(with apologies to Shakespeare)

Calls to improve the quality of care in the NHS and social care are getting louder. The events at Mid-Staffs and Winterbourne View has shocked us all. The announcement on nursing by the Prime Minister  reflects this concern and is stimulating nursing a debate about why nursing care is not what it should be – and not what it once was.  Policy documents are heavy with rhetoric and exhortation to improve quality, dignity and respect, using language that can sound well worn and weary.

We could start with understanding empathy better. In his lecture at the RSA  Prof Simon Baron Cohen defines empathy as ‘our ability to identify what someone else is thinking or feeling, and to respond to their thoughts and feelings with an appropriate emotion.’ Empathy is being mindful of others and lies at the heart of one person caring for another, as a parent, a nurse, a doctor or social worker. Where does empathy come from? Do we all have the same amount? Can we have too much? Neuro-psychology suggests that our potential to be empathic comes from our experience of early life when early relationships set the pattern for later life. There are other factors as well. It would seem that females score higher on empathy ratings than males and that genes, social and cultural factors have a part to play as well.

Understanding empathy offers us a way of improving care by ourselves for each other and for patients and clients. The Family Nurse Partnership has given us a programme with many of the elements needed to understand, realise and harness empathy for the good of others and to enable new parents to develop their own and their children’s empathy, often breaking intergenerational patterns of behaviour.  Family nurses are selected for their ability to feel empathy and we find that clients on interview panels are skilled at picking nurses who are warm and empathic. FNP training and supervision equips practitioners to understand their feelings and behaviours as well as those of their clients.

Empathy is not an easy emotion, it can be painful to engage with the feelings of others, especially a neglected baby, and a skilled practitioner is one who is not overwhelmed by the distress of others and can simultaneously be objective and stand back whilst doing deep and skilled relational work.

Finally, lack of empathy isn’t only a problem of other people. What are our own empathy scores?  We need empathic role models to create a culture of high quality care at every level of the system. How empathic are our organisations, our leaders, managers, commissioners and colleagues? It is harder to feel empathic and care well for patients if we feel that our organisation and seniors are uncaring, critical and disrespectful.

If you are interested in understanding empathy and its role in human behaviour Prof Baron-Cohen’s lecture is a good beginning

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Alongside health visitors, GPs, midwives, district nurses and other important community services, FNP teams are working in communities torn apart by the recent riots.  The intensity and depth of the family nurse’s work with vulnerable teenage parents and their babies gives us a perspective and reality check of what life can be like on the edge of society and, importantly, how FNP can make a difference to these young people and their children’s futures. 

A recent discussion with some of the FNP supervisors revealed what it can be like to be a young parent in these communities. ‘What we see is a normalisation of violence where young people feel they have nothing to loose.” and where some young people have no regard for the consequences of their actions.  “Family Nurses work with many clients who witness extreme violence and ‘live on the edge’ with chaotic lifestyles, frequently changing telephone numbers, not knowing what they are doing from one day to the next, distrusting professionals and services.”  “Some young mothers and fathers need to project a tough and hard image as a means of self-preservation as any signs of weakness are exploited and picked on.”

FNP also tells us another story. Of how a young mother’s love of her baby can activate her protective instincts, how FNP helps them to see their environment as important for their child – to keep their baby safe.  FNP builds their aspirations for themselves and their baby, it teaches self-regulation for their child and for themselves and models a different way of relating to each other.  For young men who are so often left on the periphery – “FNP brings them in”.

“FNP can develop skills in our parents to set limits and parent with confidence and authority”

FNP is only one solution, there are many more.  FNP clients are first time mothers starting out with potential.  Whilst rioters are being punished and ‘troubled families’ are singled out for help, FNP clients are made to  ‘feel special’ by being on the programme and this is a powerful motivation to trust the programme and be open to learn and change.

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The NHS is also an enduring pillar in our society bringing security, trust and a sense of community. The NHS is there for us when we are at our most vulnerable, it signals equality and respect for each individual. When other national institutions are found wanting, the NHS becomes even more important as a symbolic national brand representing security and stability. It is therefore unsurprising that change is perceived as a threat to ‘our NHS’ prompting public reaction. This is why the listening exercise was so important and taken seriously by the coalition Government and others.

So trusting the NHS is more important than ever. But trust is always contingent and has to be continually earned, in every contact, every conversation and every act of kindness and touch. This comes from our lived experience of the local service and individuals who work in it, rather than national pronouncements. The NHS is a national unifying brand, which is experienced through local personal and family care – this is where trust is built.

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Today over 7,000 families have benefited from the programme in 54 sites across England with Scotland and Northern Ireland well underway with their first teams. We are beginning our fifth wave of new sites, strongly supported by the Government’s commitment to double capacity by 2015.

We have had many gifts of learning and the programme has had a significant influence on children’s services, some of the language has changed, new ways of working are being picked up by others and we know a lot more about what it takes to help some of our most disadvantaged parents to care well for their children and themselves. We have also learnt about the science of replication and how to take an evidence based programme developed in the US towards scale in this country.

We owe much to the expertise of the family nurses and supervisors whose skilful practice, courage and commitment to the programme and their clients has ensured the high quality delivery of the programme and high levels of client engagement.

It has taken a lot of hard work getting here. Our public services can be a harsh environment for a new programme. As we enter the next phase, no longer testing but still learning, some success factors stand out. Firstly, the strength of the programme itself. FNP makes sense to those delivering it and those receiving it. Both clients and family nurses see change taking place and the programme’s connection with parent’s motivation to care well for their children is a motivation for us all. The link between theory, evidence, training and practice gives us a coherent model supported by high quality materials refined over 30 years. Secondly, FNP gives us a response to the emerging science on early childhood development. Nationally and internationally early years services are being shaped by this science and FNP gives us a proven way of tackling some of those enduring problems in families that have seemed intractable in the past.

As we move forward I hope that we will continue to take our time, learn well and provide the expert practitioners we have in this country, including those in wider universal services, with support to do a job that so many of them aspire to do.

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Four years on, we are thinking about what FNP has to offer more widely and its potential to benefit a wider range of children and families. At a meeting of FNP supervisors recently, thanks to their thoughtfulness and wisdom, we came up with some ideas about how best to share the learning. As well as respecting the license and its underpinning research the following suggestions may resonate with anyone involved in innovation and working in new ways.

Firstly, allow time to learn. As a family nurse said when asked by a director to share the learning after the first year ‘how can I share what I haven’t yet learnt?’ It takes at least two years to learn how to deliver FNP and probably another 2 years to really understand how to deliver it well. This is not surprising given the estimate that it takes 10,000 hours (3 hours a day for 10 years) to learn a craft[1].

Secondly, will it make a difference to children and families and deliver better outcomes? The evidence base for FNP may be strong but that doesn’t means that taking aspects from the programme and applying them more widely will benefit children and families.

Thirdly, what are we expecting others to do with this learning? To train all staff in a new way of working, for example motivational interviewing, without providing them with tools and materials, and a system that is motivating can increase dissatisfaction and frustration rather than helping them to work more effectively.

Finally, every minute a professional spends with a family is precious, every contact matters and if their time is being taken up training others this is time not spent making a difference for vulnerable children.

None of this means that we should not share learning -  far from it, but we need to approach this with thought and make sure that:

• It forms part of a wider development programme for evidence based service improvement
• Learning is focused on changing systems as well as practice
• We recognise that learning happens organically through personal relationships and by people working together, respecting each other and seeing the work in action
• We understand the world of the recipient and make any learning connect with and enrich their role

This is why the FNP National Unit has focused on the systematic development of products for the Healthy Child Programme as a whole that draw on the learning from FNP, such as a framework for Preparation for Parenthood and PREview – both of which should be available over the next few months.

In a world of hares we may have chosen to be tortoises but this may just get us to where we need to be.

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Management is important and some would argue that doctors would benefit from more of it. Nonetheless, we need to create the environment and space for nurses who want to be involved in commissioning, leadership, management whilst remaining in clinical practice. The Family Nurse Partnership programme has learnt a lot from the supervisor role. FNP supervisors have to practice clinically and keep a caseload of families. At the same time, they are responsible for clinical and safeguarding supervision of the nurses in their team, for managing and quality assuring the work, supporting team learning as well as engaging colleagues and ensuring the systems are in place for delivery of the programme locally. A tall order no doubt, but one that FNP supervisors are showing can be done – with training, support and a good service model to focus on.

This system still needs local clinical leaders but with a different role from before. We need people who are experts in their field, in our case prevention and early childhood development, who understand evidence based practice and replication, with a good understanding of how to use data and outcome measures and who can mirror the ethos of FNP in their relationships and behaviours. It seems to me that key in this is staying close to communities, clients and practice. Perhaps credible and applied clinical leadership comes from being only 1 or, at a maximum, 2 handshakes away from clients/patients as well as 1 or 2 handshakes away from decision making. Otherwise, how can we ever make sure that ‘no decision about me, without me’ happens?

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In his RSA paper ‘N squared’  , Paul Ormerod shows how powerful social networks are in influencing choices and behaviours from binge drinking to overeating. This presents a challenge to those concerned with public health,  but understanding how behaviour is contagious has other implications too. 

How we are treated affects how we behave towards others – even when we try hard not to pass the feelings on. When a manager or commissioner (or politician) questions the value of your work or shows a lack of understanding or commitment to your service,  this can be passed on to your patients/clients who in turn pick up a lack of commitment to them. We know from FNP that when an organisation lacks understanding and commitment to the programme, the rates of attrition of parents and the turnover of nurses goes up reducing the benefits to children and families.  This may happen unconsciously as the family nurses work hard to protect their clients from organisational uncertainties.

The emotional commitment that practitioners make to their patients is a hallmark of good relational care, and for the most vulnerable, this is especially true. If negativity in the system is contagious and impacts on health outcomes down the line, so then are positive behaviours. Valuing professionals, understanding the complexity and emotional demands of their work and being authentically committed is one way in which those of us who stand behind the front line have a direct impact on outcomes.

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One of the best parts of my job is to visit the FNP sites and meet the families who are receiving the programme. These are teenage mothers and fathers with their babies. Life has often been hard for them and their own troubled beginnings will have made it more difficult for them to provide the good parenting that their baby needs in the womb and during early life. At every visit I hear and see something new.

Recently I met a young father in one of the northern FNP sites who, when I asked him what he had got from the FNP, said that ‘FNP had brought peace to our house – because we know that our baby needs a peaceful home.’

Whether or not you find this moving will depend on many things, but all of us round that table were deeply moved. This young father connected with our inner feelings about childhood, parenthood and being human. He also articulated something new about the programme and about what we are all trying to achieve. To provide a peaceful home for a child in their most formative years is an important gift and one than many children still do not receive. As a society we need to wake up and acknowledge how important it is not to get it wrong for babies.

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In FNP we have a programme that we know will improve the life chances of a child and its family, so we all want to make sure that this mother engages with the programme. Giving up after three ‘no access’ visits would once again leave behind those who need our services most.

Imagine that you are 17 years old and expecting a baby. You have been in and out of care and most of your relationships with adults have been abusive. You are distrustful of professionals and services as you think, like your teachers, they see you as a failure. You feel angry and frightened about becoming a mother and every time you go to antenatal clinic you get asked about smoking. So, when a health professional comes to see you trying to build a relationship with you, all your natural defences come into operation and you run away or stand and fight.

In these circumstances, the family nurse needs to use all her skills to engage this vulnerable young mother. This requires her to be tenacious and resilient – being told to ‘F***off’ or being ‘dumped by text’ and not taking it personally, as well as coming back for more. Never giving up on this young client – like everyone else has done before. The family nurses need to find the one thing that will connect with this girl’s strengths and her intrinsic motivation to protect and care well for her baby and show emotional commitment by standing by her – ‘I will be with you until your baby is 2 years old.’ Family nurses consciously role model a positive and committed relationship, understanding the meaning behind the rejections and testing that comes their way. The client may be thinking, ‘If I don’t turn up will my nurse still care?’. A DNA does not mean that nothing is happening – a relational process is being played out that needs to be attended to.

If it takes 10 DNAs and on the 11th this young mother engages in the programme, then those 10 failed contacts were not a waste of time – in fact they were an important part of the engagement process. Professionals need to be able to exercise discretion when deciding how often to follow up a family, rather than having this laid down through management or commissioning rules.

As a young mother said in a text to her family nurse ‘You bug me because you care so much.’

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This is a tremendous vote of confidence for a new programme that, although it has a strong evidence base in the US, we really didn’t know if we could deliver in this country. It is a reflection of the high quality of our family nurses and the strength of the programme that we have this endorsement at this time.

Delivering this evidence based programme has brought its own particular challenges; replicating the programme with fidelity, learning a new way of working with some very high risk families and adapting the programme to this country.

There is a lot for us all to do over the next four years. We need to maintain the quality and make sure that more children benefit from the FNP and that the new systems support its long-term sustainability. At the same time, we need to remain cautious and continue to build the evidence base and find out more about the impact and cost benefits of the programme.

It is hard to scale up a new evidence based programme and to become accepted as part of ‘how we do things round here’ at this time. It will be a challenge, but one that I know the FNP National Unit, local leaders and fantastic family nurses and their clients will relish because they are already seeing the difference it is making.

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