changes in client participation in home visits with multiple nursing contacts
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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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