NFP Model​​​​​​​

Overview

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.  

Nurse-Family Partnership Program Goals

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: 

  1. Improve pregnancy outcomes by helping women alter their health-related behaviours, including reducing use of cigarettes, alcohol, and illegal drugs
  2. Improve child health and development by helping parents provide more responsible and competent care for their children; 
  3. Improve families’ economic self-sufficiency by helping parents to develop a vision for their own future, plan subsequent pregnancies, continue their education and find work.

All program materials and the education program for the NFP Nurses /Supervisors are designed to specifically contribute to the achievement of these three goals.

Strength-based Approach and Use of Motivational Interviewing

There are four strategies intrinsic to the Nurse-Family Partnership strength-based approach:

  1. Listening to what families want and making that the starting point for any collaborative activities
  2. Acting on the belief that families are the experts on their own lives and are capable of making choices to attain desired goals
  3. Expanding families’ visions of options
  4. Helping families set small and reasonable goals that when attained contribute to their growing sense of efficacy 

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. 

Client-centered Principles

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 as Home Visitors

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.
  • Nurses’ abilities to competently address mothers’ and family members’ concerns about the complications of pregnancy, labor, and delivery and the physical health of the infant are thought to provide nurses with increased credibility and persuasive power in the eyes of family members.
  • Nurses have unique knowledge that resonates and is attractive to a first-time mother. Expectant women have many questions and concerns about their pregnancy and the baby’s health. Mothers value the expertise of registered nurses during this critical life transition. NFP nurses are welcomed into clients’ homes and in the community.
  • In the Denver trial paraprofessionals received exactly the same education as the NFP nurses and in addition received twice the amount of supervision. The paraprofessionals produced small effects that rarely achieved statistical or clinical significance while NHVs produced significant effects on a wide range of maternal and child outcomes (Olds et al., 2002).

Conceptual Model

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.
  • On the far left side of this figure are the three broad domains of proximal risks and protective factors that the program is designed to affect: 1) prenatal health-related behaviors; 2) sensitive, competent care of the child; and 3) early parental life course (pregnancy planning, parents’ completion of their education, finding work, and father involvement in the lives of their children).
  • The middle set of outcomes reflects corresponding child and parental outcomes that the program was designed to influence: birth outcomes (obstetric complications, preterm delivery, and low birth weight), child abuse, neglect, and unintentional injuries; child neurodevelopmental impairment; and later parental life course (family economic self-sufficiency, welfare dependence, maternal substance abuse).
  • On the far right, child and adolescent outcomes that the program might affect years after completion of the program at child age 2 years are shown, including school failure, antisocial behavior, and substance abuse. 

Olds, D. L. (2006). The Nurse–Family Partnership: An Evidence-Based Preventive Intervention. Infant Mental Health Journal, 27(1), 5-25.

STAR Framework

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.

Screening and Assessment Tools + Data Collection

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.

Nurse Education

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 

Home Visit Schedule

  • Mothers participating in the NFP receive up to 64 visits. Nurses personalise the standard visit schedule (weekly for the first 4 visits, then bi-weekly during pregnancy until the baby is born, weekly for 6 visits postpartum, then bi-weekly until the child is 21 months old, then monthly until the child is 24 months old) for each woman
  • It is preferable that the first home visit takes place by the 16th week of pregnancy and should be no later than the 28th week of pregnancy
  • Home visits last approximately 60 - 90 minutes and the focus of each visit is mutually agreed
  • NFP nurses regularly check-in with clients to see how the visits are going for them and to agree any adjustments to be made re frequency and length of visits

Visit-to-Visit Guidelines

The NFP Visit-to-Visit Guidelines provide materials and suggested content for visits and are designed to:

  • Ensure consistency in implementing the NFP model
  • Ensure that comprehensive and essential evidenced-based information is introduced to clients. 
  • Provide the flexibility needed to meet the clients’ needs and desires as well as program goals (partnership)
  • Provide a framework to help NFP nurse and client avoid focusing solely on the day-to-day challenges the client may be facing (proactive vs reactive)
  • Offer NFP nurses and clients a guide to explore the content topics most relevant to the client
  • Introduce content that supports clients in developing the knowledge, skills and self-efficacy to obtain the three NFP goals

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. 

Theory-driven

The Nurse–Family Partnership (NFP) is grounded in three theories:
  • Human ecology: emphasizes that children’s development is influenced by how their parents care for them, and that in turn is influenced by characteristics of their families, social networks, neighbourhoods, communities, and the integration among them (Bronfenbrenner, 1979).
  • Self-efficacy: proposes that individuals choose those behaviours that they believe will lead to a given outcome and that they can carry out successfully (Bandura, 1977).
  • Attachment: hypothesizes that children’s trust in their world and their later capacity for empathy and responsiveness to their own children once they become parents is influenced by the degree to which they formed attachment with a caring, responsive, and sensitive adult when they were growing up (Bowlby, 1969; Bowlby & Ainsworth, 1992).
  • Together, these theories emphasize the importance of families’ social context and individuals’ beliefs, motivations, emotions, and internal representations of their experience in explaining the development of behaviour
  • The theories that serve as the foundation for NFP complement one another and have been a part of the model since the original three US trials
  • The theories provide a framework that guided the development of the NFP Visit-to-Visit Guidelines, NFP nurse + Supervisor Competencies, and NFP education content/methods 

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. 

Core Model Elements (CMEs)

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.

  1. Client participates voluntarily in the Nurse-Family Partnership (NFP) program.
  2. Client is a first-time mother.
  3. Client meets socioeconomic disadvantage criteria at intake.
  4. Client is enrolled in the program early in her pregnancy and receives her first home visit by no later than the end of the 28th week of pregnancy.
  5. Each client is assigned an identified NFP nurse who establishes a therapeutic relationship through individual NFP home visits.
  6. Client is visited face-to-face in the home, or occasionally in another setting (mutually determined by the NFP nurse and client), when this is not possible.
  7. Client is visited throughout her pregnancy and the first two years of her child's life in accordance with the current standard NFP visit schedule or an alternative visit schedule agreed upon between the client and NFP nurse.
  8. NFP nurses and supervisors are registered nurses or registered nurse-midwives with a minimum of a Baccalaureate/bachelor's degree.
  9. NFP nurses and supervisors develop core NFP competencies by completing the required educational curricula and participating in on-going learning activities.
  10. NFP nurses, using professional knowledge, judgment, and skill, utilize the Visit-to-Visit Guidelines; individualizing them to the strengths & risks of each family, and apportioning time appropriately across the six program domains.
  11. NFP nurses and supervisors apply the theoretical framework that underpins the program (self-efficacy, human ecology, and attachment theories) to guide their clinical work and achievement of the three NFP goals.
  12. Each NFP team has an assigned NFP Supervisor who leads and manages the team and provides nurses with regular clinical and reflective supervision.
  13. NFP teams, implementing agencies, and national units collect and utilize data to: guide program implementation, inform continuous quality improvement, demonstrate program fidelity, assess indicative client outcomes, and guide clinical practice/reflective supervision.
  14. High quality NFP implementation is developed and sustained through national and local organized support.

Therapeutic Relationship

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.


Six Program Domains

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. 

Innovations

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

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.  


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