Developing a fidelity assessment instrument for nurse home visitors.

Fidelity monitoring is a core component for successful translation of evidence-based interventions, yet little guidance is available on developing tools to assess intervention fidelity that are valid and feasible for use in community settings. We partnered with nurses in the field to develop a fidelity monitoring instrument that would capture the essential elements of the nursing intervention that is the core of Nurse-Family Partnership, a prenatal and early childhood home visitation program. Using a grounded approach, we employed concept mapping to identify the salient behavioral characteristics associated with the program, and then, adapting Dreyfus' model of skill development, created a tool to assess nurse home visitors (NHVs) according to their stage of growth. In a pilot, the Nursing Practice Assessment (NPA) form was used to assess 188 NHVs. The average time to complete the tool was 1 hour, and skill development stage was concordant with years of NHV experience. According to surveys of supervisors and NHVs, the tool captured the essential elements of the program model. Articulating the essential elements of each skill development stage can provide a foundation for professional development for NHVs. In response to feedback, online training modules were developed prior to large-scale implementation in the field. The grounded methods used to develop the NPA enhanced its internal consistency and implementation feasibility and could be utilized by other public health nursing programs.

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.