Family Nurse Partnership - a family nurse's perspective: 10 year anniversary

A reflection of the first 10 years of the Family Nurse Partnership (FNP) programme in Scotland from a family nurses’ perspective.

HOW do family nurses work?

To understand family nurses work, it's necessary to understand how they see the programme.

"FNP to me is a programme of support, learning and guidance for our young people, taking them on a journey from early pregnancy to toddlerhood by being the best parent possible for their new baby," says one. "It's about exploring our young people's strengths and capabilities and nurturing them throughout this amazing time in their lives.

"I feel very privileged in my role as a family nurse to share this time of young people's lives and being able to contribute and possibly shape their future as a young adult, parent and a valued member of the community. Our therapeutic relationship is crucial to the success of our work within the FNP programme."

"FNP is an investment in the principles of public health nursing," suggests a second. "It's about not looking at short-term measures, but instead taking a holistic view of what can be provided to build scaffolding to support clients to make positive behaviour change for themselves and their babies. FNP is an investment in reducing health inequalities and improving outcomes for those who statistically are not expected to achieve very much.

"Many of the clients we work with have had very poor childhoods, with multiple, complicated factors and early infancy trauma. Sometimes their ability and desire to be a mum is overwhelmed by countless factors, but they can still achieve and break the cycle of previous generations. We can support them through what can be very challenging experiences."

Another FNP nurse highlights the elements of the FNP approach that for her stand out in relation to engaging with young people.

"It's about having a non-judgemental, friendly, knowledgeable approach, involving dads and other family members where possible. It requires a guiding but client-led communication style, ascertaining what knowledge the client has to begin with, recognising that the client is the expert in her own life, agenda-matching by ensuring the relevant programme materials for the client and having a consistent, sensitive and responsive approach to delivery of the programme."

Family nurses are very positive about the possibilities training provides to enhance their skill set and its effects when put into practice with clients.

"I've developed the knowledge and skills of how to spend time walking alongside clients to support them and assist in facilitating change, while using the motivational interviewing skills I learned through FNP training and skills practice has helped me to recognise when clients are beginning to think about making a change," says one.

"The strength-based approach adopted in FNP has enabled me to see that despite facing numerous adversities, clients can be guided to recognise what resources and strengths they have within themselves to challenge adversity and make significant changes to improve outcomes for themselves and their children in the future. I can see how amazingly well the FNP the programme works in practice – it never ceases to amaze me."

"I appreciate the introduction to mindfulness[3]  and meditation the role has brought to my personal and professional life," adds another. "Small things, like stopping your car between visits for a few moments and applying hand cream while breathing deeply can help to manage any negative emotions you take away following contact with a client or other services. Practising mindfulness is important for building resilience and helps me to be a positive role model for my clients. Returning your attention to the moment, focusing on your breathing, can help you to step away from unhelpful thoughts."

The learning from training that stands out most prominently for one FNP nurse is something her supervisor said to her.

"She said, 'Information we don't want is like junk mail – it goes in the bin'. This makes me mindful when delivering information to my clients – I make sure the information I provide is want they want to find out about and is useful to them. My motivational interviewing skills help me deliver information the young women want and not what I think they want."

The major training benefit for another FNP nurse is the communication style she has learned about.

"This is the first nursing role I've had where the communication style is a counselling mode", she says. "It is without doubt very effective, as it places the client at the centre of all we do – it's truly person-centred. Prior to FNP, clients didn't always have a choice. Some of them were told they needed to take medication whether they wanted to or not. In FNP, the nurse is guided by the client and supports her to achieve goals and desires that she has determined, not the nurse or the service. The result is a deeper therapeutic relationship with clients."

Setting the right conditions for allowing the individual relationship with the client to develop is key to the family nurse role.

"Having a steady programme recruitment rate[4]  and engaging with clients early in their pregnancy is daunting," says one. "It's crucial that you sell yourself as well as the service. The client is going to be seeing a lot of you and she has to like you right away to agree to join the programme.

"Following the client's heart's desire is crucial, which means really finding out what she wants, what she has experienced and where she sees herself in the future. This is a powerful tool, not only to help the client reach her goals, but also for the nurse to reach hers."

Sometimes, the most challenging issues are unearthed right at the start and end of the relationship.

"The recruitment is challenging, trying to engage with young clients and to encourage them to allow someone new into their homes and lives," a family nurse notes. "Unless they know someone who has had a family nurse, they may be reluctant to engage initially.

"At the end of the programme, the clients feel vulnerable that they no longer have the support from FNP. But this is also when we are under most scrutiny as we try to evidence the changes the young client has made. The small changes may not always be evident to someone who has not made the journey with them. Using key issues can help to highlight even the smallest of changes."

While the personal relationships with clients is clearly paramount, all family nurses also recognise the importance of having positive relationships with other services, working as part of integrated teams to provide the best possible opportunities for their clients.

Several FNP nurses describe how they have excellent multi-agency working relationships with, for example, social work teams involved with families and clients whose babies have been accommodated since birth or are on the child protection register. Another has developed a good relationship with a local health promotion officer and other professionals.

"The health promotion officer is responsible for co-ordinating a young mum's group," the FNP nurse says. "I arranged a meeting with the health promotion officer, the community learning and development worker, health visitor and midwife to talk about how family nurses could become more involved in the group.

"I'm now delivering a learning topic once a month and making sure the FNP nurses are available to the mums throughout the session. I recently delivered a session on emotional resilience and postnatal depression, with very positive feedback from professionals and clients. I text all my clients in the locality each week to remind them about the group. Seven have attended the group and two others are now considering going along. This joint working has strengthened my relationship with all the professionals involved in the group and helped FNP to be more visible in the local community."

Regular supervision is an important part of being a family nurse.

Family nursing can be very draining emotionally and at times is overwhelming. Some family nurses had not anticipated the level of child protection, social and psychological issues they would encounter, and supervision allows them to have protected time to analyse, plan and reflect, with huge benefits in terms of reducing stress levels.

"Being a family nurse is very emotionally demanding, and the support of the supervisor is so important," says one. "You must have a place to explore emotionally what you're feeling. Reflective, restorative supervision supports nurses in delivering and developing the care they give to their clients. It ensures the nurses keep well emotionally so their interaction with clients continues to be therapeutic and beneficial."

"Supervision allows you to explore challenging situations in a safe environment," a family nurse explains. "On a good day, you leave feeling able to cope with the challenges and emotional burden of our clients' lives. It helps you plan your interventions in a positive, strengths-based way."

Another says supervision allows her to manage the challenges and difficulties she faces by learning from them.

"Supervision has been invaluable," she says, "as has support from the child protection advisor and the psychologist. We are a new team who learned and trained together, so we also support and encourage each other."

"I attend weekly supervision and am able to discuss my achievements and any clients I have concerns or questions about," says another. "The supervision lasts one hour and without it, I do not believe that the job would be possible. It helps to contain me and put things into perspective. Being able to discuss key issues is important for analysis. We also have supervision with child protection officers and the psychologist, which allows us to look at clients from a different perspective."

Some family nurses find the experience of supervision in FNP is very different to any they have encountered before.

"In previous roles, I felt supervision was something of a tick-box exercise, but in FNP, it has high value," says one. "It happens every week and the supervisor is genuinely interested in where I'm at and what might be challenging or troubling me. She will ask probing questions that allow me to explore issues on a wider level. At times my supervisor has asked a question that leads me to realise something I hadn't previously thought about. It's nurturing and supportive and very much about my agenda as a family nurse."

Juggling the responsibilities of the role with family and other commitments can be tricky.

"The role of family nurse can be lonely, and the nurse needs to be resilient to this," says one. "The demands at times are physically and emotionally draining. For me, this occasionally has been to the detriment of my own family, and there have been times when I feel I have not been as available as I should have been to support them. This is something I have wrestled with."

Another found learning about the role and managing a caseload made work and home life tricky to balance, but has seen her way through.

"At times I felt like I was sinking," she says. "But I'm pleased that I came through the other end and, as a result, everything I've learned and experienced has not only made me a more confident and skilled practitioner, but has also had an impact on my home life and parenting. At times it can backfire when my boys use some motivational interviewing on me!"

One Supervisor found that the challenge of creating a healthy work–life balance was a burden that would best be approached through a shared effort.

"As a team, we reflected on all of our challenges and made some changes prior to recruiting our second cohort,"[5] she recalls. "We looked at prioritising our work–life balance, which has helped with things like travel. And we have dedicated requested times for supervision and team meetings to ensure the needs of the nurses are addressed."

All this means that taking time out for self is an important part of providing a top-quality service.

"One of the biggest lessons I've learned so far is the importance of self-care and prioritising looking after yourself," a family nurse comments. "When you're working in such an emotionally charged job, it's vital to use strategies and supports to relax and refuel. This allows you to have some emotional space to provide containment to clients; otherwise, I think you'd burn out!"

"The driving, carrying lots of notes and equipment and using the car as an office is not conducive to healthy outcomes and can lead to resentment and tension," says another. "It's often necessary to take calls or write notes in a layby. This is harder when you take time to prepare visits and drive several miles and the client cancels at the last minute or is not in. Feelings of frustration can be high!"

"Working at such an intense level with clients for a prolonged period of time can be emotionally draining, and it has been very hard work protecting my own mental health," says a third. "I'm being open about this as I feel it's important not only to focus on the personal value in the role, but also to be realistic about the challenges it brings.

"This is where the starring role of excellent supportive colleagues and great teamwork come into play," she continues. "Without the support of an excellent supervisor and colleagues and some input from occupational health, I would certainly have had to take a period of sick leave for work-related stress and anxiety. I've learned that to be effective in working with clients, I must take good care of my own health. This has been a hard lesson."

No service can work effectively without strong administrative support, particularly around areas like data management.

One of the FNP data managers says her ongoing commitment is to run an administration base that meets the needs of the rest of the team while being adaptable and flexible enough to ensure that the usual day-to-day business is not affected when special events occur.

"The office is a place where the team has easy access to the paperwork, equipment and tools they need to deliver the programme," she says. "This is a priority for me. I know how busy the team is with their caseloads, supervision and training, so providing a smooth-running office and great administrative support means they are able to use their skills with their clients without the distraction of having to undertake unnecessary admin tasks."

Family nurses are hugely appreciative of this kind of support. One says: "The data manager has been the most underrated member of our team, but she has been invaluable throughout our whole journey – she has been so organised, knowledgeable, resourceful and we would never have managed without her."



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