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Nurse-Family Partnership

Blueprints Program Rating: Model

A nurse home visiting program for first-time pregnant mothers that sends nurses to work one-on-one with the pregnant women to improve prenatal and child rearing practices through the child’s second birthday.

Program Outcomes

  • Child Maltreatment
  • Delinquency and Criminal Behavior
  • Early Cognitive Development
  • Internalizing
  • Mental Health - Other
  • Physical Health and Well-Being
  • Preschool Communication/Language Development
  • Reciprocal Parent-Child Warmth

Program Type

  • Home Visitation
  • Parent Training

Program Setting

  • Home

Continuum of Intervention

  • Selective Prevention (Elevated Risk)

Age

  • Infant (0-2)

Gender

  • Female only

Race/Ethnicity

  • All Race/Ethnicity

Endorsements

  • Blueprints: Model
  • Coalition for Evidence-Based Policy: Top Tier
  • Crime Solutions: Effective
  • OJJDP Model Programs: Effective
  • SAMHSA: 3.2-3.5

Program Information Contact

Nurse-Family Partnership National Service Office
1900 Grant Street, Suite 400
Denver, Colorado 80203
Direct phone: 303-327-4240
Toll free: 866-864-5226
Fax: 303-327-4260
email: info@nursefamilypartnership.org
www.nursefamilypartnership.org/

Program Developer/Owner

  • David L. Olds, Ph.D.
  • University of Colorado Health Sciences Center

Brief Description of the Program

Nurse-Family Partnership begins during pregnancy as early as is possible and continues through the child's second birthday. Nurses work with low-income pregnant mothers bearing their first child to improve the outcomes of pregnancy, improve infant health and development, and improve the mother's own personal life-course development through instruction and observation during home visits. These visits generally occur every other week and last 60-90 minutes.

Specific objectives include improving women's diets; helping women monitor their weight gain and eliminate the use of cigarettes, alcohol, and drugs; teaching parents to identify the signs of pregnancy complication; encouraging regular rest, appropriate exercise, and good personal hygiene related to obstetrical health; and preparing parents for labor, delivery, and early care of the newborn.

The Dutch study (Mejdoubi et al., 2013) adapted the program for Dutch women and their health care system. The most important adaptations included placing more emphasis on home delivery, instructing women to stop smoking during pregnancy, and offering more information about the advantages of breastfeeding. Similarly, a German adaptation of the program (Sierau et al., 2016) used social workers or midwives rather than nurses as home visitors. It also used a German developmental screening instrument and provided information on well-child check-ups.

Robling et al. (2015) adapted the program for use in a publicly funded healthcare system in England. In this context, mothers have access to publicly funded health and social care, including universally offered screening, education, immunization, and support from birth to the child’s second birthday. The FNP program also provides an assigned family nurse, who makes up to 64 home visits, while other mothers receive care as needed from a specialist community public health nurse.

See: Full Description

Outcomes

The three studies of pregnant women and their children – Elmira, Memphis, and Denver – found intervention-group improvements relative to the control group in the following areas:

Mother (Elmira, Memphis, Denver)

  • Unintended subsequent pregnancies, and the interval between first and second births
  • Domestic violence among married or cohabiting women
  • Maternal employment and use of welfare and food stamps

Infants and Young Children (Elmira, Memphis, Denver)

  • Health-care visits and hospitalization for injuries and illnesses
  • Emotional vulnerability, particularly among children born to mothers with low psychological resources
  • Language and mental development, particularly among children born to mothers with low psychological resources
  • Child abuse and neglect, and behavioral problems caused by use of alcohol or drugs (seen in mothers at 15- and 19-year follow-up in Elmira)

6-to-12-Year Follow-up (Memphis)

  • Intellectual functioning and receptive language
  • Behavioral problems at age 6
  • Relationship quality of mothers with current partners
  • Children's use of substances and internalizing mental health problems at age 12

15-year and 19-Year Follow-up (Elmira)

  • Among children, arrests and convictions

Significant Program Effects on Risk and Protective Factors

  • Prenatal health, such as hypertension and use of cigarettes
  • Responsive interactions with child
  • Parent social support (Elmira)

Netherlands Study (Mejdoubi et al., 2013, 2014)

  • Significant program effects on cigarette smoking, psychological aggression, physical assault, sexual coercion, injury, and combined forms of intimate partner violence. No effects on pregnancy outcomes, such as birthweight.

England Study (Robling et al., 2015)

  • No significant positive effects on 3 of 4 measures and one possible iatrogenic effect for emergency attendance or admission.

German Study (Sierau et al., 2016)

  • No significant positive effects on 7 measures of child development
  • Marginally significant effects on 2 of 8 measures of maternal competencies (parental self-efficacy and feelings of attachment)
  • Marginally significant effect on 1 of 5 measures of family environment (maternal stress)

Race/Ethnicity/Gender Details

The Elmira program consisted of a largely white population from the Appalachian region of New York. The Memphis and Denver programs, however, were designed to target low-income African American and Hispanic women, children, and their families living in major urban areas, respectively.

One Dutch study (Mejdoubi et al., 2013) included Surinamese, Turkish, and Moroccan women.

Risk and Protective Factors

Risk Factors
  • Individual: Stress
  • Family: Family conflict/violence*, Family history of problem behavior, Household adults involved in antisocial behavior*, Lack of prenatal care*, Low parental education, Low socioeconomic status*, Mother substance use during pregnancy*, Neglectful parenting*, Parent history of mental health difficulties, Parent stress, Parental attitudes favorable to antisocial behavior, Parental attitudes favorable to drug use, Parental unemployment*, Poor family management, Psychological aggression/discipline, Unplanned pregnancy*, Violent discipline
Protective Factors
  • Family: Attachment to parents*, Breastfeeding*, Non-violent discipline, Opportunities for prosocial involvement with parents, Parent social support*, Rewards for prosocial involvement with parents

*Risk/Protective Factor was significantly impacted by the program.

See also: Nurse-Family Partnership Logic Model (PDF)

Training and Technical Assistance

Training of Staff

Training begins with the initial one-week session for the nurse home visitors and their supervisor, offered by the staff of the PRC in Denver, Colorado. This session is followed by a three-day and two-day follow-up training offered on site at times that coincide with the nurses' need to begin using the infancy and then toddler protocols with families. In addition to the group training sessions, the PRC staff are available for technical assistance by phone as needed.

The first training session is offered prior to the initiation of the program. It covers:

  • the history of the program
  • the research evidence to support its efficacy
  • the theoretical and clinical foundations of the program
  • the principles of forming effective therapeutic relationships with family members
  • solution focused therapies
  • understanding women's stages of readiness for change
  • issues related to ethnic and racial diversity
  • the prenatal content
  • safety issues related to home visiting
  • the program protocols
  • the record keeping system

The second and third training sessions reinforce the theories and clinical strategies introduced in the first session, cover the content of the infancy and toddler programs, train nurses in the P.I.P.E. program, and review selected cases that have been served in the program to date with the entire staff to ensure fidelity of program implementation.

Training Certification Process

Nurse-Family Partnership Supervisor Initial Education Units:

  • Supervisor Unit One: All new, expansion and replacement supervisors are required to complete the five distance education lessons in this course prior to attending Supervisor Unit Two. Each lesson takes approximately 20 to 30 minutes to complete. The lessons are designed to orient a supervisor to her/his role and responsibilities in the Nurse-Family Partnership program and concentrate on program logistics, including agency setup, documentation, referrals, and hiring nursing staff. Supervisors access this course by logging in to the online Tracker system http://training.nursefamilypartnership.org/Tracker3/. You will be asked to reset your password the first time you login to Tracker. You may use the same password for both the NFP Community and Tracker.
  • Unit Two: see description under Unit 2 below.
  • Supervisor Unit Three: This distance education session focuses on Nurse-Family Partnership implementation issues, provides the supervisor with support in assessing the quality of nursing practice and implementation, and supports the professional development of nurse home visitors. A lesson is included to help supervisors learn how to connect with their community to sustain and grow their program. Supervisors access this course by logging in to the online Tracker system http://training.nursefamilypartnership.org/Tracker3/. You will be asked to reset your password the first time you login to Tracker. You may use the same password for both the NFP Community and Tracker.
  • Supervisor Unit Four: This face-to-face three-day session occurs approximately 4-6 months after completion of Unit Two. The session again focuses on the Nurse-Family Partnership model to promote supervisor skills around teambuilding and job stress and burnout. It also builds on reflection and motivational interviewing skills learned in earlier sessions. All new, expansion, and replacement supervisors are required to attend.

Nurse-Family Partnership Initial Education Units:

  • Unit One: The goal of Unit One is to equip newly hired nurses and supervisors with foundational knowledge of Nurse-Family Partnership and the home visiting intervention. This distance education session is completed prior to Unit Two. Unit One is comprised of three components: completion of the Unit One workbook and online self-assessment; completion of the Partners in Parenting Education (PIPE) self-study workbook and online assessment; submission of the PIPE lesson plan; and completion of the online lesson using the NFP Visit-to-Visit Guidelines. Nurse home visitors and supervisors access this course by logging in to the online Tracker system http://training.nursefamilypartnership.org/Tracker3/. You will be asked to reset your password the first time you login to Tracker. You may use the same password for both the NFP Community and Tracker.
  • Unit One workbook: Completion of Unit One and the PIPE assessments and submission of the PIPE lesson plan are prerequisites to attending the face-to-face Unit Two session. All new, expansion, and replacement nurse home visitors and supervisors are required to complete the Unit One workbook and corresponding assessment. Anticipate spending approximately 25 hours on this self-study module.
  • Unit Two: This face-to-face session takes place from Monday afternoon through Friday, and is required for all new, expansion, and replacement Nurse-Family Partnership Nurse Home Visitors and Supervisors. The goal of Unit Two is to build on the foundation provided in Unit One and prepare new nurses to implement the intervention with fidelity to the Nurse-Family Partnership model. Unit Two provides interactive learning where nurse home visitors receive instruction and assistance to begin applying information and building skills in the Nurse-Family Partnership intervention. NFP Model diagram http://community.nursefamilypartnership.org/assets/PDF/prof_dev/Training/NFP_Model_Diagram.
  • Unit Three: Building on Units One and Two, the goal of Unit Three is to provide nurses an opportunity to deepen their understanding of the Nurse-Family Partnership model, specifically in regards to infant temperament, motivational interviewing, and fidelity to the Nurse-Family Partnership Model Elements. Following Unit Two, you will consult with your supervisor regarding the best time to start the Unit Three distance lessons. The distance lessons will take approximately one to two hours per month over a six-month time frame. Nurse home visitors and supervisors access this course by logging in to the online Tracker system http://training.nursefamilypartnership.org/Tracker3/.

National Education Symposium:

The NFP National Education Symposium is for all Supervisors, Nurse Consultants and Administrators. For more information, click here http://community.nursefamilypartnership.org/Nursing-Education/National-Education-Symposium.

Brief Evaluation Methodology

Three major studies done in Elmira, New York, Memphis, Tennessee, and Denver, Colorado, used similar designs. Each study recruited women who were pregnant for the first time and faced special risks such as low income, teen pregnancy, or single parenthood. Investigators randomly assigned the women to the Nurse-Family Partnership or control conditions. Follow-up assessments done after the two-year program measured a variety of outcomes for the mothers and their children.

The Elmira study used data from 400 pregnant women who were recruited in 1978 from clinics in a rural Appalachian area of New York State with a largely white population. The study included 15-year and 19-year follow-ups, with about 310 adolescent children participating.

The Memphis study began in 1990 and obtained data from a sample of 743 pregnant, mostly black women. A variety of measures for the mother and child were obtained at 3 years, 9 years, and 12 years after the birth. At the 12-year follow-up, 613 first-born children of the 743 randomized women were studied.

The Denver study, which began in 1994, obtained data on a sample of 735 pregnant, mostly Hispanic and white women. Unlike the other studies, this one randomized women to two intervention conditions, one using nurses and one using paraprofessionals, and to one control condition. Posttest and two-year follow-up assessments were done for 86% of randomized mothers and 82% of the children.

A replication study of Dutch women (Mejdoubi et al., 2013) examined intimate partner violence using a randomized controlled trial and longitudinal data through 2 years after the child’s birth. The sample had 460 women at baseline but attrition reached 42% by posttest.

In a study completed in England (Robling et al., 2015), first time mothers aged 19 or younger were recruited from local maternity services. A total of 1,645 women were assigned randomly. The treatment group received screening, education, immunization, and support from birth to the child’s second birthday from an assigned family nurse, while control mothers received usual care from a specialist community public health nurse. The study measured the program’s effect on mother’s smoking at late pregnancy, additional pregnancies within 24 months after birth, child’s birth weight, and child’s emergency attendance or admission within 24 hours of birth.

A study conducted in Germany (Sierau et al., 2016) included 755 low SES mothers with at least one social risk factor, such as low education or experience of violence. All recruited women were volunteers and were randomly assigned, after being stratified by site, age, and nationality, to either the treatment or control groups. The study measured the program’s effect on the family environment, maternal competencies, and child development.

Peer Implementation Sites

For Information on Peer Sites, Contact:
Michelle Neal, MS, RN
Colorado Program Director, Nurse-Family Partnership
1775 Sherman Street, Suite 2075
Denver, CO 80203
303.839.1808 ext. 101
mneal@iik.org

References

Eckenrode, J., Campa, M., Luckey, D. W., Henderson, C. R., Cole, R., Kitzman, H., ... Olds, D. (2010). Long-term effects of prenatal and infancy nurse home visitation on the life course of youths: 19-year follow-up of a randomized trial. Archives of Pediatrics & Adolescent Medicine, 164, 9-15.

Kitzman, H., Olds, D. L., Cole, R. E., Hanks, C. A., Anson, E. A., Arcoleo, K. J., ... Holmberg, J. R. (2010). Enduring effects of prenatal and infancy home visiting by nurses on children: Follow-up of a randomized trial among children at age 12 years. Archives of Pediatrics & Adolescent Medicine, 164(5), 412-418.

Kitzman, H., Olds, D. L., Henderson, C. R., Hanks, C., Cole, R., Tatelbaum, R., ... Barnard, K. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. Journal of the American Medical Association278(8), 644-652.

Mejdoubi, J., van den Heijkant, S. C. C. M., van Leerdam, F. K. M., Heymans, M. W., Hirasing, R. A., & Crijnen, A. A. M. (2013). Effect of nurse home visits vs. usual care on reducing intimate partner violence in young high-risk pregnant women: A randomized controlled trial. PLOS One. DOI: 10.1371/journal.pone.007818.

Mejdoubi, J., van den Heijkant, S. C. C. M., van Leerdam, F. K. M., Crone, M., Crijnen, A., & Hirasing, R. A. (2014). Effects of nurse home visitation on cigarette smoking, pregnancy outcomes and breastfeeding: A randomized controlled trial. Midwifery 30, 688-695.

Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R., ... Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: 15-year follow-up of a randomized trial. Journal of the American Medical Association278(8), 637-643.

Olds, D. L., Henderson, C. R., Cole, R., Eckenrode, J., Kitzman, H., Luckey, D., ... Powers, J. (1998). Long-term effects of nurse home visitation on children's criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. Journal of the American Medical Association, 280(14),1238-1244.

Olds, D. L., Henderson, C. R., & Kitzman, H. (1994). Does prenatal and infancy nurse home visitation have enduring effects on qualities of parental caregiving and child health at 25 to 50 months? Pediatrics, 93, 89-98.

Olds, D. L., Henderson, C. R., Chamberlin, R., & Tatelbaum, R. (1986). Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics, 78, 65-78.

Olds, D. L., Henderson, C. R., Tatelbaum, R., & Chamberlin, R. (1986). Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics, 77,16-28.

Olds, D. L., Kitzman, H., Cole, R., Hanks, C., Arcoleo, K., Anson, E., ... Stevenson, A. (2010). Enduring effects of prenatal and infancy home visiting by nurses on maternal life course and government spending: Follow-up of a randomized trial among children at age 12 years. Archives of Pediatrics & Adolescent Medicine, 164(5), 419-424.

Olds, D. L., Kitzman, H., Cole, R., Robinson, J., Sidora, K., Luckey, D. W., ... Holmberg, J. (2004). Effects of nurse home visiting on maternal life course and child development: Age 6 follow-up results of a randomized trial. Pediatrics, 114, 1550-1559.

Olds, D. L., Kitzman, H., Hanks, C., Cole, R., Anson, E., Sidora-Arcoleo, K., ... Bondy, J. (2007). Effects of Nurse Home Visiting on maternal and child functioning: Age 9 follow-up of a randomized trial. Pediatrics, 120, 832-845.

Olds, D. L., Kitzman, H., Knudtson, M. D., & Anson, E. (2014). Effect of home visiting by nurses on maternal and child mortality: Results of a 2-decade follow-up of a randomized clinical trial. JAMA, 472, E1-E7. Published online July 7, 2014.

Olds, D. L., Robinson, J., O'Brien, R., Luckey, D. W., Pettitt, L. M., Henderson, C. R., ... Talmi, A. (2002). Home visiting by paraprofessionals and by nurses: A randomized, controlled trial. Pediatrics, 110, 486-496.

Olds, D. L., Robinson, J., Pettitt, L., Luckey, D. W., Holmberg, J., Ng, R. K., ... Henderson Jr., C. R. (2004). Effects of home visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial. Pediatrics, 114, 1560-1568.

Robling, M., Bekkers, M.-J., Bell, K., Butler, C. C., Cannings-John, R., Channon, S., ... Torgerson, D. (2015). Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): A pragmatic randomized controlled trial. The Lancet,  published online 14 October 2015.

Sierau, S., Dähne, V., Brand, T., Kurtz, V., von Klitzing, K., & Jungmann, T. (2016). Effects of home visitation on maternal competencies, family environment, and child development: A randomized controlled trial. Prevention Science, 17,  40-51.