In January 2012, the B.C. Government plans to launch the Nurse-Family Partnership program (NFP), a nurse home-visitation program offered to vulnerable, young, first-time mothers who have low incomes and are at an early stage in their pregnancy (28 weeks or earlier). (http://www2.news.gov.bc.ca/news_releases_2009-2013/2011HLTH0036-000672.htm). The program is based on compelling research evidence from US studies that demonstrates the importance of intensive nurse follow-up for high risk families.
As nurses, we should support the introduction of NFP as a key strategy that could expand the family-focused programs that currently exist in British Columbia. Unfortunately, B.C. health authorities have been instructed to implement this program without the benefit of new funding. As a result, public health nurses and families are very concerned that the program will replace existing family-focused services instead of complementing those already in place.
Currently, all families who have a newborn may access a visit from a public health nurse. The NFP program however, focuses only on high risk families. News about the potential loss of these universal visits has generated numerous calls and messages to the media over the past week. Parents have described their personal experiences during the first days at home with their infants and spoke of the tremendous value of home visits by public health nurses.
We do not know what the policy outcomes of implementing this program will be, but it will likely manifest in the loss or erosion of a universal family health promotion program that has for decades made a difference to the health of families in B.C.. With no new funding, valued public health nursing programs such as universal visits and follow up with new families will have to undergo cuts, likely with little input into policy decisions from the nurses who know their communities best.
Public health nurses recognize that any family whether deemed high risk or not, may face challenges that can only be identified during a trusting, intimate and knowledge-based post-natal visit. Families themselves cannot be asked to assess their own level of risk. For this reason, it is important that all families can access home visits – this has been shown to prevent problems such as post-natal depression and family violence.
Through post-natal home visits, public health nurses promote optimum health by linking families with a system of ongoing care through public health and other community resources. Public health programs are cost-effective as they receive less than five per cent of the total health budget, contributing to significant health outcomes that may not be immediately recognizable until they are no longer achieved and health data signifies that we have lost ground in child health or other family health outcomes. Despite their significant and cost effective contributions to population health, public health nursing programs have been disproportionately vulnerable to cuts over the years.
Our policy position is this -- Rather than insist the NFP be launched under the existing health authority budget, it should be allocated new resources so that the full range of existing programs and population health needs are not compromised by the addition of one new program.
Nurses must consider the evidence, ask critical questions and bring solutions to government and health authorities that clearly demonstrate how these policy decisions could impact the health of our population.
ARNBC wants to hear your views on this important topic. Please share your comments with us and your colleagues across the province.
Dr. Susan Duncan, Co-chair of the ARNBC, teaches at Thompson Rivers University in Kamloops and serves on the Board of Directors of the Canadian Association of Schools of Nursing.
There are a lot of stories in the media about this program right now, but this is one of the more clear explanations of what it is and why it could be a problem. I commend you for your balanced approach. I wonder where the voice of the 'experts' in psychiatry and psychology are in this discussion? We hear from the determinants of health sector that this is an important program for targeting high risk families, but I would like to hear from therapists who deal with mid and upper class families who have problems of abuse and alcoholism as well. You never know what's lurking below the surface of some families, and while it's true that the risk is higher for those who suffer from economical disparity, cutting off all programming seems like a bad idea. So a well-to-do woman whose husband is abusive no longer has the option of a nurse coming and recognizing the problem and intervening? Something the nurse might be trained to know and see? That option will be gone? What do we do about this then?
I am hopeful about the Nurse Family Partnership RCT being proposed by the Provincial Government. The program, to my understanding, provides frequent home visits by a Public Health Nurse to socially at risk mothers. As a frontline Public Health Nurse for over 10 years, I know that there is a need for extra service for these families.
However, like Dr. Duncan, I too am sad to see that the program it is coming (likely) at the expense of our universally offered home visiting program to new mothers.
For the past 15 years, hospital stays have shortened drastically, from an average 5-8 days to 12-48 hours after a normal birth. This has been a good change as most mother/baby pairs are healthy and to keep them in hospital is an unnecessary cost to our healthcare system. However, many significant physiological and psychological transitions are taking place in the postnatal period. For this reason the Canadian Pediatric Society recommends the newborn baby be evaluated 48 hrs after discharge. In most situations this is currently done by the Public Health Nurse.
Given all the changes that occur during birth it is easy to see that every first time mother/babe pair is at a “small risk” for potential problems. Commonly encountered issues in the immediate days after having a baby include: breastfeeding problems, significant newborn weight loss, postpartum depression and jaundice. The visiting RN is skilled in identifying and often preventing further problems, and refers for early treatment as necessary. Preventing problems and early intervention saves us all healthcare dollars.
Here's an example from my own practice: I recently spoke with a new mother on the phone who told me breastfeeding was going well and that she had no concerns. This was a married, educated mother in her 30’s who would not be identified in any way as “at risk”. When I came to the home I could see that baby was significantly yellow and dehydrated - a situation exactly as Dr. Duncan describes, families are often unable to accurately assess their own risk. Baby was referred for medical help and tested for jaundice and readmitted to hospital where he received treatment. Mother was supported to breastfeed both in hospital and in her home visits after discharge. This mother went on to nurse her baby successfully. It is important to note that this mother did not know that there was an issue with baby when I spoke with her on the phone. In this situation, our “universal home visiting” program averted the potential brain damage that can occur with severe jaundice. Hospitalization was relatively short because the jaundice was caught early. This mother went on to have a thriving breastfeeding relationship with her son. And since breastfeeding has well documented benefits for both mother and baby, our healthcare dollars are saved here too.
Situations like this are why universal home visits by a PHN, offered to all new mothers, are so vitally important and shouldn’t be at risk of being cut. We will not save more tax dollars if we are looking at longer hospital stays and/or an increasing readmission rate and length of stay because problems are missed when all that is offered these mothers is a phone call. Hospital care already represents the largest and most expensive place where our healthcare budget goes. When it's necessary to be hospitalized, great. Of the 16.6 billion dollars that our province spends on health care only 6% goes to all public health programming. Yet increasingly we know investing early saves us money. In a society that values mothers and babies, utilizing both universal public health strategies, for those at small risk, and intensive strategies, for those who are at high risk, are important.
Thank you to Dr. Duncan for her timely blog. I hope that the Association continues to aritculate concerns with these provincially mandated changes as I believe that there will be a negative effect on our families who may not qualify for a home visit with a nurse because the government has not provided new money for this program. The Family Partnership shouldn’t come at the expense of offering home visits to every new mother who needs it. All our mothers and babies are worth it.
This issue is also being addressed through the efforts of BCNU. BCNU has held press conferences and provided cards for Public health nurses to hand out to families who want to contact their local MLA and voice thier concerns.
I think words need to be paired with action.
So access the web page below and send a web letter to Premier Christy Clark outlining the concerns about cutting services in order to deliver this program.
I am a 4th year BSN student, who recently completed a practicum in a perinatal outreach program. This program addresses the nutritional, emotional, and educational needs of “high-risk” pregnant women until 6 months postpartum. The announcement of the roll-out of the NFP program and the simultaneous cuts to the universal postpartum visits has elicited much dialogue and concern regarding its implications.
A common question I have heard is in regards to the amount of consultation and community surveillance carried out before the decision was finalized. Were Public Health Nurses, managers, and the variety of pregnancy outreach programs operating in BC consulted with beforehand? From what I understand there was limited communication and consultation between stakeholders. Consequently, the decision carries an impression of being a “top-down” edict, thus creating suspicion and conflict between policy makers and frontline workers.
The NFP program has shown remarkable positive outcomes longitudinally in a variety of American sites. But these programs are all within the context of the American health care system, and most of which are within urban centers. The only (to my knowledge) other Canadian community to adopt the NFP is in Hamilton, Ontario, a site that has been running since 2008. Have three years in a single community provided sufficient data on the conversion of the NFP to a larger Canadian expanse? Does the US include similar no-cost prenatal and post-natal supports similar to those in BC?
I also wonder about the families who do not qualify for the NFP, but who are also not in communities that have ready access to pregnancy outreach programs and other postnatal supports (much like the pregnancy outreach program I held a practicum in). These isolated families who are limited in their understanding of what potential challenges to be aware of will no longer have those vital PHN visits.
This is a disappointing blow to the health promotion and disease prevention initiatives that are so important to the health and wellbeing of British Columbians. When will these interventions be given the same degree of importance as caring for our acutely ill in our hospitals?
Thank you, Dr. Duncan for highlighting the issues surrounding such an important topic in Public Heath Care in BC.
Hello Dr. Duncan,
I want to thank you for your blog post "Positioning the Nurse Family Partnership Program in BC - How can it be a win-win for optimum family health?".
I have been asking myself this same question.
I have watched Dr. Old's lecture at SFU earlier this year and the longitudinal research is impressive. Although I have strong doubts that the results of his "RCT" here will be as significant, because the Canadian milieu is not as impoverished as the American one, I am still confident that there will be benefit to those families who qualify and then receive the intervention. However, the real problem as you've outlined is that this "study" does to come with any additional funding. The means that something will have to give in public health in order to staff and support this program.
Anyways, like many nurses, I wear more than one hat. I work in public health and have done so for 3 different health regions. I am a breastfeeding volunteer in my community and a board certified lactation consultant.
My passion is breastfeeding support and advocacy, however, it is not to be the breastfeeding police in any way shape or form. I am proud to say that in my community I have earned a reputation among mothers for non-judgemental support of *their* goals. On community level I work to make space for breastfeeding, both literally and figuratively.
Good breastfeeding support means that all perinatal staff have solid, basic knowledge to keep things on track, some staff have expert knowledge when things go off track and a system that recognizes that there is a need for resources to make this happen. Making breastfeeding the easy choice (not the only choice) does not come without intention.
However, I am a staunch public health nurse, having worked in many areas of public health. I believe in our system and would like to see it strengthened.
I am unsure how to proceed. I don't want to see an erosion of other services and my bias is that I definitely don't to see an erosion in the support of mothers, breastfeeding or otherwise. From my own experience working with mothers I know that help offered in the home by a PHN is valued. And the literature indicates that home visiting after early discharge helps mothers' achieve their feeding goals and ensures safe care of the mother and babe.
I am deeply concerned that neither mothers' idea of what is needed in the postpartum nor the literature indicating best practices has been considered.
The Ministry of Health’s Core Public Health Functions include promotion and support for breastfeeding as part of their list of Reproductive Health strategies, but I don't read anywhere that there is additional resource allocation in this area. Additionally, Dr. Nasir Jetha has been on CBC radio talking about the increased length of stay likely to result if there are less PHN home visits.
Is there a possibility of a position statement from the Association of the Registered Nurse's of BC on a definition of and the evidence for support of breastfeeding?
Perhaps a collaboration with other stakeholders, BCMA, La Leche League Canada, BC Midwives?
And how do we ensure that the families receiving these services have their voices heard?
Other ideas or thoughts on how to ensure that we don't see an erosion in services in public health?
Thank you for this forum to discuss this change affecting public health.