Early intervention and holistic, relationship-based practice with fathers: evidence from the work of the Family Nurse Partnership
This paper seeks to add to the literature on working with fathers by focusing on early intervention. It draws on research into fathers involved in a home visitation service delivered by the Family Nurse Partnership in England and evaluates the men's experiences of the intervention. The vulnerability of fathers was striking and many were helped to develop their practical skills and confidence in caring for their babies. The intervention was effective because of the quality time that was invested in developing relationships with fathers (as well as mothers), the focus on their strengths as well as areas for improvement and the skilled, therapeutically oriented, holistic approach through which the service was delivered. The ‘early’ nature of the help was crucial to its success because of how it so effectively tapped into the men's redefinition of themselves as caring fathers during pregnancy and following the birth. We argue that there is important learning here for social care and health services in general about how to engage men and promote fathers' capacities to care for their children.
While the literature on fathers and social care and health interventions has grown in recent years, significant gaps remain in our understandings of the characteristics of those who use the services, their backgrounds, strengths and vulnerabilities as fathers. Similarly, studies documenting fathers' experiences of interventions and the extent to which they impact on fathering have grown (Featherstone et al. 2007; Featherstone 2009; Walters 2011). However, knowledge of what capacities men need to develop to care for their children and the best ways of engaging fathers in the work is in its infancy (Maxwell et al. 2012). Scourfield's (2003; 2003,2006) research into social work and Peckover's (2002) research into health visiting has shown that negative assumptions about ‘feckless’ and dangerous men abound, often to the exclusion of attempts to engage with them (see also, Ferguson & Hogan 2004). In a review of international literature on parenting support, Moran et al. (2004) gave high priority to the need for further research which will identify: ‘What aspects of parenting support work are most effective when working with fathers and how programmes may need to be designed to better meet their needs’.
The aim of this paper is to contribute to such knowledge by analysing the characteristics of the fathers involved in a home visitation service delivered by one programme in England, known as the Family Nurse Partnership (FNP) (Department of Health 2009). The FNP programme was established in the UK in the late 2000s to provide ‘early intervention’ or ‘early help’ to first time teenage mothers, during pregnancy and until the child's second birthday. The aims and experience of the programme in relation to fathers is more ambiguous and the research on which this paper is based was commissioned due to awareness within the FNP that there were sometimes difficulties in engaging fathers in the context of a growing recognition of the importance of fathering to child development (Department for Education and Science 2004). In child welfare, fathers can be categorized as ‘resources’ and as ‘risks’ (Featherstone 2004) and the FNP's concerns fitted with a general recognition that fathers tend not to be engaged by health and social services providers, and that some fathers avoid such involvements (O'Hagan 1997; Daniel & Taylor 2001; Featherstone & White 2006; Brown et al. 2009). The objective of the research was to evaluate fathers' experiences of the FNP and explore whether and how the FNP worked with them, with the intention of informing practice in order to increase the presence, involvement and engagement of fathers.
Some research into younger father's experiences shows that most of those studied were very involved in their child's life, providing support and care to their partner during pregnancy and in early parenthood. Although some reported positive experiences, often men felt excluded or judged when accessing services (Fletcher & Visser 2008; Ross et al. 2012). We need to go further by exploring in more detail the ways in which men perform different tasks as fathers and the extent to which intervention develops their skills and confidence as carers in the areas they most need it. This paper aims to produce that kind of analysis by considering the match between the fathers' strengths and vulnerabilities and the appropriateness and effect of the service they received.
A key finding is the high value the fathers placed on the therapeutically oriented relationship-based approach taken by the FNP, which addresses not simply the practical tasks and skills of parenting but seeks to assist the fathers in an holistic way by giving them quality time and supporting them in everything from finding work and educational opportunities, to relationships with their partners and building their self-esteem and identity. The paper adds to our understandings of how (early) social care and health intervention delivered through therapeutically informed approaches can help men to develop as fathers, how this does or does not happen and identifies areas where this needs to be improved.
The Context of the Research
The FNP programme ‘is offered to first time vulnerable teenage mothers’ (Department of Health 2009, p. 8). It is a licensed programme which originated in the United States where it has been evaluated and developed for over 30 years (Olds et al. 1997a,b, 2002). The FNP programme is enormously significant in current UK child and family policy. From the outset, it has been piloted and evaluated and its impact scrutinized in depth, including the use of large scale randomized controlled trials. These are currently in progress so no results can be referred to here. It is by far the most extensive roll-out of an evidence-based programme in the UK, reaching something like 10–15% currently of the eligible population. None of the other studies in the extensive programme evaluations specifically addressed the role of fathers and the research on which this paper is based was commissioned to do that.
The programme is delivered by specially trained ‘Family Nurses’ (FN) who come from health visiting, midwifery, mental health and other branches of nursing. The FN's orientation is social and therapeutic rather than purely medical or clinical and they take a holistic, relationship-based approach where they seek to enable their service users to make informed choices about child rearing and their lifestyles. The aim is to improve pregnancy outcomes by helping women engage in good preventative health practices and to improve child development by helping parents to provide responsible and competent care. The programme, being holistic in nature, seeks to help mothers – and, we found, many fathers when they are present – to develop a vision for their own future, plan future pregnancies, continue their education and to find work/careers. The use of ‘motivational interviewing’ (Miller & Rollnick 2002) typifies how the FNs seek to use in-depth engagement with families to achieve change, at the intensive, specialist care end of early intervention and prevention. The home visitation programme begins as early as possible in pregnancy and continues until the child's second birthday. Each FN has a caseload of no more than 25 families who are each visited on a weekly or biweekly basis, depending on what stage of the 2-year programme they are at. In the city where this research took place, the FNP team was made up of seven family nurses and a supervisor (with a smaller caseload) who provided weekly supervision, learning, management and quality assurance to the nurses. At the time of the study, all of the children in FNP cases were aged under 15 months. This then, is a paper about how predominantly younger fathers in families care for babies and the kinds of help that can enable them to develop their abilities to care well.
The study was guided by four main research questions:
- What are the characteristics of fathers in FNP caseloads?
- What are the fathers' levels of involvement with their children and families?
- What is the nature of fathers' involvement in the FNP programme?
- What effect does the intervention have on their fathering and caring capacities?
The research design drew on a mix of methods. We first gathered caseload data from all the nurses on all their clients and extensively interviewed each FN twice about their experiences of working with fathers and families. Secondly, substantial data were gathered through a detailed survey of the fathers in FNP cases which included an evaluation by the fathers of the FNs' practice. This was a self-completion questionnaire that was distributed initially by the nurses and returned to us in sealed envelopes so the men could be assured the nurse would not see their answers. As already referred to, the FNP nationally had commissioned other research to measure the impact of the programme on parenting through randomized controlled studies, building on earlier US studies (Olds et al. 1997a,b, 2002). With the research questions and methods adopted in this study, we make no claim to show the ‘impact’ of the FNP programme in a robust measurable way (see for instance, Flouri 2005). Our brief rather was more qualitative: to gain a profile of the fathers and their perception of the meanings and effects of the FNP on them. Given the limited research base in this area, such approaches can contribute highly significant knowledge (Becker et al. 2012).
At the outset of this study, the FNP team were involved with a total of 144 active cases. The current or former partners of the mothers in these 144 cases who were fathers to the babies formed the initial population for the research. In collaboration with the nurses, we established that 30 of the 144 fathers were deemed ‘unreachable’ or ‘reachable but inappropriate for contact’ – the most common reason being that the men were considered domestic abusers. It was not ethically appropriate to include these men in the study, as this would have legitimized the man's role in the family in a manner which was regarded as unsafe for his partner and child and may have placed the FN at risk by being brought into contact with them. This left a potential survey sample of 114 fathers. In total, 54 out of the 114 questionnaires were returned – a 47% return rate. In surveys of this nature and with such a vulnerable population, we feel this is a respectable return rate and was only secured after a great deal of effort. The survey was extensive, with 80 questions covering age, the men's family background and accommodation, education and training, their knowledge of fathering, relationships with professionals, levels of activity in caring for the baby, their relationship with the mother and baby and their views on the FNP's intervention. A mixture of open and closed questions was used. We did not intend to undertake, nor do we report here, any detailed statistical or inferential analysis of the data from the survey. What the findings do provide are profiles of the fathers and a series of patterns and profiles of how men saw their role and involvement with their children, partners and the FNP.
We interviewed 24 of the fathers about their experiences of pregnancy, fatherhood and FNP intervention. They were recruited from men who gave consent on the survey form to being contacted about an interview. To learn about the dynamics of engagement, we selected fathers whom we knew from the survey and the interviews with nurses fell on a continuum between high and low involvement with the FNP. Nine of the 24 fathers interviewed had low levels of engagement with the programme or were not engaged with it at all. The interview sample was purposive, designed to mirror the profile of the total study population. The ages of fathers interviewed ranged from 17 to 34 years old, seven were aged 17–19; seven, 20–21; eight were 22–19 and two were 30–34. Four were from black and minority ethnic (BME) backgrounds, while seven had social care involvement, in three of which the child was subject to a child protection plan. Interviews were face-to-face and semi-structured, lasting between 60 and 90 minutes. Most took place at the man's home, while in two cases they took place in prison.
What follows is, firstly, a presentation of the findings in terms of a profile of the fathers, drawing on the survey data. We then draw on the interview data to analyse the men's subjective experiences of fathering and involvement with their children and families. Later sections present the quantitative and qualitative data in an integrated way to consider the men's experiences of becoming a father, their skills levels, relationships with partners, the nature of fathers' involvement in the FNP programme and the effects of the intervention on their fathering and caring capacities.
Vulnerable Fathers: The Characteristics of Fathers in FNP Caseloads
A striking and recurrent theme is the vulnerability of the fathers which was illustrated in data on several areas. The majority were young, poor and unemployed, with low educational attainment; they had either been in trouble with the youth or criminal justice system or had been on the edge of it. Most of the men were the biological father of the child (85%). A minority had other children, and although none lived with children from other relationships, they were seeing these children at least once a fortnight. Eighty-seven per cent of the survey samples were white/white British, while 13% were from BME backgrounds. The surveyed fathers ranged in age from 17 to 34 years, some 58% of whom were aged 21 or less, while almost a third (29%) were teenage fathers. The age range of the mothers in the sample was 16 to 21 and this narrower age range is to be expected given that the service was targeted at first time teenage mothers. There were some instances of older (and in a small number of cases significantly older) men with younger women. This finding is similar to other studies of teenage mothers where in general fathers were older than their partners (Miller 1997; Lane & Clay 2000). The majority of the children (80%) were one year old or younger and over a quarter (28%) were 6 months old or younger.
There were some striking patterns in the men's own family backgrounds. Over a third had experienced parental separation (37%), 70% of these separations happened before the men were 10 years old. Eleven per cent of the fathers had been in care and one was still in foster care at the time of the study. All of the men had siblings, while 70% had stepbrothers or stepsisters. In terms of the men's relationship with their own father, 50% described themselves as ‘very close’, while 30% ‘got on but were not too close’. Eighteen per cent had no contact with their fathers at all. This picture illustrates the widespread experience of having grown up in reconstituted and/or fractured families.
In terms of education and training, 35% of the fathers had no qualifications at all, while 28% had qualifications in five or more subjects at age 16 (data on grades obtained were not systematically provided, but anecdotally most were low). Some 20% had a further education qualification.
The majority (86%) lived in rented accommodation – either from private landlords (43%) or through social housing (43%). Almost a third of the men (29%) regarded their accommodation as temporary. Three-quarters of the fathers lived with the child's mother, either all or part of the week, while a quarter still lived with one or both of their own parents. Two of the respondents were in prison, one was in foster care and one lived alone. Of those who did not currently live with the child's mother, 19% said that they intended to live together in the future once they were financially stable, while only 4% said that they do not intend to.
For just over half (57%) of the fathers, the pregnancy had not been planned. Although unplanned, 37% said that they were very happy when they heard the news. However, 17% were unsure or worried when they found out that they were going to be a father. The men's knowledge of pregnancy prior to the conception varied enormously, a quarter felt it was ‘very good’, another quarter ‘adequate’, while a quarter felt it was ‘poor’ and another quarter ‘very poor’. The fact that at least half of the men entered pregnancy feeling that they knew little about it points to a broad lack of information and preparation for pregnancy for young men and raises serious questions about the passive role of schools in preparation for fatherhood (Ayoola et al. 2010).
A third of the fathers were in paid employment. The majority of men in the study had very low incomes and some had no income at all due to their age and the fact they were living at home with their parents. The largest proportion of fathers (40%) fell into the very low weekly income bracket of between £100 and £150, while 37% were on £150–300. Interviews showed that lack of spending power routinely prevented these fathers from buying their children (or partners) any presents or ‘little luxuries’ and sometimes rendered them unable to buy their children even essential items forcing them to borrow and rely on family. This was a source of great regret and pain to them. This is borne out by other research that shows how for younger and poverty-stricken fathers non-involvement is often due to their perception of a barrier between them and their children, often rooted in feelings of financial inadequacy and uncertainty about the type of support they should or can provide (Bunting & McAuley 2004).
In summary, the general profile of the fathers that emerged from the survey was of men whose lives were characterized as high in vulnerability factors. Their past and present experiences of difficult and challenging circumstances placed their capacity to be responsible, caring fathers at risk. Moreover, many of the mothers with whom the men were involved were also extremely vulnerable. Such was the overall challenge faced by the FNP in seeking to engage the fathers and meet their often complex needs.
Fathers' Involvement with their Children and Families: Be(com)ing a Father and Getting Early Support
Becoming a father involves a developmental transition for both women and men through which they usually experience intense emotions, face many new challenges and adjust to new responsibilities. A developmental transition involves a ‘qualitative shift in perceptions of oneself and the world’ and behavioural shifts that can be observed by others (Hawkins et al. 1995, p. 43). Following Erikson's theory of psychosocial development, the primary developmental task of adulthood is learning to care for others, a process he labelled ‘generativity’ (Erikson 1963). Generativity, or care, is defined as an interest in establishing and guiding the next generation (Walker 2010).
The challenge for the majority of men in this study was to make the developmental transition to generative fatherhood from a starting point of vulnerability. A key theme to emerge from the men's narratives was that entering fatherhood and feeling love and responsibility towards their babies had changed them.
I used to be a bit stupid when I was out. … Getting into trouble. Used to be out with my mates and I used to drink when I used to go out sometimes, but I don't do any of that any more … Once he was born I just didn't seem to do any of that any more, or want to do it anymore. I don't know what … well it must have been him being born that changed it, but I just stopped. There's no other reason that I stopped apart from when he was born, it just didn't happen anymore, I just didn't want to go out and do that. (Father 18 years; child 7 months)
One 20-year-old father typifies the pattern of those men for whom fatherhood had encouraged them to settle down. He was permanently excluded from school, and subsequently spent 3 months in a young offenders' institution for breaching his anti-social behaviour order.
I was stupid before. When you have a kid, it hits you, tells you what is best. I'm so glad to be a dad instead of hanging out on street corners. It's changed my life. (Father 20; child 11 months)
After 11 months, this man rates himself highly as a father, stating: ‘I feel like a good dad’.
For one father of a 15-month-old son, there was regret that the child came too late to settle him down and keep him out of trouble. At the time of the research interview he had been out of prison for just 3 weeks, having served a 16-month sentence for burglary, which began in the last 2 months of his partner's pregnancy; he was not allowed out to attend the birth. During the first 7 months of the pregnancy however, he attended all the scans, but he did not recollect any midwives or other professionals engaging with him.
I used to be a bad boy but because of my circumstances I'm not now. If I'd had him before I'd committed the offence it would not have happened. He would have been first and I would have wanted to be with him. (Father 20; child 15 months)
This father felt that it was not too late for the baby to provide a new motivation for him to stay out of prison and spoke positively about how the FN was helping him to achieve it. This is supported by Liz Walker's study of imprisoned fathers for whom ‘generative’ fathering had become a key goal in their lives (Walker 2010).
The lack of knowledge about parenting and the vulnerability of many of the men left them feeling unprepared for the role of fatherhood. The FNP programme helped many such fathers to gain knowledge and confidence around a myriad of parenting skills: holding the baby, feeding, bathing, communicating and soothing. The fact that this FNP work began with them early and during the pregnancy proved vital:
Yeah it was kind of weird, obviously you've got this little baby and you're holding it, and you don't want to drop it, you don't want to drop her. Yes, she [Family Nurse] teaches about that yeah. Before [baby's name] was born she brought a baby round, a fake baby, and she was telling us how to hold it and stuff like that, yeah. (Father 18; child 7 months)
Fathers felt the intervention helped them to deal with their anxieties about how to care for tiny babies, working alongside the mother.
I learned myself really by just figuring out what to do. [My partner] has helped me. Like how to hold her. I have big hands and she is so small. I didn't want to hurt her. And burping her, rubbing her back, I didn't want to hit her too hard. It has turned out brilliant and brought us closer together.
(Father 19; child 5 months)
Many men felt the way the FN helped to build their confidence was vital:
She has said I'm doing really well, and that I'm a good dad lots of times. She is not judgmental, even when I talk about drinking. She is dead good with us.
(Father 31; child 13 months)
Performing Fatherhood and Involvement in the FNP Programme
We used the survey and interviews to gain a deeper picture of what the men did as fathers, areas in which they felt competent, where they felt the intervention was helpful or not, and where they felt they still needed to learn and gain further support. In the survey, fathers were asked to estimate how much time in total they spent doing things with the baby on a typical day. Two-thirds (63%) claimed they spent at least 5 hours a day doing things for and with the baby, compared with 11% who spent very little time. While we cannot verify their estimates, there was a clear sense of significant involvement by over half of the men.
Some 41% of the fathers felt that their level of involvement with their child had increased over time and many felt that the FNP played a part in this increase and their growing skills and confidence at parenting tasks and relationships. We sought to establish not only amounts of time spent but how it was used and the level and nature of the direct care that fathers provided to their children. As Featherstone (2009, p. 79) notes, it is increasingly argued that a focus on ‘time use’ as a way of assessing involvement is too restrictive and there is a need for more refined examinations of the nature of fathers' impact on children. We followed the approach of O'Brien (2005) by assessing how involved a father is according to the number of times daily he engages in particular care activities. O'Brien's approach is based on the understanding that a baby would need to be fed between six and eight times in a 24-hour cycle and assesses the number of times respondents say they fed, changed, dressed or soothed their child. This provides deeper insights into how much of particular activities fathers do and where they feel most able or in need of support. Twenty-three per cent of the fathers claimed that in a typical day they fed their baby more than four times, 47% changed them more than four times, while 45% soothed the baby more than four times. Thus, around half of the men in the sample were engaged in providing considerable direct care for their children. Working or being in some form of education or training was a key reason for being less involved in caring activities. Being non-resident was another key factor; however, some non-resident fathers ensured that they were there in the evenings and mornings to be more involved in child care.
Interviews also revealed at a deeper level the ways in which men regarded the involvement of the FNP as being very significant to the amount and the quality of care they provided, both generally and in particular activities. Shaun for instance, is a mixed-white British-Caribbean father of a 12-month-old daughter who was 19 at the time of the study. He spoke very highly of the FN, whom he felt got him completely involved in her visits and just as involved as his partner. He felt the FN had impacted deeply on his knowledge and skills in feeding the baby, listening to the baby and weaning the baby. However, he saw no FN impact on developing his skills at holding the baby, getting up in the night and teaching the baby things, because he felt he knew about this already. Shaun relayed a vivid example of how the FN advised them about the kinds of soft toys and reading books with soft play surfaces to get for the baby. He explained how he happily fills in the FN's homework sheet exercises between visits. He believes the FN has had a hugely positive impact on his relationship with his partner, helping them to resolve arguments and differences about many issues, including parenting styles. He regarded the FN's reliability as central to what is effective in how she relates to him, how she always carries through on promises she makes – for instance, in helping him find possible college courses – how well she listens, and the generous amount of time she gives them – often up to 2 hours on a visit. He said, ‘I really like her.’
This case illustrates a key finding that many fathers felt the FNP intervention had helped them to develop their skills and confidence in some areas of parenting but not others. Overall, the survey showed that 54% of the fathers felt that their ability to be a father had changed very positively as a result of the FNP intervention; a quarter believed the intervention had a medium to low impact; while over a quarter (28%) felt it had very little or no impact at all. In terms of the specifics of different parenting activities, to give just two examples: 21% rated the impact of the FN on their baby feeding skills as very high, while 20% saw no effect at all. For 20%, the FN had a very high impact on their abilities to hold the baby, while 31% saw no benefit.
Interviews established that in some cases the reason the man felt he had not developed his skills in some areas was due to him regarding the service as having failed to meet his needs, or that despite their efforts he disliked the FN's approach. In others, however, the reason lay in the men's perceptions of their own capabilities and the fact that they knew a lot about at least some aspects of caring before becoming a father (through caring for relatives, for instance) and therefore the FNP added little to their abilities. Thus, rather than a low perceived impact being a sign of poorly focused intervention it can be argued that it reflects a strength of a programme and practitioners who develop the kinds of close working relationships that enable them to discern areas of strengths and weaknesses that need focusing on.
A majority of the men (79%) considered themselves to have a ‘brilliant’ relationship with their child; 17% a ‘good’ relationship, while 4% said that they had ‘good days and bad days’. Similarly, 73% considered themselves to be either a ‘very good father’ or a ‘good father’. Most still saw themselves as having areas they needed to learn about and improve on (see Table 1). Physical child care skills was the most cited area where they needed to learn ‘a lot’ more, while almost half felt they had nothing to learn about this. The need to learn ‘a bit’ more was evident for quite high proportions of fathers in the areas of communication with the child, taking responsibility for child care (making medical appointments for instance) and supporting the mother.
Table 1. Areas in which fathers felt they still needed to learn
The Effects of Early Intervention on Fathering and Caring Capacities: Help with the Couple's Relationship
The relationship between parents has a significant effect on the level and nature of paternal involvement. Conflict between the couple can minimize the quality of the time children spend with their parents and this can have more of a negative effect than the quantity of time spent (Lamb 1997; Marsiglio et al. 2000). Some commentators (Lane & Clay 2000), suggest that non-involvement by teenage fathers can often be influenced less by an unwillingness to engage than by barriers created by the mother (see also Rhein et al. 1997). Bunting & McAuley (2004) argue that this perception is largely due to poor relations between parents. In research interviews with both teenage fathers and mothers, Bunting & McAuley (2004) found that whereas teenage fathers would cite the mothers' opposition as a barrier to father involvement, teenage mothers would cite paternal disinterest. Given the potential for conflict and relationship breakdown, it may not be surprising that the fathers in this study placed a high significance on the help they received to better understand their partner and with the couple's relationship. What is pleasantly surprising and important is that the FNP is able to provide such a meaningful therapeutic service in an age of increasing bureaucracy and complaints from health and social care practitioners of not having the time to do such work (Munro 2004). Over half of fathers (58%) felt that the FNP had a high impact on their understanding of the support needs of their partners and 30% a medium impact.
At the time of conception, a quarter of the couples were already cohabitating, almost half were in a steady relationship but not living together, while 11% described their relationship as casual. Half of the couples had been together for at least a year. Just 8% were married at the time the baby was conceived. In terms of how fathers felt the baby had affected their relationship with the mother, 30% said it was just as good afterwards as before, 28% said it brought them closer together, 24% said it was more difficult but they stayed together, while 4% said it broke them up. Even some fathers who felt the relationship had flourished with the baby's presence valued highly the help they got with their relationship with their partner, clarifying differences and reaching agreement on parenting roles and styles.
A typical example is Steve, a working father, who was critical of the FN for not doing more to involve him by visiting at times that fitted in with his work routine. He felt that the highest area of impact the FN had was in providing help with his relationship with his partner:
It was a lot on how it would be before [baby] was born, and after [baby] was born, and then she did a lot of work on postnatal depression, coping you know together as a couple, and how we'd cope together looking after a child. She did a bit of work on that, I do give her that credit, she was pretty good with that, got some good leaflets and information on depression especially, because I was looking into that quite a bit, you know, because obviously I didn't want anything like that to happen with [partner]. (Father 24; child 3 months)
This tension over the timing of visits was one that surfaced many times, yet conflicted with the expected conditions of service of the nurses, where evening visits might have impinged on their own family life. When fathers were absent from FN visits, the single most common reason was being at work or in education or training (60%). Most men, whether in work or not, felt that a role as the breadwinner and provider was a vital dimension of their being a ‘good father’. But some were deeply conflicted about how this took them away from seeing a lot more of their babies and caring for them. FNP support helped a significant number of couples to become more stable and child focused.
Generous Time Given and a Meaningful Relationship
Viewed on their own, each of the areas discussed above – developing practical child care skills, communication and relationship skills – contributed to assisting the men in a variety of ways with their fathering. But what seemed crucial to the effects of the interventions was the ways in which these various dimensions combined and were channelled through a meaningful professional-service user relationship.
She is like a mother or a guidance person, it's a nice thing to have. She'll come up, weigh [child], check her over, have a chat and tell us what is going on at this stage in [child's name's] life. (Father 31; child 13 months)
She's kind of weird in a way, like she don't just cover that job, if you know what I mean, what she's meant to do, she kind of covers different things. I like her, I think she's a good person, but yeah she kind of covers everything. Like she helps me out, she helps [partner] out, obviously not like what she's not allowed to do, but I mean she helps, she just helps us out really. (Father 18; child 7 months)
She's been really helpful in all sorts of ways. She does involve me. We look forward to her coming. (Father 20; child 8 months)
This holistic relationship-based practice approach extended to assisting the men to look for jobs or find college courses or training opportunities. A common criticism of evidence-based programmes is that they reduce practice to a box-ticking exercise and squeeze out the relational dimension between professional and service user. Our findings show that the FNP approach is an important exception to this, managing to combine evidence and quality therapeutic work.
Problems in Help-giving and Receiving
However, not all of the men benefited from such contact and relationships. Some 58% of the fathers were present most or all of the time when the FN visited and 18% for half the visits or less. However, as many as 23% were never present when the FN visited. The nature of the relationship that was or was not formed was a product of several interacting variables. A crucial one was the men's behaviour and attitude towards receiving help. Some fathers were completely resistant to involvement and simply unreachable and would not respond to the FN's attempts to engage with them. Nor could we reach most of these men as researchers and we tried hard to. Some other men were ambivalent about involvement, which manifested in them being silent or hovering in and out of the room, there on one visit but not the next. However, this ambivalence was not picked up by the FNs, who interpreted their staying in the background as a lack of interest and in some cases just passively accepted it and focused on the mother. Practitioners need to develop deeper understandings of how such avoidance behaviours can be a reflection of how men construct a definition of masculinity that regards help seeking as a sign of weakness (O'Brien et al. 2005).
In a minority of cases, the FNs' attitude to particular fathers was negative and they were not proactive in trying to involve them. These dynamics were often compounded by the complex challenge of responding to vulnerable mothers and fathers at the same time. In general, the higher the mother's needs the harder it was for the practitioner to focus on the father's needs as well, especially when the couple and child were all in the room at the same time. The policy and practice orientation of the service towards fathers was also a crucial factor. Because the mother is explicitly named in FNP policy as the primary client, this created confusion, and some uncertainty within FNs about what their relationship to fathers should be and some were not worked with as a result. The clearer agency policies are about the need to acknowledge the presence of fathers and the need to involve them in the work, the more likely practitioners are to include them. The FNs were mostly aware of just how important their own attitudes are and how they can support men to feel they are important and are making a contribution to raising their child. Such moments of engagement need to be sensitively handled, as one FN put it:
I think sometimes they feel as if they are intruding as well. So he ran. I think if I'd done it another way and tried to encourage him to talk a bit then he might have got involved because he might have realised that it was something that he wanted. It's a bit like the ones who stay in the kitchen for a few weeks or months or even all the pregnancy and then suddenly they will come out when the baby's there and they'll listen.
When present at the visits, the majority of the men (80%) felt ‘involved or very involved’ in the FN sessions. Half of the fathers felt the FN involved them as fully as the mother and another 28% felt well involved. However, some fathers felt the service was pro-mother in a way that marginalized them and that the failure to properly engage with them was just not good enough:
I just want to be more involved with it. Though she includes me the most of anyone else, I'm not as involved as I should be. Most of the paperwork is down to [my partner] – if it was half and half it would be ok but it's like 80% [partner]. Most of the sheets are for the mother. There's a few for the dad.
(Father 19; child 5 months)
The evidence from this research broadly supports the case for early intervention into families to focus explicitly on fathering. We say this in full recognition that the study did not set out to statistically measure the impact of the FNP on fathering. Rather we sought to add to the literature and research base by establishing a profile of the fathers and their perceptions of their needs and how the FNP early intervention programme did or did not meet them. A limitation to the findings is that because fathers' levels of engagement with the service varied hugely, from very involved to non-existent the data are naturally biased towards the fathers who were more engaged with the service. Those who were not actively involved with the service were less willing to be involved with us and conversely the more cooperative the fathers were with the service, the more likely they were to cooperate with the research. However, we were still able to incorporate into the research some resistant fathers and discussion of how to engage them.
Commonly, the men involved in FNP cases are vulnerable due to the presence of several risk factors and we have tried to show in some detail the ways early intervention can assist vulnerable men to develop their capabilities as fathers. The ‘early’ nature of the help was crucial to its success because of how it so effectively tapped into the men's ‘generative’ energy and redefinition of themselves as caring fathers during pregnancy and following the birth. The paper has shown how fathers are not passive, empty vessels into who intervention programmes are simply poured. Most of the men in our study had clear views about the areas with which they needed help and those they did not. This does not mean that their self-assessments were always right. It is in the very nature of social and health care work for there to be differing views about what family members need. What it does point to is the importance in successful cases of engagement of a congruence being created between what the father needs and the professional offers and concomitantly that professionals take into consideration the needs of the father, not just those of the mother and baby. Identifying and affirming father's strengths as well as areas for improvement is crucial to creating this congruence. The key reason the programme was so positively received by fathers was due to the skilled, therapeutically oriented, holistic approach of the FNs. The fathers as well as mothers were given that crucial commodity of time, through which trust and mutual respect were built up. It was through such a meaningful relationship that many of the fathers as well as mothers were able to receive and respond to the skilled interventions of the FNs and the welfare of their babies and themselves was promoted.