One of the very successful features of the Family Nurse Partnership (FNP) programme is the excellent track record family nurses have of engaging with young mothers and fathers who are often thought of as “hard to reach”. For example, over 75% of women offered FNP enrol on the programme, 70% stay on FNP to their child’s second birthday and fathers or partners are present for approximately 25% of all visits. This is of course a crucial first step in improving outcomes. In this illuminating blog, Ruth Rothman, the FNP National Unit’s Head of Learning and Clinical Implementation, shares some insights into the practice that helps achieve such good engagement.
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Ailsa Swarbrick, Director, FNP National Unit
Stacy was 17 when she became pregnant. Her family nurse, Amy, attempted to contact her 23 times before she joined FNP. Even after Stacy failed to turn up at a local children’s centre or café, Amy persisted and kept up the contact. When Stacy and Amy finally met, Stacy agreed that she would ‘try out’ FNP. Amy learnt that Stacy had grown up in an environment where life was chaotic and at times, frightening. Her mother’s numerous violent relationships led her to recall sleeping with bin bags packed at the foot of her bed to enable her to flee in the night if she needed to. Her school books were always packed too – school was a place of safety and comfort. Stacy grew to trust Amy and really valued the programme, which she received in its entirety. During her time with FNP, Stacy volunteered to be part of a Parent Panel to recruit a new family nurse, and was asked to come up with a question she would like to ask. Her priority was clear in her response, “If a mum cancelled or didn’t turn up for an appointment, what would you think could be the reason and what would you do about it?”
On average, 70% of the young mums who opt to receive FNP continue to be supported throughout the length of the two and a half year programme. At a time when identities are developing, the teenage brain is not yet fully matured, self-awareness is heightened and life is complex, sticking with a service is no small feat. So how do family nurses manage to engage so well with young women often viewed by many services as ‘hard to reach’?
‘Engagement’ is the term we use when a young mum is making the most of the relationship she has with her family nurse as well as FNP programme materials and because a relationship is not a static thing, it needs regular attention engagement on a number of levels.
The first step is for family nurses to build up a trusting, therapeutic relationship with her client. This relationship is essential to the second step, when the mum begins to engage with the FNP programme itself, learning from the nurse using specific FNP materials. The final step can be marked when the mother begins to make changes, both for herself and for her child. This isn’t always easy for either mum or nurse, and can only be achieved by the two investing in working together.
By showing respectful curiosity into her client’s family life, a family nurse can begin to gain an understanding of her goals, aspirations and internal motivations. She is then able to skilfully align the FNP programme delivery and outcomes, building on the client’s strengths and supporting behaviour change, all the while weaving between the anticipatory guidance that is the hallmark of a prevention programme, and intervening early if a mum’s behaviour raises concern for her or her child’s safety. Family nurses call this, ‘agenda matching’. The family nurse knows the content of the programme will bring about positive outcomes for mum, and its delivery will be individualised to meet the goals of each mother.
So continuous contact and a trusting relationship is the foundation for helping mothers learn, adapt and change. Trust develops when these young women feel heard and understood, and core to this are good communications skills. Family nurses use specific approaches derived from the world of motivational interviewing, to which we owe a lot. This can support working together with an intentional, directional focus on enhancing a young woman’s motivation to change. Family nurses listen, guide and advise using these skills, and by always staying aware of their style of communication; is she following her client’s lead? Is she directing the flow of conversation, or is she being a guide? These aspects have their place in a therapeutic relationship but we know that most of the work takes place when a family nurse is in a guiding stance.
Motivational interviewing techniques aren’t the only skills family nurses use and FNP is based on three theories. Good engagement, collaboration and focusing on the mother’s strengths will increase their self-efficacy or self-confidence (Albert Bandura) over time. But when a relationship breaks down, for whatever reason, it’s the family nurse’s role to repair that rupture, rather like a mother would with her child. In doing this she is showing respect, trust and modelling a way of being. This, of course, comes from John Bowlby’s theory of attachment. Family nurses model resilience and emotional availability by investing the time to continue contacting the mum, enabling her to know that her family nurse still has her in mind, while she tries to understand the reasons for the break down and finding out what could be done differently to strengthen their therapeutic relationship to re-engage her. Generally with time, patience and compassion, most relationships are repaired and many tend to be stronger from this struggle.