Client attrition in the Nurse-Family Partnership : Revisiting metrics of impact in a home visitation program in the United States.

The Nurse-Family Partnership (NFP) is an evidence-based home-visiting program for low-income, first-time mothers. NFP has demonstrated benefits for reducing child maltreatment and improving parenting, child development and families' economic self-sufficiency. It is now implemented widely in the US where, despite the use of home visits, which generally reduce barriers to program participation, only 35% of clients nationwide complete the 2.5-year program. This concurrent mixed-methods study was conducted in 2013 in an urban northeastern US NFP site and included administrative program data, surveys (n = 56), in-depth interviews (n = 14) with nurse home visitors, and focus groups with nurse supervisors (n = 13). We explored associations between nurses' attrition rates and their perspectives on client attrition and retention strategies. We further conducted an inductive thematic analysis of the qualitative data. Findings indicate that nurses' attrition rates were not significantly associated with their views and strategies to retain clients. Nurses and supervisors noted that clients' competing priorities and 'chaotic lives' primarily explained attrition. They thought that clients often left the program upon receiving enough information and skills or achieving key milestones, which may reflect reaching a saturation point, albeit prior to the full completion of the program. We offer recommendations to assess performance based on client accomplishments rather than whether they participated until the prescribed endpoint.