Implementing Nurse-Family Partnership (NFP)^®

Information in this section relies on studies included in the HomVEE review. For NFP, we reviewed 47 publications, including 27 publications about 5 randomized controlled trials. We also reviewed 1 single case design and 19 standalone implementation studies. (Please see Studies for Implementation Experiences for a list of the studies and to link to the characteristics of the samples examined in the effectiveness studies.)

Of the 47 publications reviewed, 31 were based on at least one of three groups of participants. Throughout this section, we refer to these three samples: the Elmira sample (10 publications), the Memphis sample (12 publications), and the Denver sample (4 publications). Five publications compared and contrasted the experiences and outcomes of more than one of these three samples. Sixteen publications examined the implementation of NFP in samples other than these three. Information about the sample of participants included in the other studies is noted when available.

In the following sections, we consider all pieces of research about a particular sample to be a single study. For example, we cite all 10 publications on the Elmira sample as one study. We counted the 16 publications on other samples as 15 separate studies (one sample has two publications). The total number of distinct study samples included in our counts is therefore 18.

Mothers’ ages at enrollment averaged 19 to 20 years old (10 studies). In the Elmira sample, 47 percent of participants were younger than age 19 years; in the Memphis sample, mothers’ ages ranged from 13 to 26 years, with 64 percent younger than 18; and in the Denver sample, the average age of participants was 19.

Mothers enrolled during pregnancy, and the program offered their family home visits through the focal child’s second birthday (all studies).

Mothers were the primary participants (all studies).

Twelve studies included information about the race and ethnicity of program participants.* The percentage of participants who identified as African American ranged from 2 to 92 percent (10 studies); 11 to 100 percent identified as Hispanic (seven studies); 31 to 89 percent identified as White (nine studies); 4 to 100 percent identified as American Indian, Alaska Native, or Native Hawaiian (five studies); 1 to 5 percent identified as Asian (three studies); and 3 to 7 percent identified as another or multiple races (two studies).

Of the women who participated in NFP in the Elmira sample, 89 percent 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.

The study authors described most participants as low socioeconomic status (SES; nine studies). About 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 had incomes at or below 133 percent of the federal poverty level. Across three other studies that reported on receipt of Medicaid, 61 to 73 percent of participants received Medicaid. At the time of the study, 63 to 80 percent of mothers were unemployed (three studies). Mothers had an average of 10 to 11 years of education (seven studies).

In the studies that reported on marital status, the majority of mothers were unmarried, ranging from 61 to 98 percent of participants (eight studies). Sixty-two percent of the Elmira sample, 98 percent of the Memphis sample, and 85 percent of the Denver sample was unmarried.

* The count of studies for each racial and ethnic category comprises studies that included sample members from the racial or ethnic category. If the study did not include sample members from a particular category, the study is not included in the count.

The following locations implemented NFP:

• New York State (an unnamed 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)
• Washington State (urban, rural, and tribal communities across the state)

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

Registered nurses (all studies) and supervisors (nine studies) staffed NFP programs.

Most home visitors had a bachelor’s degree in nursing (four studies). NFP staff received training 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 model and training to use the home visit guidelines and client-centered intervention techniques (two studies).

Supervisors received training to facilitate the learning process of the home visitors, and all site staff learned how to use the Clinical Information System (two studies). The NSO provided training in three segments, scheduled to coincide with when nurse home visitors began 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 relies.

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).

The local program provided supervision to home visitors (11 studies). In the studies that indicated the program offered supervision, often (nine studies) researchers did not describe the frequency of home visitor supervision. In two studies, authors reported that home visitors received weekly supervision.

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).

The NFP model provides home visiting services to families enrolled in the program. The local programs offered home visits to a family from pregnancy through the focal child’s second birthday (17 studies). Home visitors also offered program participants developmental screenings and transportation to and from appointments (two studies). The programs offered home visits 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 (15 studies). The frequency of visits could be adapted to meet family needs (seven studies).

Nurses assessed maternal, child, and family functioning as they related to pregnancy and infant and toddler development (four 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 sought 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 participating in the workforce.

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. The program provided women assigned to the paraprofessional group screening and referral services plus paraprofessional home visitation during pregnancy and infancy (the first two years of the children’s life). It offered women in the nurse group screening and referral plus nurse home visitation during pregnancy and infancy. In these studies, the paraprofessionals received additional supervision. 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 21.0 visits from birth to the child’s second birthday. These services contrasted with services provided by paraprofessionals, who completed an average of 6.3 home visits during pregnancy and 16.0 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 received training 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 and Prevention, 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 starting conversations with families about their ambivalence toward participating 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 NSO training process has incorporated the retention guidelines.

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

One study identified five attendance patterns: (1) 22 percent of participants attended consistently (average of 51 visits); (2) 9 percent attended inconsistently, participating in 41 to 80 percent of recommended visits (average of 36 visits); (3) 15 percent dropped out late in the program and attended fewer than 20 percent of recommended visits between 15 and 24 months (average of 35 visits); (4) participation gradually declined for 27 percent of participants, with few visits after 12 months (average of 19 visits); and (5) 28 percent dropped out early (average of 7 visits). Across attendance patterns, the average number of visits was 26.

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

Several lessons about implementation related to fidelity, training, attrition, nurse support, and program sustainability emerged (13 studies).

Lessons related to fidelity (three studies) included the following:

• Programs should encourage nurses to spend equal time on all aspects of the 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 training (three studies) included the following:

• Nurses’ training should emphasize the importance of using a flexible approach to applying the NFP model to enable nurses to individualize services for families (one study).
• To address high participant attrition, training on motivational interviewing (one study) and how to identify and address families’ barriers to engagement is important (one study).

Lessons related to participants’ attrition included the following:

• Adapting the program to the participants’ needs and goals and addressing their specific concerns about pregnancy and parenting might facilitate retention (six studies). Nurses need support individualizing the program for families (three studies).
• Reassessing mothers’ needs during the program and discussing the relevance of future visits might help prevent attrition (three studies).
• Developing a strong therapeutic relationship with participants is also important for preventing attrition (four studies). Common strategies for establishing trust included assuring participants the information they shared was confidential (two studies), 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 could help improve retention. Increased outreach to mothers who drop out might facilitate reengagement (one study).
• To address problems related to external distractions such as unstable or crowded housing, meeting in another location might help to bridge a time of housing instability. It could also improve the visit’s focus and communication compared to a visit in a crowded home (two studies).
• Developing maternal organizational and communication skills early in the program might help mothers manage visit appointments and consistently engage them (one study).

Two studies 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 (one study).
• 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 (one study).
• When a program serves traumatized populations, such as victims of intimate partner violence, the program should acknowledge and address the added potential for nurse stress and burnout (one study). Researchers recommended that programs establish mechanisms to limit organizational contributors to stress, including limiting paperwork (one study). In addition, the program should prioritize nurses’ safety through ongoing training on safety protocols (one study).

The following lessons apply to model replication and 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.
• A key to successfully implementing a local NFP program is ensuring the program is integrated in the community. The local NFP program should collaborate with other community providers and establish a mutually beneficial referral system.
• Each site choosing to implement NFP needs the capacity to operate and sustain the program. These capacities include having a supportive organization and community, a well-trained and supported staff, 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 to grow and then maintain an NFP program site.
• Some families might be more invested than others in the program, which can lead to some variation in the number and length of the visits they receive.