1. Lewis, Jan MSN, RN


The author conducted a discussion with nurses participating in the Nurse-Family Partnership (NFP) in Colorado. The 10 attendees represented nine of the state's 18 NFP sites. Participants identified two elements that sustained their work: building relationships with clients and feeling they've made a difference in peoples' lives. The nurses also described it as "all-consuming" work that "never ends," and made recommendations for the retention of nurses in this important initiative.


Feedback from those working in the Nurse-Family Partnership may help retain nurses.


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Pulitzer Prize-winning author Katherine Boo observed Louisiana Nurse-Family Partnership (NFP) nurse Luwana Marts's interactions with clients for more than a year for an article published in the New Yorker.1 Boo said later that the success of the NFP "is inordinately dependent on whether nurses like Luwana stick around long enough to get good at this intense, ambitious work."2


The home visitation program serving first-time, low-income mothers is expected to expand, increasing the need for nurse home visitors. Research has detailed the initial challenges of implementing the NFP model,3, 4 but little has been written on how seasoned NFP nurses experience their work. (For more on the NFP model, see "The Nurse-Family Partnership," page 60, and Policy and Politics, page 73.) And while no studies on attrition among NFP nurses have been published, Colorado's rates reportedly are higher than the national rates: 35% of Colorado nurse home visitors leave the job within three years (compared with 27% nationwide), and 50% leave within five years (compared with 42% nationwide), according to unpublished data given to me in 2006 by the Nurse-Family Partnership National Service Office in Denver.


I decided to find out what sustains those who stay involved in the program. Fourteen Colorado nurses with four or more years of NFP experience were invited to participate in a retreat focused on improving nurse retention. Colorado NFP site supervisors were consulted on whom to invite to achieve diversity in age, ethnicity, and geography. I developed the agenda beforehand with several of the invited participants and facilitated the retreat.


Of the 14 invited nurses, 10 attended. Participants were from nine of the current 18 Colorado NFP sites; half were from urban sites and half from primarily rural areas. Three participants were serving as site supervisors while also carrying a partial caseload. (For more on the NFP in the state, see "The Initiative in Colorado," page 71.)


Ages of participants, all women, ranged from 34 to 60 years. Nine were non-Hispanic whites and one was Hispanic. Nine were married, and one was divorced. Nine held a bachelor of science as their highest degree in nursing, and one held a master of science in nursing. They had between 10 and 36 years' experience in nursing, with from four to five and one-quarter years of that with the NFP. Nine participants had experience in maternal-child health (mean, 13.7 years), eight in community health (mean, 10 years), and five in mental health (mean, 2.2 years).

Figure. Colorado NFP... - Click to enlarge in new windowFigure. Colorado NFP nurses converse during a break between retreat sessions. Discussion centered on how to sustain themselves in their work with the NFP; one nurse said, 'I offload personal and client stuff with coworkers so I can keep doing the work.'

The majority reported having a "very high" level of support for their NFP work from significant others. Four participants planned to stay in NFP work for at least five more years and five for two to five more years; one was "uncertain."


A month before the retreat, invitees received information on the purpose of and plan for the retreat, including an agenda setting out the following questions:


* What drew you to NFP work?


* What have you gained from NFP work?


* What keeps you going as you do NFP work?


* What aspects of NFP work get you down?



At the retreat, the nurses talked about what had attracted them to the NFP. Each completed a worksheet, answering the four questions provided earlier as well as a new one:


* What personal qualities and strengths have enabled you to persist in NFP work?



They then discussed their responses to the five questions as two volunteers and I recorded them. Finally, participants brainstormed ways to recruit and retain nurses for NFP work.



The following is a summary of the participants' responses to the worksheet questions.


What drew you to NFP work? A primary draw was participants' belief that the job offered autonomy, flexibility, and opportunities to develop long-term relationships with clients. Comments included "I get to see clients grow" and "I get away from Band-Aid nursing." Many also cited the appeal of the NFP model and their interest in working with young mothers and children.


What have you gained from NFP work? We saw two main rewards: participating in something of high value to society and growing personally and professionally. Comments on the value of the work included "seeing changes and knowing I made a difference," "impacting a child's life," "breaking negative generational cycles," and "modeling [to clients] a consistent, healthy relationship."


Nurses observed that


* their knowledge increased through NFP-specific and other continuing education.


* skills developed in working with clients often transferred to personal relationships. The examples given included improved conflict management ("I fight better with my husband"), problem solving, assertiveness, and self-care ("I have built better structures for emotional refueling").


* their attitudes shifted toward having greater tolerance and respect for cultural and other differences.



What personal qualities and strengths have enabled you to persist in NFP work? The responses reflected high levels of emotional intelligence (which involves sensing, assessing, and influencing one's emotions and those of others9). Among the specific strengths named were the following:


* good interpersonal skills (nurses described themselves variously as "warm," "nonjudgmental," "a good listener," "emotionally available," "reliable," and "flexible")


* the ability to maintain clear boundaries (being able to "say no" to clients when appropriate and to "balance clients' needs with personal needs")


* tenacity in reengaging lapsed clients


* overall good health


* strong organizational skills ("good time management")


* a balanced, positive outlook (having a sense of humor, looking behind negative behaviors for strengths)


* passion for the work



What sustains you and keeps you going as you do NFP work? Participants identified two elements in particular: building relationships with clients and feeling they've made a difference in peoples' lives. They also felt sustained by their ability to set appropriate boundaries with clients, the joy of watching infants and toddlers grow, and the support they received from NFP coworkers, family, and friends. Comments included "I offload personal and client stuff with coworkers so I can keep doing the work" and "I've learned to pursue [outside] interests that refuel me."


What aspects of NFP work get you down? Participants indicated that a downside is the high caseload; indeed, because NFP nurses are asked to carry a caseload of 25 active clients at all times, they must add "extra" clients (raising caseloads above 25) whenever some clients become less active or approach graduation from the program. Staff turnover can compound the situation: nurses often find themselves taking on departing nurses' clients while orienting new nurses.


Nurses described it as "all-consuming" work that "never ends." A lot of emotional energy is spent on clients "lost" to graduation, as well as new ones. Some nurses said they felt the caseload requirement "robs" them of the sustaining sense of accomplishment that results from doing the job well. They noted that their caseloads often don't allow them to prepare well for visits, reschedule missed visits, or plan case closure when graduation approaches.


Other aspects of the work identified as daunting included


* insufficient community resources.


* client-related factors (such as mental illness, heavy responsibilities at work and school).


* inadequate salaries.


* lack of agency support (some felt that public health agencies neither understand NFP work nor give credit for what NFP nurses do).




The Colorado retreat participants often mentioned the satisfaction they get from relationship building. Indeed, a small study of Louisiana NFP nurses found that they identified the "power of relationships" as the most appealing aspect of their job.4 NFP programs clearly would do well to recruit nurses who have left other positions because they wanted more patient contact.


Nurses who thrive doing NFP work tend to have good mental and physical health, emotional intelligence, and a deep humanity. They empathize with clients, look beyond undesirable behavior to see strengths, and facilitate growth. These characteristics should be sought in nurses being recruited for NFP work and nurtured in new hires.


The participants described the emotional toll of working with needy families and the importance of setting boundaries. They also estimated that they spent 30% to 75% of their time addressing mental health concerns, an estimate similar to that given by nurses in the Louisiana study.4 Supporting NFP nurses with mental health education and consultation is critical to retention.10 Most NFP nurses who thrive also report feeling sustained by their own families and friends. Such support encourages resilience.11


Participants reported feeling discouraged by a "lack of community resources to meet client needs." Most nurses working with low-income families realize that although the NFP model provides a framework for influencing people, it doesn't address poverty directly. Experienced NFP nurses can broaden their advocacy on behalf of low-income families by joining in local, state, or national antipoverty efforts.


The working conditions that Colorado retreat participants reported "got them down"-heavy caseloads, inadequate salaries, and a lack of appreciation by management-should be noted by NFP program administrators.


Experienced NFP nurses want opportunities to continue to grow professionally. Participants said that an advanced practice role for NFP nurses should be developed (by, for example, creating a quarteror half-time position at each site or several statewide positions). NFP nurses with master's or doctoral degrees might consider becoming nurse educators who recruit and train new NFP nurses.


The retreat led us to create the Colorado NFP Nursing Practice Council to encourage collaboration among nurse home visitors and the agencies responsible for implementing the program. More studies are needed to improve our understanding of how NFP nurses experience this "intense, ambitious" work.


The Initiative in Colorado

In 1998 Colorado community leaders and Nurse-Family Partnership (NFP) architect David Olds founded the nonprofit organization Invest in Kids (IIK). With support from a private philanthropy, IIK taught state and local leaders about the NFP model, leading to the passage in 2000 of the Colorado Nurse Home Visitor Program Act, which allocated tobacco-settlement funds for statewide implementation of the NFP program.5


With the help of an NFP site development specialist and nurse consultants, IIK supports and monitors Colorado program sites to ensure that they comply with the act, including its requirement that each full-time nurse carry a caseload of 25 clients. (Although states' programs vary, that caseload is an element of the NFP model.) New Colorado sites typically reach full enrollment within a year of start-up, but some struggle to reach and maintain that caseload. As a result, IIK recommends that sites enroll additional clients as participants approach graduation from the program or stop participating to ensure that each NFP nurse is always serving 25 "active" clients.


As of August, the Colorado NFP program had enrolled more than 7,000 first-time, low-income mothers overall and was actively serving nearly 2,200 families in 52 of the state's 64 counties, according to Lisa Merlino, IIK's deputy director. Active Colorado NFP participants improve their rates of employment (among clients ages 18 and older, 48% were employed at program entry and 61% at program completion) and attainment of a high school diploma or equivalency degree (41% of those entering without either had done so at program completion, and another 18% were working toward this goal).6 And screening tests used by the program showed that the children of NFP clients achieved developmental and language milestones at high rates.7


These achievements are striking given the socioeconomic conditions for poor Colorado families. A 2004 report by the Bell Policy Center noted that while Coloradans have the ninth-highest average per capita income and the eighth-lowest tax burden of state residents nationwide, the state provides little support to poor working families in housing, child care, and educational assistance.8




1. Boo K. Swamp nurse. The New Yorker 2006 Feb 6:54-65. [Context Link]


2. Dellinger M. Children of the bayou. The New Yorker 2006 Feb 6. [Context Link]


3. Kitzman HJ, et al. Challenges experienced by home visitors: a qualitative study of program implementation. J Community Psychol 1997;25(1):95-109. [Context Link]


4. Zeanah PD, et al. Nurse home visiting: perspectives from nurses. Infant Ment Health J 2006;27(1):41-54. [Context Link]


5. Invest in Kids. Nurse-Family Partnership: program overview. n.d. [Context Link]


6. Prevention Services Division. Colorado Department of Public Health and Environment. Nurse Home Visitor Program annual report, July 2005-June 2006; 2006 Oct 1. [Context Link]


7. Nurse-Family Partnership. State of Colorado Nurse-Family Partnership. Evaluation report 6. Initiation through June 30, 2006. Denver: Colorado Department of Public Health and Environment; 2006. [Context Link]


8. The Bell Policy Center. Opportunity lost: when hard work isn't enough for Colorado's families. Denver; 2004. [Context Link]


9. Goleman D. Emotional intelligence: why it can matter more than IQ. New York: Bantam Books; 1995. [Context Link]


10. Boris NW, et al. The process and promise of mental health augmentation of nurse home-visiting programs: data from the Louisiana Nurse-Family Partnership. Infant Ment Health J 2006;27(1):26-40. [Context Link]


11. President's New Freedom Commission on Mental Health. Achieving the promise: transforming mental health care in America [final report]. Rockville, MD: Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services; 2003 May. SMA 03-3832. [Context Link]