changes in client participation in home visits with multiple nursing contacts diane b. mcnaughton,...
TRANSCRIPT
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