Nurse-Family Partnership (NFP) is a non-profit organization operating in the United States that connects mothers pregnant with their first child with registered nurses, who provide home visits until the child's second birthday. Studies have reported associations between the Nurse-Family Partnership intervention and outcomes related to maternal health, child health, and economic security.
The Nurse-Family Partnership program originated from a randomized controlled trial. The trial was conducted in a predominantly white, low-income neighborhood, located in Elmira, New York, in the late 1970s. For three consecutive decades, Professor David Olds and his colleagues conducted three similar randomized control trials, gathering research from each trial, which later contributed to the evidence-based development of the NFP. Randomized controlled trials were conducted in Elmira, New York; Memphis, Tennessee; and Denver, Colorado. The outcome of these trials proved that the NFP provided a tremendous number of benefits to children born in poverty stricken environments (Mason, 2016). Many of the families that participate in these trials had been experiencing many adversities, traumatic lifestyles events, and exposed to environments that were harmful to themselves and potentially harmful for their child. These parents expressed deep desires to protect and nurture their children and the NFP nurses facilitated resources and provided motivation to help change and eliminate these adversities to help create a better lifestyle and growing environment for both the parent and the child (Rowe, 2016).
Theory
Bronfenbrenner's theory of human ecology Bronfenbrenner's theory of human ecology holds the idea that throughout the lifespan, humans are impacted by their environments, and likewise, humans impact their environments. At "ecological transition" points, developmental opportunities are created from a change in environment or in the child's role.Bronfenbrenner, U. (1979). The ecology of human development: experiments by nature and design. Cambridge, Mass: Harvard University Press.
Nurses study the mother's relationships with her partner and other people in her life, as well as the greater community dynamic, to help mothers navigate potential challenges they may face in motherhood.Guiding Theories. (n.d.). Retrieved April 17, 2019, from https://www.nursefamilypartnership.org/nurses/guiding-theories/ NFP begins during pregnancy to take advantage of this ecological transition point in the mother's life.Dawley, K., Loch, K. & Bindrich, I. (2007). The nurse-family partnership. American Journal of Nursing, 107(11), 66–67.
Bandura's self-efficacy theory Bandura's theory of self-efficacy holds that when people believe in their ability to meet challenges and be successful, they are more likely to do so, and each success further fuels this belief. Giving someone a task that they believe they can perform is one way to enhance self-efficacy.Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W.H. Freeman.
NFP aims to give mothers more confidence by asking them to recall past successes, as well as engaging them in problem-solving tasks.
Attachment theory Bowlby's attachment theory holds that infants are biologically driven to bond with others, and this drive is reinforced by attentive parenting. Further, it is the child–caregiver relationship that shapes a child's development, making the quality of parental care in early childhood vital.Bowlby, J. (1970). Attachment and loss. New York: Basic Books.
Attachment theory is used in NFP in two ways. First, it is used to encourage mothers to bond with their children (e.g., explaining that infants learn to recognize mother's voice in the womb, pointing out when the child expresses trust in and dependence on the mother). Second, it is used to inform the nurse's relationship with the mother to build trust, and to model the skill.
Goals
NFP nurses work with mothers and families to achieve three major goals, which include improving: "1) the outcomes of pregnancy by helping women improve their prenatal health; 2) children's subsequent health and development by helping parents provide competent care; and 3) women's own health and self-sufficiency by helping them set goals for themselves and take steps to accomplish those goals, including planning the timing of subsequent pregnancies." Based upon such positive results from early clinical trials NFP was implemented across the United States in 1996 and contributed to the inclusion of funding for maternal and infant home visiting in the Affordable Care Act, of 2010. The NFP National Service Office (NSO) does provide support and training to NFP accredited sites to ensure adherence to the NFP model in addition to monitoring program implementation and outcome for quality improvement purposes.
Target demographics NFP targets low-income, first-time mothers,Nurses and Mothers [Fact sheet]. (2018). Retrieved March 18, 2019, from https://www.nursefamilypartnership.org/wp-content/uploads/2018/11/Nurses-Mothers.pdf following the idea that the best time to teach health and development behaviors is during the mother's first pregnancy.Overview [Fact sheet]. (2017). Retrieved March 18, 2019, from https://www.nursefamilypartnership.org/wp-content/uploads/2017/07/NFP_Overview.pdf This also gives time for mothers to work on potentially problematic behaviors before interacting face-to-face with the child. The mothers are often young and single; based on data collected from 1995 to 2017, the mothers in the program had a median age of 20, and 84% were unmarried. Additionally, 57% had completed high school, and the average yearly income was $9,000.
While NFP was developed to target mothers, the program welcomes fathers, partners, family members and close friends, to participate. The goal is to ensure that everyone who will be supporting the baby and ideally forming close attachments with him or her will be well-equipped to do so.Dads. (n.d.). Retrieved April 17, 2019, from https://www.nursefamilypartnership.org/first-time-moms/expectant-fathers/
Intervention delivery
Length and timing Clients enroll in the program early in their pregnancy (usually during the first trimester) and continue until the child's second birthday.Nurse-Family Partnership (NFP). (2018, October). Retrieved April 17, 2019, from California Evidence-Based Clearinghouse for Child Welfare website: https://www.cebc4cw.org/program/nurse-family-partnership/ Ideally, the mother enrolls by week 16 of pregnancy, and it is required that the first meeting occur by week 28.Implementing Nurse-Family Partnership (NFP): Model overview. (2018, April). Retrieved March 18, 2019, from Home Visiting Evidence of Effectiveness website: The following table illustrates the standard visit schedule, but this is flexible, and is often adjusted based on the client's needs and availability. +Time FrameVisit ScheduleFirst Month of EnrollmentWeeklyRemainder of PregnancyEvery Other WeekFirst Six Weeks After BirthWeeklySix Weeks to 20 MonthsEvery Other Week20-24 MonthsMonthly Visits can take place in the client's home, or in another location such as a community agency. Sessions last between 60 and 90 minutes.
Format NFP is client-centered, meaning the nurse continuously adapts to ensure relevant and valuable sessions for the client; relational, meaning the primary tool for growth and learning is the relationship between the mother and nurse; strengths-based, meaning mothers reflect on their own successes to facilitate their learning and behavior change; and multi-dimensional, meaning it takes a holistic view of the mother and her life, aiming to affect various aspects of it.
Nurses use Prochaska's Transtheoretical Model of Change to help mothers work through problems. This framework assesses the mother's readiness to embrace a new behavior change and provides processes of change to guide her.
Content of Visits
The goal of prenatal visits is to facilitate compliance with health guidelines, coordinate care with physicians, and provide encouragement to the expecting mother. These sessions include completion of diet histories and tracking of weight gain, assessment and subsequent reduction of harmful health behaviors such as alcohol and drug use, training in identification of pregnancy complications, and coordination of help-seeking from nurses and physicians.
The goal of postnatal visits is to improve the child's physical and emotional care and promote parent–child attachment. These sessions include training in identification and management of child illness, facilitation of understanding child communicative signals, and enhancement of parent–child interactions that safely promote cognitive and emotional development.Olds, D. L. (2006). The nurse–family partnership: An evidence‐based preventive intervention. Infant Mental Health Journal, 27(1), 5–25.
Deliverers
Nurses NFP nurses must be registered nurses with a bachelor's degree in nursing. NFP nurse training consists of three phases. First, there is an orientation unit, which includes 40 hours of self-study. Second, there is an in-person education/experiential practice unit, which takes place in 25 hours over 2–4 days in Denver, Colorado. Finally, there is a long-distance education unit, with around 10 hours of team-based, supervisor-led professional development modules.
Supervisors "Nurse supervisors provide nurse home visitors clinical supervision with reflection, demonstrate integration of the theories, and facilitate professional development essential to the nurse home visitor role through specific supervisory activities, including one-to-one clinical supervision, case conferences, team meetings, and field supervision."Implementing Nurse-Family Partnership (NFP): Materials and forms to support implementation. (2018, April). Retrieved April 17, 2019, from Home Visiting Evidence of Effectiveness website:
NFP Nurse Supervisors must be registered nurses with a bachelor's degree in nursing, and it is preferred that they also have a master's degree in nursing. In addition to the training completed by all nurses, supervisors are required to complete four introductory supervisor-education sessions, including two in-person sessions.Implementing Nurse-Family Partnership (NFP): Training to support implementation. (2018, April). Retrieved April 17, 2019, from Home Visiting Evidence of Effectiveness website: Additionally, they attend a three-day, 20-hour supervisor education and refresher in Denver annually.
Evidence of effectiveness Findings in Relation to Intervention Goals
Improve Prenatal Outcomes
79% reduction in preterm birth for smoking mothersOlds, D. L., Henderson, C. R. Jr., Tatelbaum, R., & Chamberlin, R. (1986). Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics, 77, 16–28. 18% reduction in preterm birth in generalThorland, W., & Currie, D. (2017). Status of Birth Outcomes in Clients of the Nurse-Family Partnership. Maternal and Child Health Journal, 21(5), 995–1001. 35% reduction in pregnancy-induced hypertensionKitzman, H., Olds, D. L., Henderson, et al. (1997). Effect of Prenatal and Infancy Home Visitation by Nurses on Pregnancy Outcomes, Childhood Injuries, and Repeated Childbearing: A Randomized Controlled Trial. JAMA, 278(8), 644–652.
Improve Child Health and Development
25% reduction in child abuse and neglectReanalysis of Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R., et al. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. JAMA: The Journal of the American Medical Association, 278(8), 637–643. 48% reduction in child abuse and neglect among low socioeconomic status mothers