Changes in Client Participation in Home Visits with Multiple Nursing Contacts
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Transcript of Changes in Client Participation in Home Visits with Multiple Nursing Contacts
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Changes in Client Participation in Home Visits with Multiple
Nursing Contacts
Diane B. McNaughton, PhD, RNRush University
College of NursingChicago
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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
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Problem
• Little is know about how relationships develop
• Time needed for clients to develop trust is not known
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Purpose
The purpose of this study was to examine how nurse-client interaction changes during home visits as relationships develop.
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Research Question
How does client participation in home visits change as nurse-client relationships develop?
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Significance
• Provide insight into process of relationship development
• Beginning indicators of how much nursing contact is needed
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Theoretical Framework
• Original study guided by Peplau’s Theory of Interpersonal Relations
• 3 Relationship phases: Orientation, Working, Resolution
• Empirical indicators developed by Cheryl Forchuk
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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
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Setting
• Suburban health department• Illinois Family Case Management
Program• Focus of home visits: assessment, health
education, referral.
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Sampling
Clients• English speaking• Aged 18-34• Risk to warrant
additional nurse contact
• Diverse backgrounds
Nurses• Recommended by
supervisor• Expert PHNs
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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)
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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
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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
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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
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Characteristics of ‘Open’ Clients
• Overwhelming needs• Multiple needs• Anxiety - sought relief via nurse• Shared personal information• Friends: positive experience with PHNs
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Characteristics of Nurses Supporting Relationship
• Addressed client anxiety• Adapted to client needs• Did not take control
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Characteristics of ‘Closed’ Client
• Multiparous• Mother present at home visits• Rescheduled home visits• Possibly had intact support system
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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
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Problems Solved
Less ComplicatedNeed for baby clothesAdding protein to dietTransportation
More ComplicatedMaternal life courseImmigrationPoor social supportLack of knowledge:
pregnancy, childbirthPartner relationships
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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
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Client Outcomes
• Maternal life-course• Use of health services• Health indicators• Use of resources• Health behavior
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Summary
• Relationships are unique• Clients control home visits• Client problems complex, not easily
solved• Other problems were priority over
pregnancy
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Similarities to Previous Research
• Therapeutic alliance: relationship shifts between 3rd and 5th encounters
• Nursing: relationships develop in phases, all relationships are not mutual
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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
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Nursing Education
• Foster communication skills• Importance of psych knowledge• Cross-cultural communication skills• Supporting families with multiple,
complex problems
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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