Changes in Client Participation in Home Visits with Multiple

Nursing Contacts

Diane B. McNaughton, PhD, RNRush University

College of NursingChicago

Background

• Nurse-client relationships foundation for home visiting

• Relationships provide context for trust and problem solving

• Clinical trials show better outcomes with multiple home visits

Problem

• Little is know about how relationships develop

• Time needed for clients to develop trust is not known

Purpose

The purpose of this study was to examine how nurse-client interaction changes during home visits as relationships develop.

Research Question

How does client participation in home visits change as nurse-client relationships develop?

Significance

• Provide insight into process of relationship development

• Beginning indicators of how much nursing contact is needed

Theoretical Framework

• Original study guided by Peplau’s Theory of Interpersonal Relations

• 3 Relationship phases: Orientation, Working, Resolution

• Empirical indicators developed by Cheryl Forchuk

Methods

• Prospective, naturalistic, multiple case study design

• Home visits observed and audio recorded prenatally and postpartum

• Clients paid $10 per home visit• More nursing contact than customary

Setting

• Suburban health department• Illinois Family Case Management

Program• Focus of home visits: assessment, health

education, referral.

Sampling

Clients• English speaking• Aged 18-34• Risk to warrant

additional nurse contact

• Diverse backgrounds

Nurses• Recommended by

supervisor• Expert PHNs

Participants

Clients, N=5• Mean age 26 years• 4 primiparous• 1 pregnant 2nd time• Ethnically diverse

Nurses, N=5• Mean age 49 years• Expert• Mean PHN

experience 15 years (range 6-22)

Transcript Analysis

• NUDIST computer software• Start list of codes based on Peplau’s

Theory• Additional codes added• Percentage of interaction per code per

home visit

Results: Relationship Characteristics

• Relationships lasted average of 4 months (range 2.5-6 months)

• Clients received 4-10 home visits• 4 clients entered working relationships• 1 client did not enter working

relationship

Results: The First Home Visit

• Clients: majority of time spent answering assessment questions

• ‘Open’ clients offered information, identified problems, asked questions

• ‘Closed’ client gave short answers, did not identify problems

Characteristics of ‘Open’ Clients

• Overwhelming needs• Multiple needs• Anxiety - sought relief via nurse• Shared personal information• Friends: positive experience with PHNs

Characteristics of Nurses Supporting Relationship

• Addressed client anxiety• Adapted to client needs• Did not take control

Characteristics of ‘Closed’ Client

• Multiparous• Mother present at home visits• Rescheduled home visits• Possibly had intact support system

Client Participation in Problem Solving

• 4 Clients: Mutual problem solvingClients A & B: 1st Home VisitClient C: 3rd Home VisitClient D: 5th Home Visit

• 1 Client: Only nurse problem-solved

Problems Solved

Less ComplicatedNeed for baby clothesAdding protein to dietTransportation

More ComplicatedMaternal life courseImmigrationPoor social supportLack of knowledge:

pregnancy, childbirthPartner relationships

Relationship Shifts

2 Clients changed response to nurse– 1 Client: 4th HV, sensitive information,

catharsis– 1 Client: 5th HV, used nurse heavily as

resource, problem solved

Client Outcomes

• Maternal life-course• Use of health services• Health indicators• Use of resources• Health behavior

Summary

• Relationships are unique• Clients control home visits• Client problems complex, not easily

solved• Other problems were priority over

pregnancy

Similarities to Previous Research

• Therapeutic alliance: relationship shifts between 3rd and 5th encounters

• Nursing: relationships develop in phases, all relationships are not mutual

Implications for Practice

• Individualize interventions vs checklists• Multiple nursing contacts for complex

problems• 1 or 2 home visits is a dilution of nursing

services• Direct limited resources to persons at

greatest risk

Nursing Education

• Foster communication skills• Importance of psych knowledge• Cross-cultural communication skills• Supporting families with multiple,

complex problems

Future Research

• Explore amount of nursing contact needed to address specific issues

• Monitoring relationship development using Peplau’s theory

• Explore client’s perceptions of home visiting

• Invite community input