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Changes in Client Participation in Home Visits with Multiple
Nursing Contacts
Diane B. McNaughton, PhD, RN
Rush University
College of Nursing
Chicago
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 solving
Clients A & B: 1st Home Visit
Client C: 3rd Home Visit
Client D: 5th Home Visit
• 1 Client: Only nurse problem-solved
Problems Solved
Less ComplicatedNeed for baby clothes
Adding protein to diet
Transportation
More ComplicatedMaternal life course
Immigration
Poor social support
Lack of knowledge: pregnancy, childbirth
Partner 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