The Nurse-Family Partnership (NFP) is a targeted home visiting program provided by nurses to young, low-income, first-time mothers during pregnancy and through the first two years of the child’s life. The effectiveness of the NFP program has been rigorously evaluated in three US randomized controlled trials [1–4]. The goals of the NFP program include improving: (a) pregnancy outcomes, (b) child health and development through more responsible and competent parenting, and (c) families’ economic self-sufficiency by helping parents to plan for their future, continue their education or find work and plan subsequent pregnancies. Through these three U.S. trials, Olds and colleagues have repeatedly demonstrated that the NFP is effective and consistent findings include: 1. reductions in childhood injuries; 2. improved school readiness; 3. reductions in the number and increased spacing of subsequent pregnancies; 4. reductions in welfare dependence; and 5. increased maternal employment [1, 2, 5–7]. A longer-term study of the cohort of young adults whose mothers enrolled in the original Elmira, NY trial revealed a trend that teenage children of NFP participants were less involved in substance abuse and crime than teens whose mothers did not receive the intervention [8, 9]. Eckenrode and colleagues reported that 19 year-old female youth whose mothers participated in the NFP program were less likely to be involved in crime, had fewer children and used less Medicaid . In addition Kitzman and colleagues found that the positive effects of the NFP program on maternal life course endured three years after mothers completed the NFP intervention .
The NFP program follows set guidelines and commences with visits beginning before the 29th week of pregnancy and extending to the child’s second birthday. NFP nurses visit biweekly except during the first month of the intervention and the first postpartum month, when nurses visit weekly. The nurses focus on six domains: personal health, environmental health, friends and family, the maternal role, use of health care and human services, and maternal life course development (which encompasses planning for future pregnancies, education, and employment). During pregnancy, the focus is on fetal growth; attachment; changes in the mother’s body and life; changes in relationships with her partner, family, and friends; and questions about her labor and delivery and how to integrate motherhood into responsibilities with school and work. After the birth, the focus broadens to encompass infant growth and development, educational play, bonding and communicating with her child, and the mother’s life-course planning. The mother’s participation in the program is voluntary.
Researchers studying the effectiveness of home visiting programs in general have hypothesized that positive maternal and child outcomes are related to the development of trusting relationships between the professional and the mother [1, 12–15]. The success of the NFP has been attributed to the nurses’ development of therapeutic relationships with their clients . Wiggins and colleagues suggest that it is the mix of well trained nurses, their strengths-based approach to families and the content and length of the program that sets the NFP apart from other home visiting programs , many of which have not been found to be effective [17, 18]. Good therapeutic relationships between home visiting nurses and mothers require nurses to help mothers become empowered active participants to increase control over their own health [19, 20]. In so doing, nurses must be non-judgmental in order to create a safe environment for the trusting relationship to develop . However, Smithbattle points out that little is known about how nurses and women are able to cultivate these positive therapeutic relationships, and how nurses respond to clients’ unique life situations while following a set curriculum during home visits .
Few studies have examined mothers’ experiences and perceptions of home visiting by nurses. Jack and colleagues examined how socially disadvantaged mothers engage with public health nurses and home visitors . They reported that women experienced vulnerability and powerlessness, and had to engage in social processes of overcoming fear, building trust and seeking mutuality in order to limit feelings of vulnerability. They found that provider actions, maternal characteristics, and past experiences influenced the speed with which mothers moved through phases in order to develop a connected relationship [11, 21]. DeMay in her analysis of 62 essays written by mothers about their experiences receiving nurse home visits reported that the mothers emphasized the importance of nurse qualities, obtaining knowledge about pregnancy and child development and “feeling respected and not feeling the nurse was telling them what to do” (p.234) . Other studies report that some adolescent mothers feel stigmatized by public health nurses during home visits because they are teen mothers .
Although several studies have examined and demonstrated the effectiveness of the NFP program, no published research was found that specifically examined the experiences of mothers participating in this nurse home visiting program. Knowledge of women’s experiences within and perceptions of the NFP program is important as it will provide insights into what women like and value about the program and factors that influence their continued participation in the program. In addition, the findings may provide some insight into the mechanisms, including how the relationship between the mothers and their NFP nurses improves maternal, child and family outcomes. The aim of this study was to explore and describe the experiences of mothers participating in the NFP program from the time of program entry before 29 weeks gestation until their infant’s first birthday. The results presented in this paper are part of a larger mixed methods study examining the feasibility and acceptability of the NFP in a Canadian setting.
The Prevention Research Centre (University of Colorado) Nurse Family Partnership International Program identified the McMaster University-Hamilton Public Health Services collaboration as the team to lead all future evaluations of the NFP in Canada. To retain fidelity to the program model evaluated in the original trials, international sites are required to complete a four-step process prior to full implementation of the program: 1) adapt the NFP curriculum to meet local standards and needs; 2) complete a small scale pilot study to assess for acceptability and feasibility; 3) conduct an RCT to evaluate the effectiveness of the program in the new context; and 4) expand implementation of the program. In 2008, a feasibility study was initiated in Hamilton, Ontario to evaluate procedures for recruitment, retention and collection of clinical data. Concurrently, a qualitative acceptability study was conducted to explore NFP clients’ and their families’, public health nurses’ (PHNs), and stakeholders’ perceptions of and experiences with this specific home visitation intervention.
Six PHNs and one nurse manager completed the intensive nurse and nurse manager NFP training. In order to ensure fidelity to the NFP program, all NFP nurses and their nurse supervisors receive training from the Nursing Practice Team at Nurse-Family Partnership National Service Office in Denver, Colorado, USA. The comprehensive training includes a theoretical review of the NFP program elements, an overview of NFP program elements and application of the curriculum, and advanced skill development in nursing assessment and intervention. Prior to implementing the program in Hamilton, the PHNs had an opportunity to job-shadow a team of NFP nurse home visitors located in Pennsylvania.