were recorded as having poor housing situations on recruitment. As of November 2010, 25 of these clients are now recorded by family nurses as having improved their housing situations, two clients were in less favourable housing, whilst others had remained the same. Home safety Sixty nine out of 72 FNP clients are recorded as having a safe home environment. As of November 2010, there are 62 clients who have now had their babies and all 62 are known to be using safety equipment in the home (100%). Friends and family As of November 2010, 48 clients out of 72 are known to be maintaining their relationship with the biological father of their baby, seven clients are with a partner and 17 clients currently have no partner. Out of these 48 biological fathers, 36 are known to be currently engaged on the FNP programme and of the seven clients with a partner, three of these men are engaged on the FNP programme. Thirty four clients have other family members engaged on the FNP programme and 12 clients have both father/partner and family engaged on the FNP programme. Personal health Smoking At recruitment, clients are asked if they have smoked during pregnancy. Out of the 72 clients, 35 clients disclosed smoking during pregnancy. Out of these 35 clients, 10 clients reported at recruitment that they were no longer smoking and 25 clients advised they had smoked in the last 48 hours. Out of the original 35 clients on FNP known to have smoked during pregnancy (including before recruitment visit), in total 17 were recorded as non smokers at six weeks postnatal. Attachment Out of 72 mothers, 66 clients were described by the family nurses as having a positive attachment to their baby in pregnancy. One client was unknown prior to birth as she moved into the area later. Of the remaining five clients, five were noted as finding it difficult to enjoy the pregnancy, and three have shown some difficulties engaging with their child. This is being continually assessed and addressed by the family nurses. There has been no need to refer on to another agency as the nurses have undertaken The Cumbria Partnership Journal of Research, Practice and Learning 1(2) 25
supervision with the clinical psychologist and are able to monitor and address the areas of concern. This could suggest that the FNP programme design to engage mothers in the ante-natal period is particularly important. As an early intervention it seeks to promote maternal attachment and aids the family nurse in recognition of potential problems that can only support the overall assessment process. This therefore gives a real time analysis, before the birth of the infant, to proactively prevent later potential issues, rather than reactive plans that may already be too late. Developments in Family Nurse Experience in Cumbria Since completing the official FNP training programme, family nurses have continued to access further training in Cumbria, access research, further reading and explore the team s experiences, particularly in the psychology supported sessions. Key lessons to be learned from FNP in Cumbria Domestic violence is widespread in teenage relationships and not recognised by the teenagers (Barter, McCarry, Berridge & Evans, 2009). The majority of young people aged 13 years or older, either tell a friend, or no-one about the violence they are experiencing, with only a minority informing an adult and that domestic violence was described as messing around by some boys (Barter et al., 2009). It is easy to fall into the trap of dealing with teenage parents as adults with children rather than teenagers with children. The actual definition of a child is: anyone who has not yet reached their 18th birthday (DCSF, 2010). This trap that can befall other services working with teenage parents and can also lead to confusion with policy design having an adult focus, and not accounting for teenage behaviours. For the FNP team this has lead to a dilemma with processes such as the Common Assessment Framework process in Every Child Matters (Department for Education and Schools, 2003) as to where to best fit this assessment as the teenage parent is often a child, with a child. The normal teenage brain frontal cortex is acknowledged as affecting the ability to think, reason, use logic and make decisions, often with resultant immature emotional responses, e.g., risk taking behaviours (Morgan, 2007). However with nurturing care, pruning of the teenage brain takes place and the adult brain develops. Within abusive or neglectful relationships the immature emotional responses continue. Problematic antisocial behaviours in children and teenagers present as reckless disregard for the safety of self or others, failure to plan ahead or impulsivity, consistent irresponsibility, irritability and aggressiveness, failure to conform to social norms, lack of remorse and deceitfulness, e.g., repeated lying and deception (Utting, Monteiro & Ghate, 2007). Young parents in Cumbria have responded to the warm therapeutic relationship with the family nurses. The nurses use motivational interviewing and solution-focused, strengths-based approaches that these young parents value. In turn the nurses are impressed with how these young people are able to deal with great adversity and difficulty. The above learning must be translated into practice for other service providers. Afilliations Ann Grace, Supervisor, Cumbria Partnership NHS Lindsay Wright, Family Nurse, Cumbria Partnership NHS Ellie Healey, Family Nurse, Cumbria Partnership NHS Christine Martin, Family Nurse, Cumbria Partnership NHS Sara Lyons, Family Nurse, Cumbria Partnership NHS Sue Clunie, Administrator, Cumbria Partnership NHS Sarah Cooper, Professional Lead HV/FNP, Cumbria Partnership NHS Contact information Ann Grace, ann.grace@cumbria.nhs.uk References Barter, C., McCarry, M., Berridge, D., & Evans. K. (2009). Partner exploitation and violence in teenage intimate relationships. Report for NSPCC. Retrieved 30 August 2011, from http://www.nspcc.org.uk/inform/research/findings/pa rtner_exploitation_and_violence_wda68092.html Bohnert, K. M. & Breslau N. (2008) Stability of psychiatric outcomes of low birth weight. Archives of General Psychiatry, 65, 1080-1086. Department for Children, Schools and Families (DCSF). (2007). Teenage parents next steps: Guidance for local authorities and primary care trusts. Nottingham: DCSF Publications. 26 The Cumbria Partnership Journal of Research, Practice and Learning 1(2)
Department for Children, Schools and Families (DCSF). (2010). Working together to safeguard children: A guide to inter-agency working to safeguard and promote the welfare of children. Nottingham: DCSF Publications. Department for Education and Schools (DfES). (2003). Every child matters. Cm 5860 London: The Stationery Office. Morgan N. (2007). Blame my brain: The amazing teenage brain revealed (2nd ed.). London: Walker Books. NHS Cumbria. (2009). Breastfeeding insight report. NHS Cumbria. Olds, D. L. (2002) Prenatal and infancy home visiting by nurses: From randomized trials to community replication. Prevention Science, 3, 153-172. Utting, D., Monteiro, H., & Ghate, D. (2007). Interventions for children at risk of developing antisocial personality disorder. Report to the Department of Health and Prime Minister s Strategy Unit. London: Policy Research Bureau. An evaluation of the Carlisle locality supported stroke discharge service (Sept 2010 Feb 2011) Toni Hall, Jo Howard & Michelle Brooks Abstract This paper presents an evaluation of a Supported Stroke Discharge (SSD) service established in north Cumbria in 2010. Keywords stroke; rehabilitation; supported discharge; service evaluation Introduction The National Stroke Strategy (Department of Health, DOH, 2007) highlights the importance of providing early multidisciplinary stroke rehabilitation post hospital discharge and other markers of a quality rehabilitation service. Quality marker 10 of the National Stroke Strategy (DOH, 2007) is that people who have had strokes access high-quality rehabilitation and, with their carer, receive support from stroke-skilled services as soon as possible after they have a stroke, available in hospital, immediately after transfer from hospital and for as long as they need it. This was supported by the Royal College of Physicians (2008) whose guideline for stroke recommends that domiciliary rehabilitation services should be commissioned as part of an early supported discharge scheme to deliver specialist rehabilitation at home in liaison with inpatient services, as well as in the long term. The Cochrane Review (2005) of trials of early supported discharge services concludes that Early discharge services can allow stroke patients to return home early and improve long-term recovery. Early supported discharge services are provided by teams of therapists, nurses and doctors. They aim to allow stroke patients to return home from hospital earlier than usual and receive more rehabilitation at home. Patients who received these services returned home earlier and were more likely to remain at home in the long term and to regain independence in daily activities. The best results were seen with well organised discharge teams and patients with less severe strokes. In Cumbria between 300 and 350 stroke patients are admitted to the Cumberland Infirmary each year. In 2007 an early supported discharge scheme was piloted with positive results. All patients on the scheme achieved their rehabilitation goals and 14 acute hospital bed days per patient (total of 266) were saved. Thus, results from the pilot demonstrated that intensive multidisciplinary rehabilitation in the community setting for stroke patients can reduce hospital length of stay and improve functional goals. Following the success of this pilot and recommendations made by the Cardiac and Stroke Network peer support visit, two new posts, a specialist physiotherapist and rehabilitation assistant, were commenced in September 2010. The aims were to improve the discharge process for stroke patients in the Carlisle and Brampton area and to provide timely and intensive rehabilitation following discharge. The Cumbria Partnership Journal of Research, Practice and Learning 1(2) 27