Personalisation in FNP: testing changes as part of ADAPT

FNP is a relational intervention: the intimate bond between nurse and young mother is central to its impact. Any relational intervention is, by definition, personal: a successful relationship is reliant on interactions which are shaped by genuine empathy, sensitivity and responsiveness. Yet FNP is also a manualised intervention, shaped by a comprehensive set of evidence-based guidelines relating to participation, visit frequency, and content and length of programme.

These two aspects of FNP – personalisation and fidelity – have sometimes been in tension with each other. And, in the roll-out of and scale up of FNP across England since 2007, the FNP community has sought to achieve a balance between a strong focus on nurses and teams achieving fidelity to programme guidelines while “agenda matching” to meet client needs.

Through the ADAPT Personalisation stream we will be testing the impact of swinging the pendulum further towards personalisation of the programme. There are three key reasons for this:

  • The first comes from FNP's own research base. In the Memphis trial of FNP, nurses were asked to focus their energies on clients with the greatest vulnerabilities. This was achieved without achieving worse outcomes for those clients who had been thought of as less vulnerable and therefore received less intensive FNP support 
  • Secondly, in targeting population. First-time teenage mothers, not based on their identified vulnerability, but by being part of a group associated with risk of vulnerability. FNP works with a diverse population of differing needs, both in terns of how great the need and the nature of the particular challenges they face. Our hypothesis is that by focussing the intervention more strongly on those clients with the greatest needs, and specifically targeting the challenges they face, both the impact and the cost effectiveness of FNP will be enhanced 
  • Thirdly, a greater focus on personalisation fits with prevailing ethos within both health and social care about putting service users much more at the heart of determining their experience of services.

So what does a more personalised FNP ADAPT look like? Changes are being tested along three dimensions: 

  • ​The first is a strand informing the ways in which personalisation can occur, relating to programme eligibility, flexing the content, 'dial down, dial up' and early graduation:
    • Eligibility builds on recent changes to eligibility criteria based around age, ADAPT also looks at the effect of changing criteria aound vulnerability, accepting clients later within their pregnancy period on the basis that these are likely to be among the more vulnerable clients who could benefit most from FNP
    • Flexing the content means supporting nurses to focus the content of client visits around areas where their client has the most pressing needs, while still reflecting the core theoretical underpinning of FNP and existing guidance on supporting clients to plan ahead 
    • 'Dial down, dial up' mirrors this, but in terms of intensity, supporting the nurse to calibrate the intensity of visitation - as occured in the Memphis trial 
    • Finally, early graduation will support clients to leave FNP before their child's second birthday, if they are doing well and their nurse feels they can be supporting sufficiently by universal services and their own networks. 
  • The second element of personalisation is a new assessment framework which will support clients, nurses and supervisors to navigate these new flexibilities. We have worked with Triangle Consulting Social Enterprise, who delveoped the Family Star and other versions of the Outcomes Star used in over 60 local authorities, to co-design with family nurses and then pilot a New Mum Star. This is a collaborative tool which seeks to explicitly and systematically involve FNP mums in reflection on their progress and needs, and in decisions about their care, and help nurses focus their energies in thse areas where their supprt is most needed. It breaks FNP down to activity across 10 domains and assists parents and nurses to assess where the parents are on their journey to a strong sense of self-efficacy and capability across core areas of personal parenting and child health and development.
  • The third element of personalisation is the ethos that sits across the guidance and new materials for nurses and supervisors. Within ADAPT the focus is clearly about shifting the balance to the individual needs of parents and children and away from strict adherance to all fidelity goals.

We know that this is a significant shift, which is why it’s necessary to test carefully as we go forward. Initially we’ll be looking at how the nurses, supervisors and clients react to the new approach, then how much they are changing their practice, finally looking at the impact of these changes on outcomes. We’re excited about the various strands of personalisation and the co-production workshops have been full of energy and ideas. All this, together with the evidence underpinning the changes we are making and our approach to iteratively testing and developing personalisation, makes us really hopeful that it will improve the way FNP is delivered, its impact and cost effectiveness, and, ultimately, the support it provides to parents and babies.

By Jason Strelitz, Assistant Director for Public Health and Senior Visiting Research Fellow for Dartington Social Research Unit