The Nurse-Family Partnership (NFP) is a nurse home visiting program that is based on over 37 years of rigorous research from randomized controlled trials conducted in the United States, the Netherlands, and England. There are three program goals: 1) to improve pregnancy outcomes; 2) to improve child health and development; and 3) to improve families’ economic self-sufficiency. This research shows that first-time mothers working with a NFP nurse can transform their lives and the lives of their children. The NFP Conceptual Model summarizes how program influences on maternal & child health and development are thought to reinforce one another over time, see below.
NFP is a licensed evidence-based program that includes a set of Core Model Elements; Visit-to-Visit guidelines; Client-centred principles; underlying theories, and specifications for NFP nurse competencies, education and data collection. Specially educated NFP nurses visit clients in their home starting early in the pregnancy and continuing until the child’s second birthday. NFP nurses utilize a strength-based approach directed toward optimizing the client and family’s self-efficacy. The program is designed to activate and develop parents’ natural instincts to protect their children. Through the establishment of a therapeutic relationship with the client, NFP nurses: 1) provide empathic support and life coaching; 2) provide health education and anticipatory guidance to promote positive health, and caregiving practices 3) guide clients with system navigation; and 4) undertake continuous assessment of child development and parenting and adjust visit content and approaches accordingly. During home visits the NFP nurse provides structured support and guidance across the six program domains: personal health, environmental health, life course development, maternal role, family & friends, and health & human services.
NFP is committed to ensuring that nurses are able to sustain high quality practice for the benefit of the families served in the program. As a consequence, implementing organizations are expected to commit to a number of supporting systems and processes, including the participation in reflective supervision on a weekly basis, case conferences and team meetings. NFP is also committed to continuous refinement of the program through ongoing research internationally and the development of innovations and program enhancements. We now have over 10 years of experience of implementing the NFP in nine countries, serving more than 40,000 vulnerable children and families. This has given us valuable learning about how to implement the NFP program with quality and fidelity in different international contexts using a process of adaptation, testing and evaluation.
The Nurse-Family Partnership (NFP) focuses on serving low-income first-time parents and their families during pregnancy and through the first two years of the child’s life to accomplish three goals:
All program materials and the education program for the NFP Nurses /Supervisors are designed to specifically contribute to the achievement of these three goals.
There are four strategies intrinsic to the Nurse-Family Partnership strength-based approach:
O’Brien RA, Baca RP Application of Solution-Focused Interventions to Nurse Home Visitation for Pregnant Women and Parents of Young Children. Journal of Community Psychology.1997;25(1):47-57.
Changing families’ unhealthy practices and anticipatory adaptation to meet a child’s growing needs is a core expectation of the program. NFP nurses utilize motivational interviewing skills and approaches to explore individual circumstances, understanding, desires, and motivations with the aim of strengthening a client’s internal motivation for change. Families are supported to develop and activate change plans and followed up within visits to encourage sustained changes.
In keeping with established motivational interviewing principles and approaches (Miller and Rollnick, 2013), NFP supports and recognizes the importance of client autonomy. The guiding principles that guide NFP are that the client is the expert in her own life, and the nurse works with her to identify and follow her heart’s desire for a healthy pregnancy and positive life progression for her and her child. The mother should identify the solutions that work for her, progress is expected through small incremental changes with the understanding only a small change is necessary. Nurses use a strength-based approach focusing on the clients’ strengths, and that success builds confidence to try a further change. Agreement on the topics to be explored is gained through a negotiated process known as ‘agenda matching’ where the NFP nurse aligns the client’s aspirations and wishes with her assessment and the programme goals and content. The NHV’s role is to be a skilled ‘guide’, structuring the conversation so ambivalence regarding change can be tolerated and explored. Once changes are planned, the NFP nurse’s role is to enquire about progress, normalize relapses, encourage recommitment and affirm progress.
Nurses were selected to be the home visitors in NFP because of their pre-existing education in health and their competence in managing the complex clinical situations often presented by at-risk families.
The conceptual model summarizes how the program intervention at an early stage can prevent the emergence of subsequent issues that are thought to reinforce one another over time.
Olds, D. L. (2006). The Nurse–Family Partnership: An Evidence-Based Preventive Intervention. Infant Mental Health Journal, 27(1), 5-25.
The Nurse-Family Partnership (NFP) Strengths and Risks (STAR) Framework is new part of the NFP model and is designed to help NFP nurses and supervisors systematically characterize levels of strength and risk exhibited by the mothers and families they serve. STAR provides NFP teams with a common language and framework for characterizing and organizing client strengths and risks. STAR is intended to inform and support consistent clinical decisions made by NFP nurses and supervisors regarding visit content and dosage (time spent on the six domains). In addition, the Framework promotes identifying stages of behavioural change and appropriate corresponding actions and intervention to improve maternal and child health. By attending to specific strengths that mothers and family members bring to the program, STAR helps the NFP nurse to identify families who are doing so well on their own that they may not need to be visited as frequently as called for in the current program guidelines and to identify those that need more visits due to greater risk or need. Information organized within the STAR informs NFP nurses’ ways of working with families and helps them align the program content and frequency with mothers’ (and other family members’) abilities and interests in engaging in the program.
Collection of data by NFP Nurses and Nurse Supervisors is an integral part of the NFP program and assists in the maintenance of high quality program delivery for families. Data is collected by NFP nurses using a set of structured data forms and guidance is provided for the completion of each form. NFP utilizes a data collection system designed specifically to record and report participating family characteristics, needs, services provided and progress toward accomplishing program goals. Data are entered into the country’s national NFP information system (or equivalent). Reports are generated locally and used during reflective supervision to monitor individual and team progress in delivering the program with fidelity. The data collection system is utilized by each Nurse-Family Partnership National Unit and their partners to monitor implementing agencies’ program fidelity and provide feedback as appropriate.
NFP requires highly skilled NFP Nurses and Supervisors so that they may work effectively with the families participating in the program, many of whom are experiencing multiple complex issues. Comprehensive education and support of NHVs and Supervisors is therefore critical to the success of NFP. Effective education, reflective supervision and the provision of relevant program materials will maximize the likelihood that program implementation will utilize clinical interventions with families comparable to those tested in the trials (O’Brien, 2005; http://link.springer.com/article/10.1007/s10935-005-3599-z). All NFP nurses participate in a comprehensive program of education designed to support them in developing: 1) strong communication, personal relationship building and problem-solving skills; 2) a deep understanding of all facets of the NFP program model; 3) skill in delivering all components the NFP program with fidelity; and 4) the ability to adapt the program as necessary to “make it work” for each client and family. NFP nursing teams meet regularly for team meetings and case conferences, where they receive guidance from supervisors and colleagues to help them deliver the best possible care to their clients. Each country’s program of education and its delivery methods, have evolved in unique ways, however the core content is very consistent
The NFP Visit-to-Visit Guidelines provide materials and suggested content for visits and are designed to:
The Visit-to-Visit Guidelines have been developed to reflect the three phases of the NFP program: Pregnancy, Infancy, and Toddler. Although NFP nurses have a structured set of guidelines to guide the content of each visit, they adapt them as needed to address the individual and unique needs/circumstances of each family (agenda-matching). The structure helps the NFP nurse remain focused, but it does not dictate her actions.
The Nurse–Family Partnership (NFP) is grounded in three theories:
Olds, D. L., Hill, P. L., O’Brien, R., Racine, D., & Moritz, P. (2003). Taking preventive intervention to scale: The nurse-family partnership. Cognitive and Behavioral Practice. 2003;10(4), 278-290.
Olds DL (2007a). Chapter 10: The Nurse-Family Partnership: Foundations in Attachment Theory and Epidemiology. In Berlin L, Ziv Y, Anaya-Jackson L, Greenberg MT (eds.), Enhancing Early Attachments: Theory, Research, Intervention, and Policy (pp. 217-249). New York: Guilford Press.
The NFP Core Model Elements (CMEs) are supported by evidence of effectiveness based on research, expert opinion, field lessons, and/or theoretical rationales. When NFP is implemented with fidelity to these CMEs, implementing agencies/countries can have a high level of confidence that results will be comparable to those measured in research. The CMEs were revised in 2017 through an extensive review process.
The goals of the program; improving pregnancy outcomes, improving child health and development; and Improving families’ economic self-sufficiency require the NFP nurse to invest in building a ‘therapeutic relationship’ with the client. Once a strong therapeutic relationship has been established this becomes integral to supporting a client with behaviour change. Supporting positive behaviour change is key to the aims of the program and underpins the role of the NFP nurse. Nurses rely on both theory and nursing clinical judgement to help the client focus on solutions and strengths while also following the client’s heart’s desire. This also means recognizing that only a small change is necessary, and that the client is the expert on her own life. The NFP nurse is supported to develop this working alliance, being ‘caring, clear, boundaried and strength- focussed’ by a variety of methods including robust Reflective Supervision and associated role modelling.
NFP has six key areas of exploration called program domains: personal health, environmental health, life course development, maternal role, family & friends, and health & human services. Paying attention to aspects of each domain within most home visits, contributes directly to the achievement of the three program goals. The proportion of time spent on each domain varies depending on the phase of the program (Pregnancy, Infancy, and Toddler). It is expected that NFP nurses will give more emphasis to the health of the expectant mother (personal health) and its potential impact on fetal development during pregnancy. Following the baby’s birth, NFP nurses spend more time on supporting the mother’s care giving skills (maternal role) and life course development. Within each domain, NFP nurses focus on understanding the client’s circumstances, usual practices and views whilst also exposing her to new information and a structure within which to explore change. This is done with the aid of NFP Visit-to-Visit guideline materials, which are organized by domain, with suggested content for each visit.
Nurse-Family Partnership (NFP) is a work in progress and will always be subject to improvement through adaptation and innovation (previously known as augmentation). Through sound research and quality improvement methodology, NFP continues to embrace program innovations that enhance nursing practice, support program growth & sustainability, and improve outcomes for children, mothers, and their families. Incorporating new scientific knowledge, learning from NFP nurses and others closely involved in the implementation of the program, is integral to the development and implementation of program innovations.
Reflective supervision (RS) in NFP is based on a collaborative relationship between NFP supervisor and supervisee that is constantly evolving and maturing, embracing new knowledge and skills. It allows the NFP nurse to reflect on their practice and examine complex situations within families, at the same time helping them ‘contain’ or ‘emotionally regulate’. Effective RS is also a protective factor in preventing burn out or compassion- fatigue for the NFP nurse.
The use of RS in NFP implementation has also been shown in several studies to significantly increase program retention, reduce attrition and provide nurses with a positive modelling framework that ultimately cascades down to the client and her baby. Recently an International framework for RS in NFP was developed collaboratively across all NFP implementing countries to support best practice in the use of RS.
Based on the importance of RS in NFP and the evidence from NFP focussed studies, the expectations for the use of reflective supervision (RS) within NFP are embodied within the International Core Model Element # 12, which states:
Each NFP team has an assigned NFP Supervisor who leads and manages the team and provides nurses with regular reflective supervision.