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DISCUSSION

Family Nurse Partnership: why supervision matters

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Supervision is vital in the Family Nurse Partnership but issues raised may apply to all nurses. Broadening use of the supervision model may be beneficial

Abstract

First-time teenage mothers and their babies are likely to have increased levels of need. This article explores how supervision supports Family Nurse Partnership (FNP) nurses to undertake complex work with teenage, first-time mothers and their babies. Careful application of a supervision model can provide the structure for a safe, containing, reflective space.

Citation: Andrews L (2016) Family Nurse Partnership: why supervision matters. Nursing Times; 112: 3/4, 12-14.

Author: Lindsay Andrews is clinical educator and clinical adviser Family Nurse Partnership National Unit, Tavistock and Portman NHS Trust, London.

Introduction

The Family Nurse Partnership (FNP) is an internationally recognised, evidence-based, public health, primary prevention programme (Olds, 2006). Developed in the US on the basis of 35 years of extensive research, it was tested with diverse populations in different contexts in Elmira, New York (1977), Memphis (1988) and Denver (1994). Studies of the trials demonstrated a range of benefits for children and mothers over the short, medium and long term.

The FNP approach

In 2007 the FNP was introduced in 10 pilot sites in England. Since then it has become a key part of the early intervention strategy (Allen, 2011) and expanded significantly. In 2015, FNP provision is up to 16,000 first-time teenage mothers in 135 local authority areas. It is widely accepted that first-time teenage mothers and their babies are likely to have increased levels of need (Brandon et al,  2011) so family nurses in England offer this intensive home-visiting programme to this cohort. The programme is carefully designed and structured to promote positive behaviour change, benefitting mother and baby.

Family nurses are trained in motivational interviewing techniques (Miller and Rollnick, 2013), along with a range of communication skills that help them support behaviour change. The therapeutic relationship they develop with teenage mothers forms a vehicle to deliver the FNP programme. Publication of the first evaluation of FNP in England concurs that the family nurse is highly valued by those receiving the programme (Robling et al, 2015). This relationship is, in itself, an intervention as the nurse seeks to model reliability, structure and emotional availability to the teenage mother through regular planned visits, from early in pregnancy until the child’s second birthday.

In addition, the family nurse uses a comprehensive, well-developed curriculum comprising licensed and tested materials, tools and clinical methods. The FNP programme goals are to improve:

  • Pregnancy outcomes of teenage, first-time mothers;
  • The health and development of their child;
  • The economic self-sufficiency of the family by helping the teenage parent to develop a vision for their own future, including planning future pregnancies, and continuing to develop their future education and employment opportunities.

Supervision

Supervision is a licensing condition of the FNP programme and must take place weekly. The development and integration of reflective practice is regarded as a foundational concept of public-health nursing practice in the FNP programme (Beam et al, 2010).

Rationale

The rationale for supervision can be split into three areas:

New learning

The FNP programme is innovative, and its effective implementation requires significant new learning for staff. The development of a new role is an iterative process, requiring action and reflection (Schon, 1990). As the programme has a psycho-educational approach, the family nurse enables the teenage mother to look back on her own experiences of being parented, reflect and contextualise these, and then think forward to the parenting of her own child, possibly leading to intergenerational patterns of parenting being interrupted. This potentially has an emotional impact on the client which the family nurse contains by assessing, planning and providing effective interventions to support the client in her role as a mother.

Supportive

Family nurses work with a caseload of up to 25 teenage parents and their infants. Teenage mothers are more likely to be in relationships in which domestic abuse features, to have been subject to sexual exploitation, and have personal experience of negative parenting. As such, family nurses work in close proximity to vulnerability, which can evoke feelings of uncertainty and anxiety (Ruch, 2011). Laming (2009) acknowledges the demanding work of frontline staff who work with vulnerable children and young people, and suggests they require skill, determination, courage and an ability to work with intense conflict. An independent unpublished review of safeguarding arrangements in the FNP recognised that family nurses are managing higher levels of risk ‘in house’ than they would be as health visitors and midwives working in universal services (Cantrill and Hughes, 2010).

Monitoring

A real-time FNP information system provides data to help monitor the progress of the programme and the achievement of goals with the mother. It is important the family nurse can objectively consider the impact and quality of their work and adjust methods and future plans for work accordingly.

The UK context

While the rationale for reflective supervision was recognised as a core FNP element in 2007 when the FNP was introduced in England, the supervision method needed to be developed for a UK context. Supervision in nursing had traditionally fallen into three categories: safeguarding, clinical and restorative (Wallbank and Wonnacott, 2015). There was a tendency for these categories to sit in silos so a more integrated approach was needed. A supervisory approach that supported family nurse development and safe practice, and modelled the therapeutic relationship with an embedded restorative element was identified as more likely to meet family nurses’ needs.

Kadushin (1976) helpfully identified three functions of supervision, which provide a template for FNP supervision:

Formative, educative or development

Reflecting and analysing the nurse’s experience to deepen learning. In FNP supervision this includes thinking about the application of the methods, approaches and materials of the FNP programme; the nurse articulates and reflects on their experience of using them, as well as how the mother engaged with them. The FNP supervisor can then highlight the nurse’s growing skillset and knowledge base of the approaches, their efficacy and increasing skills and experience of working with the mother and her infant.

Restorative or resourcing

This highlights the emotional labour of the work. Space is given to allow nurses to consider how the work affects them and helps to remain reflective and objective in the therapeutic relationship. This can lead to a more accurate empathic response by the nurse and protects empathic distress that may lead to burnout (Kinman and Grant, 2011). Nurses may feel anxious about managing their workload; supervision facilitates consideration of the nurse’s feelings and ability to meet all clients’ needs.

Normative or management

This provides quality control and helps identify any potential “blind spots” the nurse may have. Professional boundaries are discussed, as is the intelligent application of rules, policy and procedure, and being risk sensible as opposed to risk adverse (Munro, 2011). The nurse is supported to remain open and thoughtful about monitoring progress of the programme delivery and impact with each mother on her caseload.

Supervision framework

A working framework to guide and structure the supervisory process was identified as another requisite. Hawkins and Shohet (2008) provided a supervision model that incorporates all three functions and facilitates a holistic, reflective approach so this model has been adopted. Good FNP supervision should involve all areas of the Seven-Eyed Model of Supervision (Fig 1, attached), although not necessarily all in each session.

At any time in supervision there are many interrelated subjects to explore. As a minimum, these are the:

  • Supervisor (FNP supervisor);
  • Supervisee (family nurse);
  • Client (teenage parent);
  • Work context.

Only the supervisor and the nurse are present at the supervisory meeting but the mother, baby and context are carried into the session, both consciously and unconsciously; the Seven-Eyed Model takes this into account.

In the model, the family nurse is within overlapping concentric circles as they have a direct relationship with the mother and baby, as well as a direct working relationship with the supervisor. The supervisor’s relationship with the mother and baby is indirect and occurs through the nurse.

Box 1 outlines an example of an FNP supervision session; it demonstrates how each eye of the model can be visited and how it meets the nurse’s developmental, restorative and management requirements. Both parties in the supervisory process are responsible for the quality of the supervision.

Box 1. Sample supervision session

Background

This family nurse is reflective and shows good insight into her clients. She is aware of her own emotional response to clients, issues that arise during visits and the potential impact of this on her work. She is insightful, descriptive and gives a clear picture of the clients she brings to supervision (Eye 4).

The FNP supervisor (Eye 6) enjoys supervision with the nurse and they feel they work well together (Eye 5) – the supervisory relationship is an effective forum for exploring the complexities of the nurse’s work (Eyes 2 and 3).

Supervision session

The nurse arrived at the supervision session and wanted to discuss a mother she had just visited (Eye 4), who was 24 weeks pregnant (she had been recruited to the FNP programme when she was 16 weeks pregnant). The mother was a looked-after child, experiencing very low mood and had expressed some suicidal thoughts during home visits. She attributed these to difficulties in her relationship with the father of her unborn baby (Eye 1).

The nurse had previously accompanied the mother to the GP and, having identified the presence of domestic abuse, referred her to social care (Eye 2). The mother presented as being engaged in working with the nurse, enjoyed the home visits and continued to meet with her weekly or  fortnightly (Eye 3).

Supervision began and the nurse recounted the morning visit. The mother had told her she was planning to move to Manchester with the baby’s father despite their relationship being volatile; she said she could not imagine life without him (Eye 1).

The supervisor found it increasingly difficult to focus on what the nurse was saying (Eye 6); this had never happened before. The nurse excused herself from the session (Eye 4); this had also never happened before. When she returned, the supervisor said she was finding it difficult to focus on the mother, was surprised the nurse had needed to leave the room and asked her if she had any thoughts about this (Eye 6).

After some reflection the nurse said: “I think it is because this mother is just going to up and leave and move away (Eye 1) and that makes me wonder what the value of my work with her is (Eye 2)”. The supervisor and nurse then analysed the feelings this evoked in the nurse (Eye 4). Once these had been processed and acknowledged, the nurse was able to develop a clear set of action plans that encompassed safeguards for the mother and baby, in the event of a transfer out of the area.

The impact on general nursing

What can FNP supervision teach the wider nursing profession? Many people become nurses in the spirit of care and compassion, but remaining compassionate is not without its challenges. The lack of compassion in nursing, as outlined in the reports on Winterbourne View (Department of Health, 2012) and Mid Staffordshire Foundation Trust (Francis, 2013), were difficult to read and findings from those reports led to the development of NHS England’s (2012) Compassion in Practice strategy.

NHS England’s (2014) Building and Strengthening Leadership offers an approach to bolstering compassion through the four dimensions of self, manager/leader, team and organisation, but pays little attention to the role supervision could play. Professional conversations within nurse revalidation (Nursing Midwifery Council, 2015) present an opportunity to promote quality, development and the emotional capacity of the nurse.

FNP is one example of how supervision can model compassion in care. It has clarity of purpose and supports the development, emotional restoration and safe practice of each family nurse. The FNP approach could be used to shape supervision in general nursing. As one FNP supervisor in West Yorkshire said to me:

“Sometimes in supervision you have to put the clinical work to one side and prioritise the restorative function of supervision. Attending to, and understanding, the difficult mix of emotions involved in [the nurse’s] work allows [them] to think with greater clarity and compassion about the complexity of issues [their] client faces.

Key points

  • The Family Nurse Partnership is a health-led intensive home visiting programme developed in the US to support first-time teenage mothers and their babies
  • Thousands of teenage mothers are supported across England through the FNP
  • Family nurses’ caseloads can be extremely challenging as they include very vulnerable individuals
  • Supervision is a vital part of the FNP framework, allowing family nurses to work through complex issues and reflect on their practice
  • The supervision model used by the FNP could prove beneficial for nurses in general settings
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