RNs Guiding At-Risk Pregnant Teens in California


RNs Guiding At-Risk Pregnant Teens in California

The Nurse Family Partnership Program

By Elizabeth Hanink, RN, BSN, PHN
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Eighteen, pregnant and still in high school, Angela (name changed for privacy) was also grappling with depression and a serious blood disorder. To make matters even more difficult, she lived in foster care. Angela found little support from the world around her, but, thanks to the Nurse Family Partnership, her story has a happy ending.    


The Nurse Family Partnership (NFP) evolved from a program first established in the early ‘70s by David Olds, Ph.D., a professor of pediatrics and nursing who realized that children born into poverty needed interventions even before birth.

NFP works with first-time mothers, most of them young and unmarried. Nurses visit clients at home at set intervals throughout the client’s pregnancy and for the first two years of the child’s life. During each visit, the nurses teach and model positive health-related behaviors and competent childcare while encouraging the mother’s own positive development, including education and employment.

The NFP program in Southern California was established in 1996 and now employs about 50 public health nurses, most of whom are based in the offices of the L.A. County Department of Public Health. There are several satellite offices, but the real work happens in the field. 


NFP is nurse-driven and client-centric. Each case is different and not all clients have the same needs. Naturally, the nurse’s first priority is crisis management and tackling any problems that may affect the baby’s health. For example, given how devastating fetal alcohol syndrome can be, one of the initial goals might be to get a client who drinks to give up alcohol at least during the pregnancy.

Other goals depend on each client’s specific situation. If mother and baby have a poor diet, the nurse can focus on teaching nutrition and meal planning. If the mother needs help maintaining her baby’s oral hygiene, the nurse can bring the “dental box” to the next visit. Nurses have been asked to do everything from finding books for a client to read to her child to supporting clients through labor and delivery.

Sometimes a client has needs the nurse can’t meet, requiring other professionals to intervene. Such situations emphasize the importance of trust between client and nurse. The nurse must connect with the client on several levels so that the client will open up about things like drug abuse or impulses to harm her child. Nurses must then act in ways that will safeguard both mother and child.

About 90 percent of NFP’s clients still live with one or more of their own parents, so the home visits often involve other family members, not just moms and babies. The babies’ fathers are sometimes involved as well, although earning their trust may require creativity. Maria Mejia, RN, MSN, supervisor of NFP’s Lancaster office, says one nurse — not a young one — eventually managed to establish a bond with her client’s suspicious boyfriend by riding her motorcycle to each visit.


One of the challenges of being an NFP nurse is working with each client’s individual strengths and limitations. That includes respecting that the client’s priorities may differ from the nurse’s. “You have to separate what you want for the client and what the client wants for herself,” says Mejia.

She recalls one client she thought had a real chance at obtaining a higher education. While the young woman seemed to want to go back to school, she instead went on to have several more children in quick succession. Mejia consoled herself with the thought that while the client might someday return to school, in the meantime she would be a better mother thanks to the NFP interventions.

Ultimately, NFP’s goal is not to change clients, but to support them and equip them to better care for themselves and their children. Evelyn Hines, RN, PHN, a staff nurse who works out of the California Hospital office, notes that success doesn’t have to be dramatic to be meaningful. “Even a 5 percent change in behaviors can make a difference. If we can get a mother to read to her child even 10 minutes every day, that is a success,” she says. “We are hoping that the seed that we planted stays and grows.”


While NFP is often able to make a real difference in clients’ lives, the success rate is not 100 percent. The nurses must learn to accept that outcomes are never certain, particularly in really tough situations like Angela’s. “Acceptance comes with experience,” says Hines.

Because the home visits require nurses to make themselves available in so many ways, supervision is handled differently than in other settings. Mejia and Jeanne Smart, RN, MSN, the NFP’s local director, describe it as “supporting the nurses.” Each nurse meets weekly with a supervisor and partners with a supervisor for a joint visit each quarter. Every other week, nurses have group meetings to “refuel and vent.”

Although the emotional toll this type of work can take on nurses is far from negligible, Smart says turnover is low. The nurses love what they do and the job offers the opportunity to see real progress. When a client achieves something positive like graduating from high school, the nurses “feel quite humbled.” The passion and dedication are impressive, as is Smart’s obvious pride in her nurses.


Clients are typically in the program for roughly three years, which costs NFP about $13,600 per client. That isn’t cheap, but NFP is another reminder that an ounce of prevention can be worth a pound of cure. Two long-term studies have correlated NFP interventions with a reduction in the mothers’ use of welfare and shown other significant, quantifiable benefits (see sidebar).

Of course, getting the funds to finance even proven social programs is often a struggle. NFP receives both public and private funding and competes for every dollar, resulting in what Smart calls “a constant scramble for money.” On occasion, NFP has resorted to ad hoc flower sales to raise money and nurses have even reached into their own pockets to provide items they felt clients needed.

Smart is also frustrated that not all county leaders appreciate the logic of meeting clients where they are. For example, it took seven years to get into the Los Angeles Unified School District despite the fact that most of NFP’s clients are between 15 and 17 years old. Smart’s exasperation with such resistance is palpable. “Why is this so hard to understand?” she laments.

Smart thinks officials simply don’t grasp the extent of the issues facing NFP’s clients, which may include serious mental illness (primarily depression) and learning disabilities in addition to an array of physical health problems. Many clients have faced domestic violence and others have been victims of human trafficking.

Despite the occasional recalcitrance of local officials, NFP has won widespread accolades. The organization was singled out in the New York Times bestseller The Way to Beat Poverty by Pulitzer Prize-winning authors Nicholas Kristof and Sheryl WuDunn. The Coalition of Evidence-Based Policy has cited NFP as a “Top-Tier” intervention that actually produces results. NFP has also earned the endorsement of the Center for High Impact Philanthropy.

A variety of other nations, including Canada, the Netherlands, England, Scotland, Northern Ireland and Australia, are now implementing the NFP model.


What does it take to be an NFP nurse? Hines and Mejia agree it is not necessary to have come out of poverty or have given birth as a young single woman to appreciate clients’ difficulties. In fact, Mejia says that many of NFP’s nurses come from backgrounds very different from the ones nurses confront on the job.

What is necessary is the ability to “walk gently,” as Smart puts it, while still functioning as a nurse. Flexibility is also paramount, as is being able (and willing) to use different skills at different times.

Another key attribute is perseverance — “doggedness,” in Smart’s words. A client’s situation may be very difficult and clients themselves can be frustrating at times, so it’s important that the nurse be able to respond constructively to setbacks.

Above all, nurses must be willing to work hard for the best possible outcome and go above and beyond to help clients, whether that means riding a motorcycle to appointments or selling flowers so a client can afford a new refrigerator or a prom dress.


The NFP nurse who worked with Angela was a self-described neophyte. “I had barely completed my Unit 2 Training as NFP Nurse in Denver, Colorado,” she recalls. “Excited and idealistic as a neophyte nurse home visitor, I armed myself with the fresh learning and training to achieve the NFP outcomes for my first-ever referral and enrollment.”

The nurse’s visits with Angela and her foster parents and doctors helped the teenager to develop her own strengths as an individual and mother and fulfill her various responsibilities. As Angela’s involvement with NFP comes to an end, her baby is thriving; Angela is out of foster care; and, thanks to grants and scholarships, she’s now in her second year of college.

“I would always hold her case close to my heart,” says her nurse, “because she has validated that a constant, reliable and honest presence can create a strong impact to inspire and motivate.”



An Ounce of Prevention

48% reduction in child abuse and neglect
59% reduction in arrests among children
72% fewer convictions of mothers
56% reduction in emergency room visits due to accidents and poisonings
67% reduction in behavioral and intellectual problems among children



The NFP Model

The Nurse Family Partnership’s work is based on several fundamental tenets:

Clients must:

  • Participate voluntarily
  • Enroll in the program early in their pregnancies
  • Be visited in their homes and establish a one-on-one relationship with the nurse.

Nurses must:

  • Be well-educated in NFP principles
  • Adhere to established guidelines, including the collection of data
  • Be part of a community-based organization that has a proven record of effectiveness.

The program also has stringent requirements regarding caseload (no more than 25 clients for each nurse at any one time) and definite expectations regarding the type of supervision and support given to nurses.

This article is from workingnurse.com.

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