What are the goals of Nurse-Family Partnership?
The goals of the program are: Improve pregnancy outcomes; improve child health and development; and improve the economic self-sufficiency of the family. The program achieves these goals by helping women engage in good preventive health practices, including obtaining thorough prenatal care from their healthcare providers, improving their diet, and reducing their use of cigarettes, alcohol and illegal substances; child health and development is improved by helping parents provide responsible and competent care for their children; and economic self-sufficiency is improved by helping parents develop a vision for their own future, plan future pregnancies, continue their education and find work.
Why is Nurse-Family Partnership only available to first-time, low-income mothers?
Becoming a mother for the first time is an event associated with a large amount of change in a woman’s life. It is hypothesized that such women would be more receptive to home-visitation services than women who had already given birth. Moreover, the skills and resources these mothers develop in coping with their first pregnancy and child set a pattern for their parenting of any children they have later. In addition, generally it will be easier for women to return to school and work if they plan and space their children.
Serving low-income women allows a focus on families with limited resources who are more likely to experience increased risk factors. Each community determines their own measure of what constitutes low-income, often using the same local income guidelines as programs like WIC and Medicaid. “Proof of income” procedures, however, are discouraged as they create barriers for entry, if the client is refereed by Medicaid or WIC; income status has already been ascertained.
Within the population of first-time, low-income mothers, it is possible to narrow those served to one or more subsets of this population without undercutting the program’s effectiveness. Some communities limit the first-time mothers served by age, or other appropriate factors to allow the program to be adapted to different community circumstances and to fit within available resources.
How do mothers enroll in Nurse-Family Partnership?
That depends on the community in which the program is developed. Participation in the program is entirely voluntary, but it is crucial that women enroll as early in pregnancy as possible – ideally by the 16th week. Women are referred by a range of sources that may include: a school nurse or counselor, health clinics, obstetricians' offices, family planning clinics, and programs that serve low income women, such as Medicaid offices and WIC clinics (the Special Supplemental Nutrition Program for Women, Infants and Children). Sometimes, pregnant women hear about NFP through community outreach efforts, and in some cases new mothers are referred by friends who are already in the program.
What is the frequency of visits and what do the visits consist of?
- weekly visits during the first month following enrollment;
- bimonthly visits for the remainder of the pregnancy;
- weekly visits during the first six weeks after delivery;
- bimonthly visits thereafter through the 21st month of childhood; and
- monthly visits until the child reaches age two.
The visit schedule has been designed to meet two needs: (a) to enable the nurse to provide the different services and information required during the different phases of pregnancy and early childhood, and (b) to foster the setting of small, achievable goals for the nurse and family to work on between visits. This second need is quite significant in that families participating in the program generally make progress most readily when it occurs in manageable, incremental steps. The actual timing and frequency of visits will depend on the nurse home visitor's judgment and the family’s own situation.
During these visits NFP nurse home visitors follow visit-by-visit guidelines which provide a comprehensive structure for working with families, focusing on several domains of content: personal health, environmental health, quality of care giving for the child, maternal life course development, family and friend support, and health and human service utilization.
During pregnancy, the nurse home visitors help women complete 24-hour diet histories on a regular basis and plot weight gains; they assess women’s cigarette smoking and use of alcohol and illegal drugs and facilitate a reduction in the use of these substances through behavioral change strategies. They teach women to identify the signs and symptoms of pregnancy complications, encourage women to inform the office-based staff about those conditions, and facilitate compliance with treatment. They give particular attention to urinary tract infections, sexually transmitted diseases, and hypertensive disorders of pregnancy (conditions associated with poor birth outcomes). They coordinate care with physicians and nurses in the office and measure blood pressure when needed.
After delivery, the nurse home visitors help mothers and other caregivers improve the physical and emotional care of their children. They teach parents to observe the signs of illness, to take temperatures, and to communicate with office staff about their children’s illnesses before seeking care. Curricula is employed to promote parent-child interaction by facilitating parent’s understanding of their infants’ and toddlers’ communicative signals, enhancing parents’ interest in interacting with their children in ways that promote emotional, cognitive, and language development, and creating households that are safe for children.
The nurse home visitors also help women clarify their goals and solve problems that may interfere with their education, finding work, and planning future pregnancies.
Are other family members present during a visit?
Yes, they are invited if the mother wants them to be present. The nurse home visitor tries to involve the father and grandmother of the child, but they are actively engaged in only a portion of the visits.
Why do Nurse-Family Partnership nurse home visitors have to be nurses?
Pregnant women have many questions and concerns about their health and the baby's health, and highly value the expertise that nurses can bring to them during this critical life transition. This helps attract families to the program, and retain their involvement. The educational background, preferably baccalaureate, of nurses make them ideally prepared to conduct the strengths-focused assessment and teaching that is part of much of the program, and to exercise good judgment in tailoring the program to keep it relevant to each family's interests. Research on client perceptions of different professionals has revealed that nurses are the most trusted profession. Since participation in the program is voluntary, and relies heavily on developing a relationship with each family that is trusted and highly valued by the family, NFP chose a profession perceived by the target audience as trustworthy and knowledgeable. Working in families requires skill, professionalism and sensitivity, and well-trained nurses who are attracted to the role of nurse home visitor tend to have those characteristics.
Moreover, there is evidence from the Denver Trial (1994) that examined the effectiveness of home visiting by paraprofessionals and by nurses as separate means of improving maternal and child health. The results concluded that nurse visits produced statistically significant benefits in terms of the participants’ health and welfare, versus paraprofessional (workers with no formal education in care giving professions) visits which produced small effects that rarely achieved statistical or clinical significance.
What specialized education do NFP Nurse Home Visitors and Nurse Supervisors receive?
Nurse-Family Partnership Nurse Home Visitors and Nurse Supervisors are required to participate in extensive educational sessions that prepare them for delivering the Nurse-Family Partnership Model. They complete two distance units and two face-to-face education units delivered by the Nurse-Family Partnership Nursing Practice Department. NFP Core Education Unit 1 is a distance module explaining the underlying theories and components of the NFP model of nurse home visiting. NFP Core Education Unit 2 is a 2 ½ day face-to-face session held in Denver for Nurse Home Visitors that provides an opportunity to deepen their understanding of the NFP model of home visiting, ask questions about the model, domains and theories and how they integrate into their nursing practice and apply the knowledge they gained through the study of NFP Unit 1 workbook in a safe and supportive atmosphere.
NFP Nurse Supervisors spend an additional two days in Denver learning about NFP Supervision. NFP Core Education Unit 3 is also a 2 ½ day face-to-face session held in Denver for Nurse Home Visitors and an additional two days for Nurse Supervisors. This session provides time to more deeply understand the domains and theories learned in Unit 2, applying them in a practical setting, and then integrating the model components into their overall nursing practice. Unit 3 also provides education in the Partners in Parenting Education (PIPE) curriculum, developed by How to Read Your Baby. The goal of the NFP Core Education Units 2 and 3 is to provide a face-to-face setting for active learning. NFP Core Education Unit 4 is a distance education that deepens understanding of the concepts taught in Units 1, 2 and 3. In addition to receiving the NFP Core Education, participants build practical skills in the NFP model, with help from highly experienced NFP Nurse Educators from the National Service Office; and they build a network of Nurse Home Visitor and Nurse Supervisor peers from NFP Implementing Agencies from around the country.
Is there a limit to the number of families a Nurse-Family Partnership Nurse Home Visitor can serve?
Due to the comprehensiveness of the program model, the visit schedule, and the overall intensity of the intervention, nurse home visitors’ caseloads are capped at 25 families, which helps ensure that the program achieves the anticipated results. Experience in implementing Nurse-Family Partnership to date indicates that continuity in the relationship between the nurse home visitor and the family is a critical factor in achieving desired outcomes. This continuity is best realized when the size of the caseloads is kept within manageable limits.
A balanced caseload of less demanding and more demanding cases is also desirable. Results from the research trials suggest that the program has differential effects on outcomes as a function of the parents' personal and social resources. For example, the impact on decreasing welfare dependency is evident among mothers with greater personal and social resources (i.e., higher intellectual and mental health functioning). In addition, the impact upon children's encounters with the health care system for injuries and ingestions during the first two years of life is greatest among those born to low-resource women. Thus, a balanced caseload of high/low resource mothers is most likely to yield the reduction in government expenditures reported in previous trials. Such a balanced caseload also is essential to maintaining a caseload of 25 families per home visitor. A caseload comprised of a disproportionate number of low-resource women would necessitate more frequent home visits and, thus, reduce the size of the caseload that could be managed by the home visitor.
Experience further indicates that nurse home visitors should have baccalaureate preparation in nursing, prior experience working with maternal/child populations, strong interpersonal skills, and sensitivity to the values and beliefs of differing racial and ethnic minorities. While nurses need not be matched with families on the basis of race or ethnicity, there are obvious advantages in composing a culturally varied team of nurses to carry out the intervention.
What research has been done on this program?
This intervention has been subjected to some of the most rigorous scientific testing possible. It has been examined in three different randomized controlled trials, each conducted with a different population, living in different settings. The first was conducted with Caucasian mothers in a semirural community in upstate Elmira, New York in 1977. The second was conducted with African- American mothers in inner-city Memphis, Tennessee in 1988. The third study was conducted in Denver, Colorado in 1994, with a large population of Hispanic mothers as well as Caucasian and African-Americans. Each study has been reevaluated and participants have undergone subsequent interviews and follow-ups to find out if the program effects seen while families were receiving home visits faded out once the program ended, or were sustained over time. The results of each study have been positive, and provide the evidence necessary to justify offering the program for public investment. In addition, several independent economic evaluations of the program have been conducted that show that the cost of the program is recovered by the time children are four years old; and when properly targeted to low-income families, the costs are returned four times over once children reach adolescence. Dr. David Olds continues to lead this program of research, based at the Prevention Research Center for Family and Child Health, which is part of the University of Colorado's School of Medicine, Department of Pediatrics, located in Denver, Colorado.
The program effects that have the strongest evidentiary foundations are those that have been found in at least two of the three trials. They are listed below:
Consistent Program Effects
- Improved prenatal health
- Fewer childhood injuries
- Fewer subsequent pregnancies
- Increased intervals between births
- Increased maternal employment
- Improved school readiness
Positive Program Effects Found in First Trial at Child Age 15:
- Benefits to Mothers
- 61% fewer arrests
- 72% fewer convictions
- 98% fewer days in jail
- Benefits to Children at Child Age 15
- 48% reduction in child abuse and neglect
- 59% reduction in arrests
- 90% reduction in adjudications as PINS (person in need of supervision) for incorrigible behavior
What kind of quality control is in place?
A well-designed and maintained record-keeping and web-based data collection system, called the Clinical Information System (CIS) has proven to be highly useful in the successful operation of the program. Each nurse collects information on every visit which allows the local nurse supervisors, program directors, and the NFP National Office to monitor the implementation of the program and to use this information as a foundation for continuous improvement. Personal identifiers are stripped from the data. The National Office Reporting team can generate reports that compare the local implementing agencies outcomes against national data and “benchmarks” that are produced from the original randomized trials, early implementation data and national standards such as Healthy People 2010. This is a crucial element in the strategy for ensuring that the program is implemented with fidelity and that program improvement is continuous and ongoing.
What does the program cost, and how is it funded?
The cost of the program is determined largely by the local standard for community health nurses' salaries. A cost estimate for NFP implementation that can serve as a guide to local communities in procuring funds for NFP implementation is: $1,430,357, which represents the three year minimum cost to establish the program for 4 nurses with the capacity to serve 100 families. Again, local nursing salaries are the largest variable in the budget, so the cost may be higher or lower depending on that cost.
Each community that develops the program must find sustainable funding to operate it. States and local agencies have tapped Medicaid, TANF, tobacco settlement funds, child abuse prevention dollars, the Maternal and Child Health Block Grant, and crime prevention dollars to support the program. It varies by state and community.
Several independent economic cost and benefit analyses have demonstrated significant cost savings to communities implementing Nurse-Family Partnership with savings in many areas, including health care, criminal justice, and welfare. Cost savings accrue further over time.