The Family Nurse Partnership (FNP) in Scotland

The FNP was introduced to Scotland in 2009. The FNP in Scotland is provided by qualified and skilled nurses and midwives who have successfully completed prerequisite master’s level training. Since its introduction, the FNP has been extended to more than 10,000 families across Scotland [7,8]. While the FNP was originally designed to provide support services to first-time mothers aged 19 years and below, this has recently been expanded to young parents aged up to 24 years old in Scotland [8].

The COVID-19 pandemic placed a significant burden on the health and economy of many countries across the globe, including Scotland [7]. A report of the Scottish Government during the COVID-19 crisis stated that “the COVID-19 pandemic has brought a renewed focus on the specific vulnerability of the client group who receive FNP and it is imperative to recognise the essential role of FNP in response to the pandemic” [9]. The burden of the COVID-19 pandemic exacerbated the already existing difficulties and disparities faced by vulnerable and minority populations [10]. Additionally, a nationwide report in the UK underscoring the effect of the COVID-19 pandemic and the first UK lockdown on children (0–2 years old), showed that young children were indirectly affected by the COVID-19 crisis by being more susceptible and vulnerable to a broad range of ‘hidden harms’ [11]. These ‘hidden harms’ comprised factors such as poor parental mental health, traumatic experiences, invisibility to professionals [11]. Therefore, many service providers and policy officials judged that the FNP programme was an important service to help mitigate these harms during the COVID-19 pandemic.

The COVID-19 pandemic brought a focus on telehealth as healthcare services moved rapidly to implement remote delivery systems in line with infection control measures. A national clinical guidance was produced by the Scottish Government to guide nursing and allied health professionals and community health staff during the COVID-19 pandemic [12]. Fundamental and essential changes occurred to enable and assist the delivery of regular and continuous care alongside crucial services, where possible. Regarding the FNP, this involved a predominant shift to remote service delivery using technology such as telephone calls, SMS messaging and video calls via platforms such as ‘Attend Anywhere’ or ‘Near Me’ [9]. This supported clients to maintain regular contact with their family nurses. Home visiting was provided for vital circumstances only [9].

Rationale and aims of study

Some challenges of telehealth usage during the COVID-19 pandemic have been captured by a systematic review, which included papers from 64 studies across 18 countries [13]. The review found that the most common challenges were technology acceptance and adoption, concerns about the accurateness of subjective patients’ assessment and technical issues with technology [13].

Further, a study has revealed that young mothers in the UK are less likely to engage with digital health and online support sources, relying instead on trusted interpersonal sources and community-based support that adequately address the complexity of their needs [14]. Considering the FNP programme targets young mothers and the essential role telehealth played in the delivery of the FNP programme in response to the COVID-19 pandemic, it is vital to gain a thorough understanding from the perspectives of FNP nurses and their clients to better characterise the implications of the service adaptation for future programme delivery. This study, therefore, addressed the following aims:

1) to understand the features of telehealth employed to deliver the FNP programme during COVID-19 in Scotland; 2) to examine how FNP nurses and clients responded to the delivery of FNP through telehealth; 3) to evaluate the challenges of delivering the FNP through telehealth during COVID-19 and its implications for future delivery of the programme.

Design, setting and context

This evaluation employed a mixed-methods parallel (convergent) design. Firstly, qualitative (interviews and focus groups) and quantitative data (survey) were collected concurrently. Secondly, we independently analysed qualitative and quantitative data using appropriate methods (see data analysis section below for detail). Finally, data integration occurred by comparing and contrasting the results from both analyses. The approach facilitated a more comprehensive and nuanced understanding of the research problem because the qualitative findings provided in-depth explanation to the quantitative results.

The study was conducted in the eleven (of a total of fourteen) Scottish Health Boards currently running the FNP programme. However, Health Boards were not identified in this paper to protect the identity of participants. Data collection was carried out from January 2021 to March 2021, and this was during a period where a range of public health measures and restrictions were in place to mitigate the COVID-19 pandemic. In the UK, a strict national lockdown was in place from 24th March to 28th May 2020. Lockdown restrictions were gradually eased in phases until regional level restrictions were implemented across Scotland on 1st November 2020. However, from January 2021 to April 2021 a second national lockdown was introduced.

Sample

Thirty-one family nurses took part in one-to-one interviews (n = 23) and focus groups (n = 8). Fifteen clients were involved in one-to-one interviews: six clients were enrolled onto the FNP programme prior to the COVID-19 pandemic, nine clients were enrolled after the introduction of COVID-19 restrictions. As of 31st March 2021 there were 2,909 active FNP clients in Scotland [15]. All family nurses across Scotland were invited to complete an online survey and ninety of them completed it at eligible response rate of 41%.

Recruitment and data collection

Due to COVID-19 restrictions in place at the time of the research, all data were collected remotely using telephone and digital methods, including video calls and online surveys. Throughout data collection, participants were asked to reflect on their experiences of delivering and receiving the FNP service following the COVID-19 outbreak in March 2020 up until the point of data collection in January 2021 to March 2021.

Qualitative interviews and focus groups

Family nurses were recruited via nurse managers who distributed study invitation letters and information sheets to their staff by email. Those interested in taking part in either a one-to-one interview or focus group completed informed consent via Qualtrics using an online data form.

FNP clients were recruited by their family nurses. Family nurses were provided with the study recruitment materials containing participant and study information sheets, which were shared with clients in various formats (i.e., text message, email, or verbal conversation). Clients interested in the study contacted the research team directly by completing an online Qualtrics data form to provide informed consent. Options were also provided to contact the research team via email with any questions prior to participating. The online form allowed clients the option of choosing a preferred time and day for a telephone interview. We also gave clients the option to request a female researcher or additional support from their family nurse, if required.

Interviews were conducted mainly by telephone. In few instances Microsoft Teams was used. All focus groups were conducted via the Microsoft Teams video platform. All interviews and focus groups were recorded using an encrypted digital audio recorder and then transcribed verbatim. All transcripts were anonymised and pseudonymised prior to analysis. Each client received a £20 high-street voucher as a thank you for their participation.

The interviews and focus groups were conducted by KM, TH, and LD. KM worked as a Research Associate, and holds an Masters Degree in Public Health and has extensive experience of conducting evaluations of home visiting programmes. LD is a Senior Lecturer in Applied Public Health and holds a PhD in Public Health. TH worked as a Research Assistant and holds an MSc in Health Policy. All members of the research team involved in undertaking the interviews had received training and had experience in qualitative methods and interview etiquette. Both TH and LD are male, while KM is female. None of the researchers had prior relationships with any of the participants in the study.

Survey of family nurses

Family nurses were invited to take part in the survey through their local nurse managers, who distributed links to the Qualtrics survey via email. The survey questionnaire was developed using existing FNP programme documents and findings from a rapid review [5], therefore no validated instrument was used. For participants to access the survey questionnaire, they had to first access the participant information sheet and complete a consent form. Informed consent was received via Qualtrics using an online data form. Participation in the survey was anonymous.

Data analysis

Ethics and approvals

This research was approved by the School of Health in Social Science Research Ethics Committee, University of Edinburgh and Tier 1 approval was also gained from the Public Benefit and Privacy Panel for Health and Social Care (HSC-PBPP) in Scotland. Each participant completed a written informed consent prior to taking part in the study.

Ethical restriction by the Public Benefit and Privacy Panel for Health and Social Care (HSC-PBPP) in Scotland prohibits the authors from making the minimal data set publicly available because data contain potentially identifiable information which may compromise patient and staff privacy. However, request to access the data from the researchers could be made through the Ethics Committee via phs.PBPP@phs.scot.

Sample

Thirty-one family nurses took part in the qualitative research and 90 responded to the online survey. Fifteen clients participated in one-to-one interviews. The results are presented thematically.

Prior experiences of FNP service provision via telehealth

The use of a range of telehealth modes in the FNP delivery prior to the COVID-19 pandemic was infrequent. In the qualitative study many family nurses reported that they had never used telehealth modes in delivering FNP services prior to the pandemic. However, in the survey, 92% reported using telephone calls. Only 9% and 7% of family nurses reported previously using ‘Attend Anywhere’ and ‘Near Me’ platforms respectively, while 11% reported using other video call platforms with clients, see Table 1. Aside from telephone use, low usage of video call platforms by family nurses prior to COVID-19 is in line with existing evidence that demonstrated that despite its potential benefits for patients and healthcare providers, telehealth was underutilised and understudied prior to COVID-19 [17].

Download:

• PNG
  larger image
• TIFF
  original image

Table 1. Previous experiences of using different telehealth modes to deliver FNP prior to the COVID-19 pandemic.

https://doi.org/10.1371/journal.pone.0337080.t001

Response to COVID-19 outbreak and restrictions

Several family nurses mentioned that the initial six weeks subsequent to the UK-based outbreak of the COVID-19 and the onset of national lockdown restrictions brought the most uncertainty concerning the FNP service provision. The closure of offices and workplaces in March 2020 led to an abrupt shift to home working for FNP nurses and changes were implemented rapidly across the service. Swift adaptation was required to deliver FNP in accordance with newly introduced public health measures and restrictions while using locally available technologies and resources.

“So I very quickly had to get my laptop, collect a pile of paperwork and head home, as we were advised to do, and it took me quite a bit of time to work out how to do remote working and get all that set up, and I just found it incredibly stressful, it was like learning a whole new job.” [Family Nurse, E]

“It felt like overnight it was, like, that’s it. You know, no home visit. We need to be really careful. It’s lockdown.” [Family Nurse, N]

Modes of delivery

Family nurses were predominantly delivering the service remotely, but in vital circumstances home visiting was possible. Home visiting included face-to-face and outdoor meetings with clients, while remote delivery included phone calls, SMS ‘text’ messaging, emails, video calls, WhatsApp and other mobile media apps. Although various communication formats were suited to different forms of contact or programme delivery more than others, a significant finding was that having a range of communication options was highly beneficial for family nurses. Text messaging, telephone calls and video calls were among the most frequently used telehealth modes. See Table 2.

Download:

• PNG
  larger image
• TIFF
  original image

Table 2. Frequency of use of service delivery modes reported by family nurses.

https://doi.org/10.1371/journal.pone.0337080.t002

Home visiting

The ability to offer home visits during the COVID-19 outbreak was critical to family nurses as it allowed them to offer timely and vital support to many vulnerable and at-risk clients during this time. All surveyed staff (100%) reported delivering home visits during the COVID-19 outbreak. When a home visit was offered to clients, 41% of family nurses reported that offers of home visits were always taken up while 51% indicated that these were taken up most of the time. Barely half of clients not taking up home visit offers perhaps reflects the client group that the FNP programmes often serve. A vulnerable client group often sceptical about health professionals and reluctant to engage with their services [18]. The proportion of caseloads who were offered home visits from March 2020 to March 2021 varied between family nurses as shown in Fig 1. Twenty-nine percent of family nurses offered home visits to 100% of their caseloads; 15% of family nurses offered home visits to 75–99% of their caseload; 20% of family nurses offered visits to 50–74% of their caseload; and 22% of family nurses offered home visits to 25–49% of their caseload.

Download:

• PNG
  larger image
• TIFF
  original image

Fig 1. Reported proportion of FNP client caseloads offered home visits during COVID- 19 outbreak, from March 2020–2021.

https://doi.org/10.1371/journal.pone.0337080.g001

Crucial home visits were typically conducted by family nurses for developmental assessments, new-born visits, and child protection reasons. Clients with mental health conditions and those at risk of domestic violence were also prioritised for home visits. For non-English speaking clients, visits to their homes were undertaken by family nurses while connecting with their interpreters remotely.

“So in COVID we’ve obviously had to be directed by Scottish Government to which visits we can do face to face, in their communication with us which visits we could do face to face and which visits have to be done on a digital pathway. However, in all of this we have had...we’re qualified nurses so we have had freedom to be able to assess ourselves whether a face-to-face visit is required. And predominantly I would say that would be for domestic abuse or for child protection. […] We’ve had to work very carefully with Scottish Government from a FNP point of view [and] with our health board as well, but we’ve had to keep our clients and our nurses safe.” [Family Nurse, N]

Often clients understood COVID-19 risks when being offered a home visit. Most clients felt safe during home visits and noted that they trusted their family nurses as health professionals to appropriately use Personal Protective Equipment (PPE) and mitigate transmission risks.

“With the PPE and stuff, we were all well protected, she had her mask and her gloves and her apron on at all times, she never came in the house without it. And I knew at any point if she felt she wasn’t well or anyone in this house wasn’t well, that we wouldn’t allow her to come in, so we felt safe with her in the house.” [Client (W), enrolled during COVID-19]

Where home visits were offered, most clients were reported to take these up. However, in some instances, clients declined home visits due to reasons such as being clinically vulnerable or at higher risk of serious illness if infected with COVID-19; having a ‘shielding’ family member; being afraid of COVID-19 infection risks; or having to self-isolate as a result of COVID-19 exposure.

Similarly, some family nurses also reported feeling afraid or anxious about contracting COVID-19 during in-person visits. Some family nurses perceived that it was not always safe to enter the clients’ home due to large numbers of people sharing a household, despite taking precautions such as wearing PPE.

“They’re also going to home visits that sometimes, despite every best effort, they’re doing their risk assessment, they’re trying to keep themselves safe, they’re going in and having their PPE on, but they go in and the house is really full with other family members. And they’re thinking to themselves, ‘are they all following the rules … I’m in the house and putting myself out there, even though I’m trying to follow the rules myself.’ And that for them at times has been scary.” [Family Nurse, W]

Remote delivery

Programme activities, assessments, and observations.

Both survey and qualitative findings all showed a negative impact on the ability of family nurses to effectively conduct assessments and observations using telehealth. Inability to conduct a comprehensive assessment of the physical environment of clients and undertake vital measurements via remote consultation presented a barrier to most health professionals during COVID-19 [13]. Similarly, in our study, Fig 2 illustrates the survey findings and shows that the ability to conduct assessments of the home environment was most affected, with 98% of family nurses reporting this had been negatively impacted, overall. Observations of the child were perceived to be negatively impacted by 94% of family nurses and child health assessments were reported as being worse by 86% of family nurses. No family nurses reported improvement in any of the key assessments and observation domains.

Download:

• PNG
  larger image
• TIFF
  original image

Fig 2. Self-reported impact of telehealth on ability to carry out assessments and observations, including observations of the child and assessments of the home environment.

https://doi.org/10.1371/journal.pone.0337080.g002

The qualitative findings further explain the survey findings. Family nurses felt that remotely assessing home environments was extremely difficult, or ‘impossible’ in some cases. Key challenges related to being unable to identify who else might be present in a room with a client and being unable to detect the overall condition of a home as well as more subtle signals including family dynamics, body language, smells, and potential hazards. One of the key theories underpinning the FNP programme is human ecology theory, which recognises the importance role external or environmental factors play in parental and child development [18,19]. Therefore, inability for family nurses to undertake full assessment of the home environment is a challenge for delivering the FNP programme. For instance, some of the family nurses explained that whilst NHS Attend Anywhere and Near Me helped to some extent, it did not facilitate a complete assessment of the home environment.

“… the fact that you can say that you actually saw the child has been incredibly helpful by Attend Anywhere. But in terms of a robust assessment of the home environment…and again all of that stuff about picking up cues if you’re thinking about domestic violence and what’s going on for a family, that has been very, very challenging, doing that by virtual means.” [Family Nurse, W]

Programme dosage and fidelity.

The FNP programme as a licensed programme has a clear structure and content, although it provides room for tailoring and adaptation to local context [18,20]. Adaptation and fidelity to remote delivery should therefore be balanced. Most clients did not experience any major differences in the number of contacts with family nurses during COVID-19 compared with prior programme delivery. Many clients reported keeping in contact with their family nurses via text messaging between scheduled programme contacts and most felt they were able to contact family nurses with queries and concerns during this time if necessary. The quote below from a client reflects this:

“Every two weeks I think where we have a proper catchup, but I can text her or phone her any time if I’ve got any questions or anything. So, sometimes it’s maybe like once a week, but it will just be over text type thing, but we have a proper catchup every two or three weeks.” [Client (W), enrolled pre-COVID-19]

Further analysis of the survey data conducted with family nurses showed that there were small differences in the overall self-reported provision of visits to clients, before and during the COVID-19 pandemic. Fig 3 below shows that during COVID-19 there was a slight decrease in the number of contacts conducted. For example, family nurses reported a decrease of 14% in always meeting programme fidelity following the outbreak, and a 5% decrease in meeting this most of the time.

Download:

• PNG
  larger image
• TIFF
  original image

Fig 3. Self-reported changes in the number of expected contacts, based on fidelity, provided to clients before and during the COVID-19 outbreak.

https://doi.org/10.1371/journal.pone.0337080.g003

Training

Family nurses who deliver the FNP programme are highly experienced. However, the rapid adaptation of the programme for remote delivery, required training and many of the family nurses said they received training as illustrated by one of them below.

“We had guidance for delivery of FNP on telehealth. We had a training session about the delivery of PIPE [Partners in Parenting education], activities via ‘Near Me’.” [Family nurse, N]

The survey data also indicated that a high number of nurses were trained to adapt the programme to remote delivery. Of surveyed family nurses, 90%, reported being provided with some form of guidance to support their work following COVID-19. In addition, 68% of family nurses reported being offered formal training opportunities to support remote working. Nevertheless, 23% reported being offered no training and 10% were unsure. Family nurses reported receiving or accessing training and support from a variety of sources. Local FNP teams were also cited as being extremely supportive and involved in peer-learning activities, especially in the midst of frequent changes to COVID-19 guidelines.

Future delivery of FNP

It was recognised that the adaptation of the FNP programme to remote delivery was an opportunity to explore the place of telehealth in the future delivery of the programme. Clients and family nurses were asked about their opinions on the future delivery of FNP based on their experiences of receiving or delivering the programme. Fifty-seven percent of surveyed family nurses agreed (46% somewhat agree and 11% strongly agree) that they would like to continue using telehealth to some extent to deliver FNP in the future; 29% disagreed (15% somewhat disagree and 14% strongly disagree) and 13% neither agreed nor disagreed.

When asked to rank most preferable delivery formats, ‘in person visiting only’, was most preferred by surveyed family nurses (55%). This was followed by ‘mixed-mode (face-to-face and telehealth) delivery’ (42%) with ‘telehealth delivery only’ being the least preferred option (77%) (see Fig 4 below).

Download:

• PNG
  larger image
• TIFF
  original image

Fig 4. Ranked order of preference for future delivery formats in FNP, reported by family nurses.

https://doi.org/10.1371/journal.pone.0337080.g004

When asked if FNP could be delivered effectively to clients using a multi-faceted (hybrid model) approach without compromising the essence or outcomes of the programme, 68% of family nurses agreed this was possible while 32% disagreed. Of the proportion of nurses who agreed with this statement, most commented that offering a hybrid model of delivery provided convenient options to maintain high levels of engagement for clients with commitments such as work or education, especially considering the target age group of the FNP clients are more prone to non-engagement [18]. However, family nurses emphasised that the provision of this should be dependent on clients’ needs and their level of vulnerability.

The qualitative interview data further explained the findings of the survey data. It showed that a hybrid delivery model was beneficial for improved time management. Family nurses referred to benefits such as reduced work-related travel in between visits or meetings and limiting the time lost due to missed appointments. Improved access to clients living in more rural or remote areas was also perceived as a potential benefit of hybrid-delivery.

“So, I’d normally do 50 to 100 miles a day and it was a lot of driving, so that would mean that when I got back from my last visit, maybe it would be nearly five o’clock, but then I’d still have to write up all the visits that I did that day and I didn’t really have any time. So, I ended up doing at least an hour but probably more like two hours unpaid overtime a day, to be honest, because you just never had time to write everything up that you had to do.” [Family Nurse, E]

Limitations

Data collection for qualitative interviews, focus groups and surveys were undertaken remotely due to COVID-19. It is possible that this approach to data collection might have excluded the perspectives of the most vulnerable clients due to digital exclusion or other barriers preventing their participation. Recruitment of clients via their family nurse presents a problem of selection bias. There is a risk that the family nurses preselected clients who had a more favourable opinion and experience of the service. This could mean that clients with less favourable opinions or those from more vulnerable backgrounds could have been excluded from the sample. Demographic characteristics of the small number of participants who took part in the study was not presented to protect participants confidentiality. The survey was also purely exploratory, to support the qualitative findings and provide a broad snapshot to address the aims of the study, therefore no inferential statistics were undertaken.

Information governance requirements prevented demographics data from being captured, this information could have been used to further contextualise the findings.