My meeting with Maxine Cull, nurse supervisor of the Enfield team in Middlesex, enabled me to gain insight into the implementation of the FNP program in a local government area in the UK. With 5000 births a year, the size of the Borough is larger than, but comparable to Hume City. The social demographic of the Borough is similar to Hume City, with pockets of social advantage, and other areas with significant disadvantage and associated vulnerabilities.
The majority of referrals to the program come via the local maternity services, although as the program becomes more established, the number of self-referrals is increasing. The criteria for selection are that the woman must be under 20 years of age at her Last Menstrual Period (LMP), she must be a resident of the Borough, and it must be her first live birth. The team also worked closely with the Child Protection Services (safeguarding) in identifying those families that needed to have priority access.
Maxine described some of the tools and work structures used to support the nurses. To enhance security while doing home visits, the nurses use the “What’s App”messaging tool, which enables group chat, and also enables nurses to check in and out.
The nurses have a weekly team meeting, in one week the focus will be on team education and skill development, for example “saying goodbye, letting go”, and in the other week, the meeting will have more of a business focus. The nurses have a monthly 2-hour case presentation, and a monthly 2-hour group supervision session with a psychologist. In addition, each nurse has a weekly supervision session with the nurse supervisor. This intensive support for nurses is an integral part of the program, and many nurses speak about how well supported they feel by the program. In addition, the National Office provides support via education and resources. As one nurse said “You never stop learning in FNP.”
Once recruited, the nurses undertake an intensive initial education comprising a one week residential program. In the journey from novice to competent practitioner, they have 40 prescribed competencies to achieve, and nurses supervisors an additional 40 competencies. The first 18 months of practice is a steep learning curve for most nurses, as they work through each of the facilitators for the first time.
I was interested in the recruitment of nurses, and Maxine explained that when a site is created, the nurse supervisor is appointed first with the Quality Support Officer. The nurses are then recruited via a two stage interview process, one panel comprises the nurse supervisor and staff from the National Office and the Local Health Authority, and another panel comprising teen clients of the service. Maxine said that almost always the two panels coincided in their choice.
We discussed the workload of the nurses, and Maxine spoke how difficult it was to achieve and maintain a caseload of 25 clients, as prescribed by the program. I shared with her my knowledge of the Canadian nurses working conditions, where because of their shorter working hours and additional weeks of annual leave compared to US nurses, they aimed to achieve a caseload of 20 clients. The working conditions of UK nurses is comparable to the Canadian nurses, which would make a caseload of 25 clients unsustainable.
Later in the day, I attended the weekly meeting, and met the team of FNP nurses. They spoke about the facilitators (resources for the home visits) and the adaptations required for the local context. For example, the women may not know the same nursery rhymes, and brand or store-names needed to be made local, such as Tescos instead of Walmart, or Farex instead of Gerbers.
As for other teams I have met, I was impressed by the passion and commitment expressed by the nurses. One of the nurses said “This is the hardest job I have ever loved.” Another described the learning process when she first started as FNP nurse, that she had to “learn, re-learn, and un-learn” in order to engage with the partnership model. She described it as “the gift of the program”.