The New Mum Star is an assessment tool which facilitates structured and collaborative decision-making between clients and nurses about flexing the FNP programme content, adjusting visit intensity and graduating clients early. We spoke to Sara Burns, Director at Triangle, the social enterprise responsible for the Outcomes Star and Emma Cook, Clinical Quality Lead at the Family Nurse Partnership National Unit about the development of the New Mum Star, the iteration process, the lessons learnt from both sides and how both family nurses and FNP clients were instrumental in its final design.
[Sara Burns, Triangle] The Outcomes Stars have been widely used in children and family services in the UK for many years and there were already a number of versions for parents, young people and children when FNP approached us. The Outcomes Stars work when there is one-to-one support over time and services work holistically with people – they are not usually the right tool for short-term, crisis or narrowly-focused interventions. Clearly the depth and range of support provided by FNP meant that there would be time for family nurses to really get to know young mums and to use the Star effectively. Although there are over 30 versions of the Star, and more in development, because of the particular needs of young, new, vulnerable mothers, none of the existing versions were quite the right fit. That meant we needed to create a new one– particularly a version spanning pregnancy as well as the first 1-2 years after birth.
[Emma Cook, FNP National Unit] Well there were a couple of drivers. Firstly, our workforce had raised the challenge of working with clients who have progressed really well and who no longer need an intensive service but whom they continue to visit as per the 64-visit FNP schedule. Secondly, local commissioners of the programme wanted to increase its reach to the eligible local population by increasing throughput and improving the programme’s cost benefit. Furthermore, research from the Memphis trial suggested that engagement with the programme was maximised when an individualised approach was used and attrition rates dropped. We were aware from discussions with David Olds and the team at the University of Colorado in Denver that they had developed what they also call the STAR framework, however this wasn’t the right fit for our UK context.
We were aware that Outcomes Stars were widely used across other services in the UK and had heard of successes in a number of other areas. Triangle agreed to collaborate with us on the development of an Outcomes Star that would work well for the clients we support and the FNP programme.
[Sara Burns, Triangle] - The process of development involves a lot of listening, modelling and many iterations and rounds of feedback. The FNP National Unit put together a working group made up of family nurses and FNP supervisors and we took them through a number of mini focus group style discussions. They described to us how young mums are when they first meet them, or in a worst-case scenario, how they know change is starting to happen, and then how change deepens and becomes sustainable. We also elicited information about the areas of life in which they help young mums make changes so that they and their babies can thrive, and to describe different case studies of mums they knew well and had supported. Even within the very first workshop we drew learning together and fed back suggestions for the Star areas and journey of change, gathering responses from the working group and refining further. Between workshops we drafted and refined the scales. There is a huge amount to take into account in developing a new version of the Outcomes Star, but I imagine we’ll come on to that…
[Emma Cook, FNP National Unit] – It was an incredibly interesting and rewarding experience for both FNP and hopefully for Triangle to be able to develop the New Mum Star together. I think for the nurses, having the opportunity to think together about what was important to their clients and create something which assists in their work was really quite special. Moreover, having the chance to test it and refine it further based on experiential learning has meant that the final iteration is based on the feedback of many nurses and – crucially – their clients. This is a really important element of the FNP ethos. Clients are at the heart of what we do and it was fantastic to be able to see this at work with the development of the New Mum Star.
[Sara Burns, Triangle] – It was very collaborative. The process was both positive and rewarding - and also very thorough! We [Triangle] are not experts in any of the sectors in which we create Outcomes Stars – our expertise is in modelling complex change in a way that makes it accessible and measurable. We rely on collaborators within a sector to provide the learning and expertise, feedback and piloting. Even after so many developments, I still love the process of creating new Outcomes Stars, particularly the requirement to really get under the skin of the client group and sector, understand the needs, the changes and the change process. That was particularly easy to do with FNP nurses because of the depth of understanding they have about their clients and their very wholehearted engagement with the development throughout, both within the working group and the steering group leading the project. It was a very real and effective collaboration.
[Emma Cook, FNP] – I would have to agree, we learnt a lot from all stages of the process. It was also a good learning experience for us.
[Emma Cook, FNP] - The team at Triangle produced our first pilot version following workshops with representatives from our first wave of ADAPT sites, which is where we began the process of developing the specific areas we felt were important for the New Mum Star. Triangle then provided training to the FNP teams involved in ADAPT on all aspects of using the New Mum Star in practice. Sites then went out there and ‘gave it a go’! They were very brave and courageous as this represented a huge shift away from how they had delivered the FNP programme previously.
I think the initial challenges were multi-faceted. We have a skilled and committed workforce who had been delivering the programme over the last ten years with fidelity and we were asking them to work and think in a completely different way. Following feedback from our focus groups and subsequent workshops, the nurses raised some areas where they felt some changes needed to be made to the New Mum Star. We worked with the Triangle team and developed a further iteration, which was reviewed by the nurses before we agreed on a final version. We worked on amending our guidance and the data system to reflect the changes. The new version of the New Mum Star was rolled out in January 2018, which was fabulous and down to the commitment on both sides to get this right.
[Sara Burns, Triangle] - From our perspective, everything went according to plan up to the point of hearing feedback from the first pilot. At that point, it was clear that the changes needed were more substantial than for most new Outcomes Star developments, so it would be necessary to gather a new round of feedback. This was done very efficiently by the FNP National Unit, helped by the fact that the nurses involved in the development were much more positive about the revised version - we had change the scale from 1-10 to 1-5 in response to feedback, and also combined two areas so that there were nine areas instead of 10. This made the resulting version more accessible for FNP clients and supported nurses to accept it and embed it well.
[Emma Cook, FNP] – We [the FNP National Unit clinical team] and the nurses felt that having 10 points was a little overwhelming for some clients and by decreasing this, nurses were able to have a better, more involved discussion with clients. Equally, clients were able to get a better understanding of the specific areas, personal to them, which they wanted to focus on.
[Sara Burns, Triangle] - Apart from that, the issues that we perceived family nurses would face were issues that we had seen with other sectors, and were mainly down to training, familiarisation and confidence. For example, some nurses were reluctant to challenge clients who had unrealistic perceptions of where they were on the Journey of Change in the New Mum Star (usually through not having enough insight into difficulties). This led to unrealistically high starting readings and therefore little potential to demonstrate the change that was taking place. Consistent, accurate completion of the Star takes time and also good support from line managers to get right, and for the nurses to really see the potential of engaging clients and helping them have an accurate, shared picture of where they are, and therefore the support they need. We were very pleased that several members of the steering group from the FNP National Unit then chose to be trained up by Triangle as Licenced Trainers, to cascade New Mums Star training internally and support effective use of the tool.
[Emma Cook, FNP] - We have gathered feedback from both nurses and their clients. This was important to us for a number of reasons but primarily so that we could be confident that the nurses found the New Mum Star clinically useful in assessing how engaged a client is in making changes in her life. For clients, we wanted to understand their experience of working through the New Mum Star with their nurse. Feedback on both counts has been very positive. Clients have reported that they like the New Mum Star, that it addresses areas which are meaningful to them and they feel involved in decision making and action planning. Nurses have reported that it provides greater autonomy to their practice as they are more able to use their clinical judgement and experience in selecting materials and methods which best suit the work they plan with individual clients. Working through the assessment often elicits deeper discussion and clients have often revealed previously un-shared information. Having the option to reduce the visit pattern by ‘dialling down’ or allowing clients to graduate the programme early when they no longer need an intensive level of support has also been welcomed by the nurses.
[Sara Burns, Triangle] - We heard direct feedback from nurses through the workshops, feedback forms and also via the steering group. Given the cautions expressed by some nurses at the start of development, it was very encouraging to receive such positive feedback at the end of the pilot.
It was also great to get feedback from 71 clients through feedback forms. We analysed this alongside other information from the pilot - this is all available in detail in the development report. It was very encouraging. For example, 97% of mums felt that their completed New Mum Star provided a good summary of their life and needs, and 93% of those who filled in a feedback form had enjoyed completing the Star with their family nurse. We are accustomed to positive feedback from service users during pilots - as a rough rule of thumb, usually two thirds of service users actively like the Star and the rest consider it no worse than any other form of paperwork - but this is unusually positive. There were many comments from mums, indicating that the New Mum Star met its purpose, including one mum who said, "I liked the fact that it praised you but also makes it clear where you need support”. The visual aspect of the Star was also particularly popular.
[Emma Cook, FNP] I agree, the visual aspect of the Star is something that really calls out to clients, focuses their attention on the bigger picture and allows them to reflect on where they currently are in the programme and where they want to see themselves.
[Emma Cook, FNP] - The Outcomes Stars are the epitome of a collaborative and client-centred approach and this was obviously really important and meaningful to us as it aligns with what we have learnt about engagement over the years. We wanted to ensure any new addition to the programme enabled our nurses to continue to work in partnership with their clients in order to personalise delivery of the programme.
[Sara Burns, Triangle] – It’s been great working on this with FNP. I very much hope that the New Mum Star supports the changes that FNP is making, as well as supporting individual clients and family nurses for many years to come.
The New Mum Star will be published and available through the Outcomes Star website from summer 2019.