A Mental Health Innovation for Nurse Home Visiting Program Shows Effectiveness in Reducing Depressive Symptoms and Anxiety.

The objective of this paper is to report on the effectiveness of a mental health addition to a national nurse-delivered home visiting program. The methods are as follows: analysis of pre/post-launch of the standard Mental Health Intervention and comparison of 356 teams randomized to standard versus enhanced implementation. Stepwise regression controlled for significant client characteristics that were related to relevant outcomes. These characteristics were used in generalized mixed effect models comparing pre/post implementation and intervention and control groups. Pre/post analysis showed that only clients with no elevated mental health screening scores or mental health diagnoses at enrollment showed a significant decrease in depressive symptoms. Clients enrolled with and without mental health needs at enrollment significantly decreased on anxiety scores while referrals to mental health care increased. Teams receiving enhanced implementation enrolled more clients with mental health needs and clients completed more well-child visits and use of safe sleep practices. By integrating mental health care into maternal, infant, and early childhood home visiting programs, a new equitable model of primary mental health care can reach populations in need. This example provides a new paradigm of accessible and equitable mental health care for the future that can be implemented in a variety of home visiting programs.

Implementing mental health interventions within a national nurse home visiting program: A mixed-methods evaluation.

Background: Up to half of low-income mothers experience symptoms of depression and anxiety that affect their well-being and increase their children's risk for behavioral and emotional problems. To address this problem, an engaged research/practice planning team designed the Mental Health Innovation (MHI), a multicomponent implementation strategy that integrates evidence-based mental health interventions within the national Nurse-Family Partnership (NFP). The MHI includes four implementation strategies: online training modules, clinical resources, team meeting modules, and virtual consultation. Methods: A convergent, mixed methods observational design was applied to evaluate implementation outcomes, guided by the RE-AIM framework. We operationalized Reach as the number and demographics of women enrolled in NFP agencies exposed to MHI strategies. Adoption was operationalized as the number and proportion of nurses and supervisors who used MHI implementation strategies. For implementation, we assessed multilevel stakeholders' perceptions of strategy acceptability and feasibility. Data were pulled from NFP's national data management systems and collected through focus groups and surveys. Quantitative data were analyzed using counts and summary statistics. Qualitative themes were generated through content analysis. Results: The MHI reached agencies serving 51,534 low-income mothers (31.2% African American and 30.0% Latina). Adoption rates varied across implementation strategies. Between 60% and 76% of NFP nurses (N = 2,100) completed each online module. Between 27% and 51% of nurse supervisors (n = 125) reported using each team meeting module. Of 110 teams invited to participate in virtual consultation, 40.9% (n = 45) participated. Mothers served by agencies participating in virtual consultation differed significantly from those who did not, with lower percentages of African American and Latina. Qualitative themes suggest that MHI strategies were generally viewed as acceptable; perceptions of feasibility varied across strategies. Conclusions: This study identified both strengths and opportunities for improvement. Further evaluation is needed to assess the MHI's effectiveness in improving mothers' mental health.

Developing a multicomponent implementation strategy for mental health interventions within the Nurse-Family Partnership: An application of the EPIS framework.

PURPOSE: The purpose of this article is to describe the process used to create the Mental Health Innovation (MHI), a multicomponent implementation strategy that integrates evidence-based mental health interventions into the Nurse-Family Partnership (NFP), a national home visiting program delivered by nurses to low-income mothers. ORGANIZING CONSTRUCT: The Exploration, Preparation, Implementation, Sustainment (EPIS) framework outlines the multistep, stakeholder-engaged process used to develop the MHI. CONCLUSION: Engaging stakeholders provided an in-depth understanding of NFP infrastructure and the needs of NFP nurses and their clients. This understanding was key to designing a multicomponent implementation strategy to integrate mental health interventions within national and local NFP infrastructure and existing care processes. CLINICAL RELEVANCE: Application of implementation frameworks such as EPIS provides a guide to integrating evidence-based interventions in a systematic, intentional, and rigorous manner, which in turn may promote their wide scale use and long-term sustainability.

Nurse-Family Partnership nurses' attitudes and confidence in identifying and responding to intimate partner violence: An explanatory sequential mixed methods evaluation.

AIMS: To evaluate the effect of an intimate partner violence intervention education component on nurses' attitudes in addressing intimate partner violence; complementary aims included understanding nurses' perceptions of the education and how it influenced their attitudes and confidence to address intimate partner violence in practice. DESIGN: An explanatory sequential mixed methods design embedded within a 15-site cluster randomized clinical trial that evaluated an intimate partner violence intervention within the Nurse-Family Partnership programme. METHODS: Data were collected between February 2011 and September 2016. Quantitative assessment of nurses' attitudes about addressing intimate partner violence was completed by nurses in the intervention (n = 77) and control groups (n = 101) at baseline, 12 months and at study closure using the Public Health Nurses' Responses to Women Who Are Abused Scale. Qualitative data were collected from nurses in the intervention group at two timepoints (n = 14 focus groups) and focused on their perceptions of the education component. Data were analysed using content analysis. RESULTS: Nurses in the intervention group reported large improvements in their thoughts, feelings and perceived behaviours related to addressing intimate partner violence; a strong effect of the education was found from baseline to 12 months and baseline to study closure timepoints. Nurses reported that the education component was acceptable and increased their confidence to address intimate partner violence. CONCLUSION: Nurses reported improved attitudes about and confidence in addressing intimate partner violence after receiving the education component. However, these findings need to be considered together with trial results showing no main effects for clients, and a low level of intervention fidelity. IMPACT: These evaluation findings underscore that improvement in nurses' self-reported educational outcomes about addressing intimate partner violence cannot be assumed to result in adherence to intervention implementation or improvement in client outcomes. These are important considerations for developing nurse education on intimate partner violence.

Effect of Addition of an Intimate Partner Violence Intervention to a Nurse Home Visitation Program on Maternal Quality of Life: A Randomized Clinical Trial.

Importance: Intimate partner violence (IPV) is a public health problem with significant adverse consequences for women and children. Past evaluations of a nurse home visitation program for pregnant women and first-time mothers experiencing social and economic disadvantage have not consistently shown reductions in IPV. Objective: To determine the effect on maternal quality of life of a nurse home visitation program augmented by an IPV intervention, compared with the nurse home visitation program alone. Design, Setting, and Participants: Cluster-based, single-blind, randomized clinical trial at 15 sites in 8 US states (May 2011-May 2015) enrolling 492 socially disadvantaged pregnant women (≥16 years) participating in a 2.5-year nurse home visitation program. Interventions: In augmented program sites (n = 229 participants across 7 sites), nurses received intensive IPV education and delivered an IPV intervention that included a clinical pathway to guide assessment and tailor care focused on safety planning, violence awareness, self-efficacy, and referral to social supports. The standard program (n = 263 participants across 8 sites) included limited questions about violence exposure and information for abused women but no standardized IPV training for nurses. Main Outcomes and Measures: The primary outcome was quality of life (WHOQOL-BREF; range, 0-400; higher score indicates better quality of life) obtained through interviews at baseline and every 6 months until 24 months after delivery. From 17 prespecified secondary outcomes, 7 secondary end points are reported, including scores on the Composite Abuse Scale, SPAN (Startle, Physiological Arousal, Anger, and Numbness), Prime-MD Patient Health Questionnaire, TWEAK (Tolerance/Worry About Drinking/Eye-Opener/Amnesia/C[K]ut Down on Drinking), Drug Abuse Severity Test, and the 12-Item Short-Form Health Survey (physical and mental health), version 2. Results: Among 492 participants enrolled (mean age, 20.4 years), 421 (86%) completed the trial. Quality of life improved from baseline to 24 months in both groups (change in WHOQOL-BREF scores from 299.5 [SD, 54.4] to 308.2 [SD, 52.6] in the augmented program group vs from 293.6 [SD, 56.4] to 316.4 [SD, 57.5] in the standard program group). Based on multilevel growth curve analysis, there was no statistically significant difference between groups (modeled score difference, -4.9 [95% CI, -16.5 to 6.7]). There were no statistically significant differences between study groups in any of the secondary participant end points. There were no adverse events recorded in either group. Conclusions and Relevance: Among pregnant women experiencing social and economic disadvantage and preparing to parent for the first time, augmentation of a nurse home visitation program with a comprehensive IPV intervention, compared with the home visitation program alone, did not significantly improve quality of life at 24 months after delivery. These findings do not support the use of this intervention. Trial Registration: ClinicalTrials.gov Identifier: NCT01372098.

Improving the nurse-family partnership in community practice.

BACKGROUND: Evidence-based preventive interventions are rarely final products. They have reached a stage of development that warrant public investment but require additional research and development to strengthen their effects. The Nurse-Family Partnership (NFP), a program of nurse home visiting, is grounded in findings from replicated randomized controlled trials. OBJECTIVE: Evidence-based programs require replication in accordance with the models tested in the original randomized controlled trials in order to achieve impacts comparable to those found in those trials, and yet they must be changed in order to improve their impacts, given that interventions require continuous improvement. This article provides a framework and illustrations of work our team members have developed to address this tension. METHODS: Because the NFP is delivered in communities outside of research contexts, we used quantitative and qualitative research to identify challenges with the NFP program model and its implementation, as well as promising approaches for addressing them. RESULTS: We describe a framework used to address these issues and illustrate its use in improving nurses' skills in retaining participants, reducing closely spaced subsequent pregnancies, responding to intimate partner violence, observing and promoting caregivers' care of their children, addressing parents' mental health problems, classifying families' risks and strengths as a guide for program implementation, and collaborating with indigenous health organizations to adapt and evaluate the program for their populations. We identify common challenges encountered in conducting research in practice settings and translating findings from these studies into ongoing program implementation. CONCLUSIONS: The conduct of research focused on quality improvement, model improvement, and implementation in NFP practice settings is challenging, but feasible, and holds promise for improving the impact of the NFP.