Where's the human?
Last month, FNP National Unit Director Ailsa Swarbrick spoke at the Global Evidence and Implementation Science Conference in Melbourne. Ailsa talked about the FNP National Unit’s passionate belief in the value of data and how our work is also grounded in relationships, asking: how do we bring the two together?
The Family Nurse Partnership (FNP) is an evidence based programme. It’s built on sound theory and rigorously evaluated over many years. Family nurses across nearly 80 local authorities collect data about every client and every home visit to help guide clinical practice, to assure quality and to inform quality improvement. They’ve made data their friend and I’m proud to be part of this thoughtful, questioning and transparent culture.
This science is then applied in the messy real world. We pay attention to context, and to systems – in organisations, across local areas, nationally. Complexity theories illuminate the constantly evolving interplay of intervention, context and wider environment and how this brings unpredictability, self-organisation and emergence. That sounds abstract, but put simply it can mean:
“The articulations, workarounds and muddling-through that keep the show on the road are not footnotes in the story, but it’s central plot” Greenhalgh T, Papoutsi C, 2018
This person has partly inspired my thinking. I’m excited by this approach to implementing high quality services, paying attention to the world as it is, not how we might like it to be. But what makes our work even more powerful is the further connection between evidence, systems and our humanity. Data and evidence is in the DNA of FNP; and so, very explicitly, are relationships – between babies and parents, and then between those parents and their family nurses. That sets a pattern of paying attention to other relationships in the system – with managers, funders, other services, local and national government.
Humans and their relationships are central to most services and systems. So why is it that the science pays relatively little attention to observing and measuring them? Why, when I google “system”, do I get images which are mathematical and mechanical, or at best organic (the brain, the body).
Where are the people who make up these systems? What about consciousness, unconsciousness, histories, emotions, responses – all those things which can help make systems unpredictable but which might just also make them work well? People can disagree, they can be hard to change and they often don’t do what they are told. But they can also help mitigate complexity. They bring new data, based on their experience; they form productive relationships; they have judgement and intuition in the moment. They are also generally committed to doing a good job.
We’ve started to explore, practically, what happens when we allow new space for the human. It’s a core part of our improvement and innovation programme, FNP ADAPT, supported by Dartington Service Design Lab. ADAPT involves co-designed changes which are then tested and refined on the basis of quantitative and qualitative data which includes feedback from nurses and clients. Here are just a few specific examples.
Identifying vulnerability at intake
We want to target FNP better, and so measured the prevalence of four specific eligibility criteria , in addition to being a young-first time mother, which based on the literature were predictive of poor outcomes for children:history of abuse; current mental health issues; substance misuse; and low educational attainment. Worryingly, our data suggested that, on this basis, clients were less vulnerable than when we started. Nurses strongly disagreed. Was this an impasse between science and human judgement?
We listened, explored different perspectives in workshops, and compared nurse notes with risks they recorded in formal data fields. A much more nuanced picture emerged. For example, we found that nurses tended to identify and recruit women who experienced domestic violence, even though this wasn’t part of formal data collection, it proved a good predictor of other risk factors. However, nurses also were more likely to enrol clients with mental health issues which were not always significant enough to benefit most from FNP. As a result of this work, we agreed to target two further risk factors – family dysfunction and domestic violence. We’re now using this new information as we refine and further test eligibility criteria.
Targeting and flexing FNP throughout delivery
We want FNP to be more flexible, balancing evidence based structure with nurse judgement and client experience of their own lives. To support this, we’ve worked with Triangle to develop a new tool, the New Mum Star, to help nurses and clients work together to identify need and plan care. It’s really helped elicit new information about both clients and practice, which we hope will help personalise care and improve outcomes.
- “When we did the star I opened up to her and told her things I haven’t told some other people” FNP mum
- “I find out things about my client that I didn’t know…I think some of them like it and they like it that they’re almost in control” Family nurse
Looking to the future - client feedback, at scale
FNP is strengths based and respectful of clients. It’s grounded in a relationship between two people, but we worry that our data only routinely represents nurse views. That’s both a data issue and an ethical issue, so in ADAPT we’ve worked hard to engage clients in designing and refining changes. We’ve largely used focus groups, but these have both practical and methodological limitations – they’re hard and expensive to organise at scale, and the sample is inevitably biased by both nurse and client self-selection. We therefore worked with On Our Radar to identify different approaches to listening to client views, and to test a prototype smartphone chatbot. We’re now thinking about next steps, and our vision is to develop this approach so we and others can hear unheard (and often unasked) voices at scale and produce good data to improve quality and outcomes.
It feels we’re making real progress in locating the human in the science, and I’m looking forward to building on this work, and learning more.
