ADAPT: Smoking cessation clinical adaptation

We’re working with 11 FNP sites from around the country and Dartington Social Research Unit to co-design a number of adaptations to the FNP programme which we will put through rapid-cycle testing over the next year. The ADAPT project (Accelerated Design and Rapid Programme Testing), is part of the wider FNP Next Steps programme.

ADAPT sites have developed clinical innovations to test in their area and are finalising their plans for implementation. We expect to start the roll-out of clinical adaptations in sites from later on in 2016.

In the first of our blog series about the ADAPT clinical adaptations, Ceri Evans, Supervisor for Dudley, talks about the smoking cessation intervention developed by her team, clients and local stakeholders.

In Dudley, there is a strong culture of smoking, with current rates higher than the national average. In 2015, data from the Department of Health showed 15.7% of women smoked at time of their baby’s delivery, compared to the national average of 11.4%. Similarly, 36% of young mums enrolled in FNP smoke (at enrolment) compared to the England-wide FNP average of 31% (April 2016).

This data helped shape the primary focus of Dudley’s clinical adaptation: to increase the ‘stop smoking’ rates for clients on the programme, both in the short and longer term, with a secondary outcome of supporting those clients who relapse to remain smoke-free. We also hope to encourage and support partners, family members and peers close to the client to quit. Smoking cessation is addressed within the current FNP programme, but in order to achieve our primary and secondary outcomes, we felt that there was more we could do to further support quit attempts with our clients.

What does the clinical adaptation look like?

We wanted to put more structure and focus on smoking when delivering the FNP programme. Midwives in Dudley currently log carbon monoxide (CO) readings in the antenatal period. As a first step, we thought we could use this as a starting point for our discussions with clients in initial visits, rather than waiting until Pregnancy visit 4, as the original programme suggests.

If smoking is an issue for a client, we will address this at every pregnancy visit using the antenatal checklist as a prompt for discussion. Postnatally, we will begin to firmly add conversations about smoking into our primary visit after birth when we discuss safer sleep with clients. If a client is enthusiastic and really focused on quitting, family nurses will also provide support to partners and other family members to quit smoking.

If the client isn’t a smoker, we would deliver the programme as usual, with the offer to refer relevant smoking family members or partners to stop smoking services where appropriate.

How will this be delivered in practice?

To assist with these planned changes, Dudley family nurses have developed new facilitators and thoroughly evaluated the current programme content, making changes were necessary.

Nurses already use visual aids with clients, but we hope to add more of these into the adapted programme at relevant intervals to convey messaging around how smoking can affect a baby’s health. This will include:

• Silicone foetuses,
• Stop smoking mobile apps, and
• YouTube clips.

Family nurses will also be given access to a pack of nicotine replacement therapy (NRT) samples to show to clients, and now have the ability to prescribe these to mums and partners who want to quit smoking.

All nurses will be given their own CO monitor to visually represent levels of CO to the baby and discuss how this can cause harm.

How will you support family nurses to deliver this clinical adaptation?

The Dudley FNP team have taken part in extra training sessions to increase skills and to help give family nurses a better understanding of how to use some of the new interventions and implement some of our changes.
We invited our local Maternity Health Support Workers to join these sessions. Maternity Health Support Workers in Dudley work alongside Community Midwives, helping mums with breastfeeding, weight management in pregnancy and already provide advice around smoking cessation. This cross-team working has been exceptionally valuable and we hope that this can help reduce maternal smoking rates locally beyond FNP clients.

How were clients involved in development work?

We held a focus group with clients, partners and some grandmothers to gather feedback on our initial changes to the programme and new facilitators we were developing. We also spoke to clients during home visits to share our ideas and developing materials, and to gain their insight into what we could further improve in the programme in relation to smoking cessation.

All of the feedback we received from clients has been exceptionally valuable, and has really helped us focus our adaptation to suit client need.

In general, we found that clients valued the ability to have an honest conversation with a professional they could trust. They felt that difficult conversations about smoking harm should be honest but kind, not to try and scare them into quitting. One of the main aspects of the adapted programme that clients liked was the addition of the nicotine replacement therapy materials.

What does success look like?

We would like to see a higher smoking cessation rate for clients, and also for family members, partners and peers. As a result of this, we also hope to see an increase in birth weight and decrease in premature labours. Together with the FNP National Unit, we will monitor all the data regularly, using the FNP Information System.

The ADAPT journey

I love a challenge, and was keen to do anything I could to help enhance the current FNP programme, and build on the great work family nurses and supervisors already do. There is a lot of motivation in family nurses to do the best they can within the time they have with the clients, and this felt like a good structured way to address smoking in pregnancy.

We’ve had excellent support from commissioners, local stop smoking services and other stakeholders. It was great to have the Maternity Health Support Workers involved in the development and training around our clinical adaptation as they work closely with mums of all ages in the area. This and the excellent support from the FNP National Unit and Dartington Social Research Unit have made the process of development enjoyable and easy.

ADAPT has been really exciting, from the initial induction meeting to the various calls, site visits and co-production meetings which have led to the development of our clinical adaptation. Group sessions, when all ADAPT sites have come together, have also been really beneficial as we’ve received valuable help and input from other FNP teams on our clinical adaptation, and we’ve been able to offer feedback to others too.