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Implementing Nurse Family Partnership (NFP)®

Meets DHHS criteria for an evidenced based model

Implementation Experiences

Last Updated

July 2016

Note: An earlier version of the Implementation Experiences included a section on costs, but HomVEE now refers readers to the Estimated Costs section of the profile for this information that has been checked by the model developer, so citations from cost-only studies have been removed from the study database. Additionally, an earlier version included discussion of an international implementation of an adaptation of NFP. This version focuses specifically on NFP as implemented in the United States, and citations about international studies have been removed.

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Summary of Sources

Information in this section is based on studies included in the HomVEE review. For NFP, we reviewed 39 studies, including 24 randomized controlled trials or quasi-experimental designs and 15 standalone implementation studies. (Please see the study database for a list of the studies.)

Of the studies reviewed, 29 were based on at least one of three groups of participants. Throughout this section, we refer to these three samples: the Elmira sample (10 studies), the Memphis sample (10 studies), and the Denver sample (4 studies). Five studies compared and contrasted the experiences and outcomes of more than one of these three samples. Ten studies examined the implementation of NFP in samples other than these three. Information about the sample of participants included in the other studies is noted where available.

In the sections below, we consider all pieces of research about a particular sample to be a single study. For example, all 10 publications on the Elmira sample are cited as one study. The 10 studies of other samples are counted as 10 separate studies. The total number of distinct study samples included in our counts is therefore 13.

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Characteristics of Program Model Participants

Mothers’ ages at enrollment averaged 19 years old (eight studies). In the Elmira sample, 47 percent of participants were under age 19 years; in the Memphis sample, mothers’ ages ranged from 13 to 26 years, with 64 percent under age 18 years; and in the Denver sample, the average age of participants was 19 years old.

Mothers enrolled during pregnancy and were offered home visits through the child’s second birthday (all studies).

Mothers were the primary participants (eight studies).

Nine studies included demographic information about program participants. The percentage of participants who identified as African American ranged from 2 to 92 percent (eight studies); 11 to 100 percent identified as Hispanic (five studies); 35 to 89 percent identified as white (six studies); and 3 to 12 percent identified as another or multiple races (three studies).

Eighty-nine percent of the women who participated in NFP in the Elmira sample were white; 92 percent of the women in the Memphis sample were African American; and 45 percent of the women in the Denver sample were Hispanic.

Most participants were described by study authors as low socioeconomic status (SES; five studies). Approximately 60 percent of the Elmira sample and 85 percent of the Memphis sample was low SES. All of the participants in the Denver sample were eligible for Medicaid, and 73 percent of participants in another study received Medicaid.

The majority of mothers were unmarried, ranging from 62 to 98 percent of participants (five studies). Sixty-two percent of the Elmira sample, 98 percent of the Memphis sample, and 85 percent of the Denver sample was unmarried.

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Location and Setting

NFP was implemented in the following locations:

  • New York State (a medium-sized urban community; and Elmira, a semirural community);
  • Tennessee (Memphis, an urban community);
  • Colorado (16 sites across the state; and Denver, an urban community);
  • Louisiana;
  • Pennsylvania (urban, suburban, semirural, and rural communities across the state);
  • California (urban communities across Orange County); and
  • Washington State (urban and rural communities across the state).

In the Elmira, Memphis, and Denver samples, health departments implemented NFP. Other implementing agencies included community-based organizations, hospitals, and public agencies.

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Staffing and Supervision

NFP programs were staffed by registered nurses (all studies) and supervisors (nine studies).

Home visitors were registered nurses with a bachelor’s degree in nursing (three studies). NFP staff were trained before delivering the intervention (five studies). Training ranged in length from one week to three months (three studies). The NFP National Service Office (NSO) provided staff with an orientation to the program model and training to use the home visit guidelines and client-centered intervention techniques (two studies).

Supervisors were trained to facilitate the learning process of the home visitors, and all site staff were taught how to use the Clinical Information System (two studies). Training was provided in three segments, scheduled to coincide with the point in time at which nurse home visitors needed to begin to use new program resources and skills with clients (two studies).

One study reported that the nurse home visitors received one week of extensive training and two follow-up trainings; the follow-up trainings included a three-day training on Partners in Parenting Education and a two-day training on toddler protocols. The nurse home visitors also received training in home visitation protocols, clinical record keeping, the Clinical Information System, and the theoretical framework upon which NFP is based.

Staff received in-service training after they began delivering the intervention (two studies). Nurses participated in cultural appreciation training (one study). Nurses and supervisors attended annual regional and statewide conferences (one study).

Supervision was provided to home visitors (nine studies). Often (seven studies) researchers did not describe the frequency of home visitor supervision. In two studies, authors reported that supervision was provided weekly.

The caseload of nurse home visitors ranged from 15 to 25 families per nurse home visitor (five studies). The caseload of supervisors ranged from 8 to 10 nurses per supervisor (two studies).

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Program Model Components

The NFP program model provides home visiting services to families enrolled in the program. Families were offered home visits prenatally through the child’s second birthday (all studies). Home visitors also offered program participants developmental screenings and transportation to and from appointments (two studies). Home visits were offered weekly the first month of enrollment, followed by visits every other week until delivery, weekly for the next six weeks, every other week until the child was 20 months old, and monthly until the child was 24 months old (all studies). The frequency of visits could be adapted to meet family needs (four studies).

Nurses assessed maternal, child, and family functioning as they related to pregnancy and infant and toddler development (three studies). The nurses then used the information from the assessments to recommend specific activities to families.

Nurses followed detailed visit-by-visit guidelines (four studies). The guidelines were designed to help women improve their health-related behaviors, care of their children, and life course development, which includes talking about future pregnancy planning, educational achievement, and participation in the workforce.

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Program Model Adaptations or Enhancements

Five studies involved adaptions or enhancements to the core NFP model.

Paraprofessional home visitors. The Denver sample compared the outcomes of women and children served by nurses in contrast to those served by paraprofessionals with a high school diploma. Women assigned to the paraprofessional group were provided screening and referral services plus paraprofessional home visitation during pregnancy and infancy (the first two years of the child’s life). Women in the nurse group were provided screening and referral plus nurse home visitation during pregnancy and infancy. In these studies, additional supervision was provided to the paraprofessionals. Paraprofessionals had twice the level of supervision (2 supervisors for 10 visitors), compared with nurses (1 supervisor for 10 visitors).

In terms of dosage, nurses completed an average of 6.5 home visits during pregnancy and 21 visits from birth to the child’s second birthday. These services were contrasted with services provided by paraprofessionals who completed an average of 6.3 home visits during pregnancy and 16 visits during infancy and toddlerhood.

Mental health professionals. A mental health professional provided case consultation and guidance to the nurses, and mental health services to selected participants (one study).

Contraceptive dispensing. Nurses were trained to offer hormonal contraceptives as part of the NFP home visits (one study). Nurses received two trainings on how to dispense contraceptives safely and reviewed client case studies. Nurses followed clinical protocols based on family planning guidelines from the Centers for Disease Control, World Health Organization, and American Congress of Obstetricians and Gynecologists. Nurse feedback indicated the need for (1) training in motivational interviewing and client empowerment; (2) additional clinical training and support; (3) logistical support with ordering, storing, and disposing of inventory; and (4) clear and directive family planning and dispensing protocols.

Retention initiative. A retention intervention implemented twice during the NFP intervention involved nurses initiating conversations with families about their ambivalence toward participation and offering to adjust visit frequency, program duration, and content to meet their needs (two studies). The nurses followed written retention intervention guidelines that included scripts, strategies, and case examples to guide conversations with families. The nurses received additional training on motivational interviewing and participated in monthly conference calls and case reviews. Across the two studies, 86 to 91 percent of families chose the standard visiting schedule despite the offered flexibility. The retention guidelines have been incorporated into the NSO training process.

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Dosage

At the Elmira, Memphis, and Denver sites, nurses completed an average of 9 (range 0-16), 7 (range 0-18), and 6.5 (range 0-17) visits during pregnancy, respectively; and 23 (range 0-59), 26 (range 0-71), and 21 (range 0-71) visits from birth to the child's second birthday. As of the child’s first birthday, fathers participated in an average of 2.4 visits compared to 21.1 for mothers (one study).

Home visits lasted 75 to 90 minutes (two studies).

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Lessons Learned

Several lessons about implementation related to fidelity, attrition, nurse support, and program sustainability emerged (eight studies).

Lessons related to program fidelity (two studies) included the following:

  • Nurses should be encouraged to spend equal time on all aspects of the program model and not shy away from topics about which they are not as comfortable. 
  • Nurses might be better able to implement NFP as they gain more experience with the model. 

Lessons related to participant attrition included the following:

  • Adapting the program to the participants’ needs and goals and addressing their specific concerns about pregnancy and parenting may facilitate participant retention (five studies). Nurses need support individualizing the program for families (two studies).
  • Reassessing mothers’ needs during the program and discussing the relevance of future visits may help prevent attrition (three studies).
  • Developing a strong therapeutic relationship with participants is also important for preventing attrition (two studies). Common strategies for establishing trust included assuring participants the information they shared was confidential, involving other family members in the visits, sharing selective information about their experiences as a parent, and adapting the program to suit participants’ needs (one study). 
  • Mothers who dropped out reported valuing the program and regretted leaving. Encouraging mothers to reach out to nurses during times of crisis may help improve retention. Increased outreach to mothers who drop out may facilitate re-engagement (one study).
  • To address problems related to external distractions such as unstable or crowded housing, meeting in another location may be helpful to bridge a time of housing instability and may also improve visit focus and communication compared to a visit in a crowded home (one study).
  • Developing maternal organizational and communication skills early in the program may help mothers manage visit appointments and facilitate consistent engagement (one study).

One study reported lessons on supporting nurses:

  • Sites should support nurses in managing families’ mental health needs. Supervision should address the importance of setting boundaries to avoid over involvement with families.
  • Sites should assess nurses’ level of satisfaction and job stressors to develop targeted supports to sustain and enhance nurses’ skills and enjoyment of their work.

The following lessons apply to program sustainability (one study):

  • NFP will not thrive in a community unless there is a clear need for the program and consensus that the model is a good strategy to reach the goals of child health and well-being. 
  • Each site choosing to implement NFP needs the capacity to operate and sustain the program. These capacities include having an organization and community that are supportive, a staff that is well trained and supported, and real-time information on implementation of the program and its achievement of specific benchmarks. 
  • Funding for a comprehensive program that spans several years must be sustainable in order to grow and then maintain an NFP program site. 
  • Some families may be more invested than others in the program, which can lead to some variation in the number of visits and length of the visits they receive.

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