Nurse-Family Partnership

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,^[2] who provide home visits until the child's second birthday. NFP intervention has been associated with improvements in maternal health, child health, and economic security.^[3]

Nurse-Family Partnership

Founded	1970s
Founder	David Olds
Type	NGO (501(c)(3))^[1]
Location	1900 Grant Street, Suite 400, Denver, CO 80203
Area served	United States
Services	provides home visits from registered nurses to low-income first-time mothers
Key people	Frank Daidone (President and CEO), Charlotte Min-Harris (Chief Operating Officer), Elizabeth Slater Jasper (Chief Legal Officer, General Counsel and Corporate Secretary), Alison Kolwaite (Chief of External Affairs), Sarah McGee (Chief Policy and Government Affairs Officer), Kate Siegrist (Chief Nursing Officer), Tony Troxell (Chief Financial Officer)
Website	www.nursefamilypartnership.org

NFP started as a randomized control 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.^[4]

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.^[5] NFP begins during pregnancy to take advantage of this ecological transition point in the mother's life.^[6]

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.^[7]

NFP aims to give mothers more confidence by asking them to recall past successes, as well as engaging them in problem-solving tasks.^[6]

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.^[8]

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.^[6]

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."^[9] 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.^[10]

Target demographics

NFP targets low-income, first-time mothers,^[11] following the idea that the best time to teach health and development behaviors is during the mother's first pregnancy.^[12] 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.^[11]

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.^[13]

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.^[14] Ideally, the mother enrolls by week 16 of pregnancy, and it is required that the first meeting occur by week 28.^[15] The following table illustrates the standard visit schedule, but this is flexible, and is often adjusted based on the client's needs and availability.^[14]

Time Frame	Visit Schedule
First Month of Enrollment	Weekly
Remainder of Pregnancy	Every Other Week
First Six Weeks After Birth	Weekly
Six Weeks to 20 Months	Every Other Week
20-24 Months	Monthly

Visits can take place in the client's home, or in another location such as a community agency.^[14] Sessions last between 60 and 90 minutes.^[12]

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.^[11]

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.^[6]

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.^[16]

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.^[14]

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."^[17]

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.^[14] In addition to the training completed by all nurses, supervisors are required to complete four introductory supervisor-education sessions, including two in-person sessions.^[18] Additionally, they attend a three-day, 20-hour supervisor education and refresher in Denver annually.^[14]

Evidence of effectiveness

Findings in Relation to Intervention Goals

Improve Prenatal Outcomes

• 79% reduction in preterm birth for smoking mothers^[19]
• 18% reduction in preterm birth in general^[20]
• 35% reduction in pregnancy-induced hypertension^[21]

Improve Child Health and Development

• 48% reduction in child abuse and neglect^[22]
• 56% reduction in emergency room visits for accidents and poisonings^[23]
• 50% reduction in language delays at 21 months^[24]
• 67% reduction in behavioral and intellectual problems at 6 years^[25]
• 59% reduction in child arrests at 15 years^[26]

Improve Family's Economic Self-Sufficiency and Future Planning

• 82% increase in months employed for parent^[27]
• 31% decrease in very closely spaced (>6 months) subsequent pregnancies^[28]
• 72% decrease in convictions of mothers^[22]

Cost/Benefit to Society

Every dollar invested in NFP saves $5.70 in future costs for the highest-risk families enrolled, most notably seen in government costs.^[29] For example, the increased economic self-sufficiency of enrolled families reduced Medicaid enrollment, leading to an 8.5% reduction in costs.^[30]

Locations

United States

NFP operates in over 700 counties across 40 states, as well as in the U.S. Virgin Islands.^[31]

United Kingdom

In the UK the programme is known as the Family Nurse Partnership and has been backed by the NHS to deliver a service to 16,000 of the most disadvantaged new parents in the country.^[32]

However, there has been less success in the UK than in the USA. A 2015 study from Robling, et al. found improved/earlier identification of safeguarding risks and a valued relationship between mother and nurse, but no benefit to short-term outcomes.^[33] In response, FNP has introduced Next Steps, which aims to increase beneficial outcomes, program flexibility, personalization, cost-effectiveness, and knowledge-exchange between services.^[34]

Netherlands

A 2011 study found that NFP was successfully adapted into the Dutch healthcare system and was expected to have a positive impact on pre- and postnatal risk factors.^[35] Later studies found that NFP was successful at reducing intimate partner violence for the duration of the intervention,^[36] reducing smoking, increasing duration of breastfeeding,^[37] reducing child maltreatment, improving long-term home environments, and reducing child internalizing behaviors,^[38] but unsuccessful at targeting pregnancy outcomes.^[37]

Funding

Private funding

NFP is supported through a combination of individual and foundation/corporation donors. Foundations and corporations that support or have supported NFP include the Edna McConnell Clark Foundation,^[39] Bill and Melinda Gates Foundation,^[40] Robert Wood Johnson Foundation,^[41] W.K. Kellogg Foundation,^[42] Kresge Foundation, Johnson & Johnson, and others.

Government funding

Many of NFP's programs are carried out in conjunction with federal, state, and local governments and are funded through various programs of these governments. Funding sources include Affordable Care Act, Medicaid^[43] and Temporary Assistance for Needy Families.

External reviews

GiveWell review

Charity evaluator GiveWell reviewed Nurse-Family Partnership in Fall of 2010.^[44] Until November 2011, Nurse-Family Partnership was rated as the top US charity recommended for GiveWell donors. In November 2011, GiveWell changed NFP's review to outstanding, because they felt that NFP did not have any short-term need for more funding.

Other reviews

Nurse-Family Partnership has received two consecutive four-star rating from Charity Navigator,^[45] the highest possible rating awarded from the U.S.-based charity evaluator. NFP received a rating of 60.37/70 with a financial rating of 56.98/70 and an accountability rating of 66/70.^[45]

The Center for High Impact Philanthropy listed the Nurse-Family Partnership as a high-impact opportunity in its holiday giving guide and elsewhere on its website.^[46][47][48]

The Coalition for Evidence-Based Policy published a detailed review of the evidence of success of the NFP's programs on its website.^[49]

GuideStar^[50] has awarded the Gold participation level to Nurse-Family Partnership for its commitment to data transparency.

Great Nonprofits^[51] awarded Nurse-Family Partnership the Top-Rated Nonprofit award.

Media and blog coverage

Nurse-Family Partnership has been covered in media outlets such as Time,^[52] The New York Times,^[53][54] The New Republic,^[55] The Washington Post,^[56][57] and USA Today.^[58]

NFP has received favorable coverage in the blogs and opinion pieces of a number of think tanks including the Center for American Progress^[59] and the Brookings Institution.^[60]

Criticisms

Practitioners may experience burn-out given that nurses carry a caseload of at least 25 families, endure emotionally taxing work, and often lack agency support. This can lead to high turnover, which then compounds the situation as current nurses must take on departing nurses' caseloads.^[61] However, a stable workforce is associated with higher retention.^[62]

See also

• Southwest Human Development

References

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2. "Beginning with trust, ending with extraordinary outcomes". Nurse-Family Partnership. Retrieved December 17, 2014.
3. . Agency for Healthcare Research and Quality. July 5, 2014 [First published 2008]. Archived from the original on February 1, 2017. Retrieved December 18, 2014.
4. Bronfenbrenner, U. (1979). The ecology of human development: experiments by nature and design. Cambridge, Mass: Harvard University Press.
5. Guiding Theories. (n.d.). Retrieved April 17, 2019, from https://www.nursefamilypartnership.org/nurses/guiding-theories/   
6. Dawley, K., Loch, K. & Bindrich, I. (2007). The nurse-family partnership. American Journal of Nursing, 107(11), 66–67.
7. Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W.H. Freeman.
8. Bowlby, J. (1970). Attachment and loss. New York: Basic Books.
9. Holland ML, Olds DL, Dozier AM, Kitzman HJ (May 2019). "Visit attendance patterns in Nurse-Family Partnership Community Sites". Prevention Science. 19 (4): 516–27. doi:10.1007/s11121-017-0829-6. PMC 5826902. PMID 28812181.
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13. Dads. (n.d.). Retrieved April 17, 2019, from https://www.nursefamilypartnership.org/first-time-moms/expectant-fathers/
14. 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/
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21. Kitzman, 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.
22. Reanalysis 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.
23. Olds, D. L., Henderson, Jr., C. R., Chamberlin, R., & Tatelbaum, R. (1986). Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics, 78, 65–78.
24. Olds, D. L., Robinson, J., O'Brien, R., Luckey, D. W., Pettitt, L. M., Henderson, C. R. Jr., Ng, R. K., Sheff, K. L., Korfmacher, J., Hiatt, S., & Talmi, A. (2002). Home visiting by paraprofessionals and by nurses: A randomized, controlled trial. Pediatrics, 110(3), 486–496.
25. Olds, D. L., Kitzman, H., Cole, R., Robinson, J., Sidora, K., Luckey, D., Henderson, C., Hanks, C., Bondy, J., Holmberg, J. (2004). Effects of nurse home visiting on maternal life-course and child development: Age-six follow-up of a randomized trial. Pediatrics, 114, 1550-9.
26. Reanalysis of Olds, D. L., Henderson, C. R., Cole, R., Eckenrode, J., Kitzman, H., Luckey, D., et al. (1998). Long-term effects of nurse home visitation on children’s criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. JAMA: The Journal of the American Medical Association, 280(14), 1238–1244.
27. Olds, D. L., Henderson, Jr., C. R., Tatelbaum, R., & Chamberlin, R. (1988). Improving the lifecourse development of socially disadvantaged parents: A randomized trial of nurse home visitation. American Journal of Public Health, 78, 1436–1445.
28. Kitzman, H., Olds, D., Sidora, K., Henderson, J., Hanks, C., Cole, R., et al. (2000). Enduring Effects of Nurse Home Visitation on Maternal Life Course: A 3-Year Follow-up of a Randomized Trial. JAMA, 283(15), 1983–1989. doi:10.1001/jama.283.15.1983
29. Karoly, L., Kilburn, M. R., & Cannon, J. (2005). Early Childhood Interventions: Proven Results, Future Promise, Santa Monica, Calif.: RAND Corporation, MG-341-PNC, 2005. Retrieved April 17, 2019, from https://www.rand.org/pubs/monographs/MG341.html
30. Miller, T. (2015). Projected Outcomes of Nurse-Family Partnership Home Visitation During 1996–2013, USA. Prevention Science, 16(6), 765–777. doi:10.1007/s11121-015-0572-9
31. National Snapshot [Fact sheet]. (2018). Retrieved April 17, 2019, from https://www.nursefamilypartnership.org/wp-content/uploads/2018/07/NFP_Snapshot_NewBrand_20180630-1.pdf
32. "Family Nurse Partnership programme to be extended". Gov.uk. April 4, 2013. Retrieved December 1, 2014.
33. Robling, M., Bekkers, M., Bell, K., Butler, C. C., Cannings-John, R., Channon, S., et al. (2016). Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): A pragmatic randomised controlled trial. The Lancet, 387, 146-155. doi:10.1016/S0140-6736(15)00392-X
34. Evidence. (n.d.). Retrieved April 17, 2019, from https://fnp.nhs.uk/our-impact/evidence/
35. Mejdoubi, J., van Den Heijkant, S., Struijf, E., van Leerdam, F., Hirasing, R., & Crijnen, A. (2011). Addressing risk factors for child abuse among high risk pregnant women: design of a randomised controlled trial of the nurse family partnership in Dutch preventive health care. BMC Public Health, 11(1). doi:10.1186/1471-2458-11-823
36. Mejdoubi, J., van Den Heijkant, S., van Leerdam, F., Heymans, M., Hirasing, R., & Crijnen, A. (2013). Effect of nurse home visits vs. usual care on reducing intimate partner violence in young high-risk pregnant women: a randomized controlled trial. PLoS ONE, 8(10), e78185. doi:10.1371/journal.pone.0078185
37. Mejdoubi, J., van Den Heijkant, S., van Leerdam, F., Crone, M., Crijnen, A., & Hirasing, R. (2014). Effects of nurse home visitation on cigarette smoking, pregnancy outcomes and breastfeeding: A randomized controlled trial. Midwifery, 30(6), 688–695. doi:10.1016/j.midw.2013.08.006
38. Mejdoubi, J., van Den Heijkant, S., van Leerdam, F., Heymans, M., Crijnen, A., & Hirasing, A. (2015). The effect of VoorZorg, the Dutch nurse-family partnership, on child maltreatment and development: a randomized controlled trial. PLoS ONE, 10(4), e0120182. doi:10.1371/journal.pone.0120182
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45. "Charity Navigator Rating -- Nurse-Family Partnership". Charity Navigator.
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48. . Archived from the original on December 16, 2014. Retrieved December 16, 2014.
49. "Social Programs That Work: Nurse-Family Partnership". Coalition for Evidence-Based Policy.
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52. Luckerson, Victor (December 10, 2012). "How Nonprofits Can Use Data to Solve the World's Problems". Time. Retrieved March 17, 2019 – via business.time.com.
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55. Cohn, Jonathan (November 9, 2011). "The Two Year Window". The New Republic. Retrieved August 24, 2012.
56. "Nurses' visits curb deaths among poor, single women and their children". The Washington Post. July 8, 2014. Retrieved June 17, 2019.
57. "Some Women Will Find Childbearing Less of a Burden". The Washington Post. June 8, 2010. Retrieved August 24, 2012.
58. "Home Visits Help New Moms". USA Today. April 14, 2010. Retrieved August 24, 2012.
59. Costa, Kristina (February 5, 2024). "Washington State Shows What Works: Data-driven Analysis of Public Programs Reaps Many Benefits". Center for American Progress.
60. "Congress Should Use Cost-Effectiveness to Guide Spending Cuts". Brookings Institution. November 30, 2011.
61. Lewis, J. (2007). Colorado Nurses and the NFP. AJN, American Journal of Nursing, 107(11), 69–72. doi:10.1097/01.NAJ.0000298068.65467.bf
62. Holland, M. L., Olds, D. L., Dozier, A. M., & Kitzman, H. J. (2018). Visit attendance patterns in Nurse-Family Partnership community sites. Prevention Science, 19(4), 516-527. doi:10.1007/ s11121-017-0829-6.

External links

• Official website
• Family Nurse Partnership (UK)