Family Nurse Partnership (FNP) is an intensive, one-to-one home visiting programme delivered by specially trained nurses, which is designed to support young first-time mothers from early pregnancy up until the child's second birthday. The programme has 3 main aims, to improve maternal health, to improve child development and to improve the economic self-sufficiency of the family. In Scotland, FNP is usually offered to young mothers aged 19 years and under, however this age-range is expanded to some older mothers, up to 24-year-olds in some Health Board areas.
The COVID-19 pandemic has brought a renewed focus on the specific vulnerability of the client group who receive FNP and it is imperative to recognise the essential role of FNP in response to the pandemic. It is vital to gain a thorough understanding around the delivery of the FNP programme and the use of telehealth in this context and better characterise the implications of these interim changes. This evaluation aims to explore how FNP was delivered, following the COVID-19 outbreak in March 2020 and series of lockdowns up until the end of data collection in March 2021 in terms of the service delivery, mode of delivery, dosage (number of visits clients receive), materials and resources. It intends to highlight how this current mode of delivery has impacted nurses, clients (women on the programme) and partnership working. It will also examine the types of challenges facing the service during this significant period of global uncertainty, as well as key considerations for the future delivery of FNP.
To address these aims, one-to-one interviews (n=23), focus groups (n=8) and a national survey were conducted with family nurses (n=90) responsible for delivering the programme in combination with one-to-one interviews with clients (n=15) receiving the programme during COVID-19.
During COVID-19 pandemic, modes of FNP service delivery varied from standard home visiting to phone calls, SMS text messaging, emails, video calls and other encounters such as face-to-face outdoor walks with clients. Having a range of communication options at this time was highly beneficial for family nurses. In spite of the options available to family nurses, all surveyed staff (100%) reported delivering home visits during the COVID-19 pandemic. The ability to continue to offer home visits during the pandemic was crucially important and allowed families and their children to receive timely and essential support. However, few clients were less comfortable about receiving home visits and did not want to put themselves, their child or family at risk of COVID-19 transmission.
The FNP service provided essential and invaluable support to many clients and their families during an ongoing time of crisis. Clients overwhelmingly acknowledged this support and felt their family nurses provided stability, advice and care for them and their children. This was true for all clients but particularly, for clients who became socially isolated during the COVID-19 pandemic. Clients perceived their relationship with family nurses as valued and highly personal, often describing this as trusting and professional friendships.
Family nurses felt well equipped and supported to conduct their work remotely and were positive about the intuitive nature of the software used to undertake video calls. Having used telephone calls and SMS messaging prior to the pandemic, undertaking contact with clients through these methods was also viewed as routine by family nurses. Family nurses reported that opportunities provided by different telehealth modes helped them achieve dosage (number of visits clients receive) with clients who were busy with work or education commitments. However, it is apparent that both family nurses and clients found the rapid move to remote delivery of the programme challenging and many were not in favour of a solely remote delivery model. Many family nurses felt strongly that FNP was developed as a home visiting programme and its success is largely dependent on it being delivered as such. Relationship building, which is a key component of FNP, was thought to be negatively impacted by telehealth especially for newer clients. Family nurses reported that it took longer and required more effort to establish a strong therapeutic relationship with new clients while working remotely. Nevertheless, clients recruited during the pandemic felt they were still able to establish a good relationship with their nurses and were happy to receive the programme regardless of delivery mode.
Whilst clients felt supported by their family nurses, many clients were uncomfortable with video calls and felt anxious or self-conscious on camera. The use of video calls was also problematic at different stages of the programme particularly in toddlerhood while clients were trying to engage with their family nurse and look after a small child. For many clients they preferred the use of telephone calls rather than video, where they could use the speaker and also look after their child at the same time. However, this limited the options for the family nurses to view the home environment and the child, a key element for child protection. Family nurses felt that remotely assessing the home environment was extremely difficult or impossible in some cases. For newer clients and more vulnerable clients, such as those with child protection or social work involvement and mental health challenges, there were less opportunities to more widely observe and fully assess any potential needs, including family dynamics, body language, smells and potential hazards.
It was felt vulnerable clients were more at risk of becoming disengaged or feeling unsupported from telehealth contacts. Recognising this, family nurses used their clinical judgement and supervision support to assess who would most benefit from a home visit rather than virtual, and family nurses visited clients during the pandemic where there was a perceived need. There were concerns among family nurses about the impact of digital literacy and digital exclusion and potential inequalities emerging in the access to the service for many of their clients, especially those most vulnerable, such as those with child protection or social work involvement and mental health challenges.
Partnership working was impacted by the COVID-19 pandemic. FNP is a holistic service and as such is able to identify where client would benefit from additional service input alongside the provision of the programme. Some services such as housing, benefits and mental health that FNP usually refer to were reported by family nurses to have limited operation during the pandemic particularly face to face contact. This coupled with elements of digital exclusion meant that family nurses felt they had to take on a broader role to ensure that clients were supported. As such, it was unsurprising that many clients described their family nurse as being their first point of call when they required support for themselves or their child.
While it is acknowledged that there were challenges to delivering FNP remotely and using telehealth, both family nurses and clients expressed the desire that telehealth can play a role in future delivery of the FNP. Overall, there is a real sense that the FNP programme provides an essential source of support for many young women and their children. The service was highly valued by clients during a time of uncertainty and crisis, which is evidenced by sustained levels of client recruitment, retention and engagement throughout the last 12 months.
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