1. Changes in Client Participation in Home Visits with Multiple Nursing Contacts Diane B. McNaughton, PhD, RN Rush University College of Nursing Chicago

2. 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

3. Problem Little is know about how relationships develop Time needed for clients to develop trust is not known

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

5. Research Question How does client participation in home visits change as nurse-client relationships develop?

6. Significance Provide insight into process of relationship development Beginning indicators of how much nursing contact is needed

7. Theoretical Framework Original study guided by Peplau’s Theory of Interpersonal Relations 3 Relationship phases: Orientation, Working, Resolution Empirical indicators developed by Cheryl Forchuk

8. 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

9. Setting Suburban health department Illinois Family Case Management Program Focus of home visits: assessment, health education, referral.

10. Sampling Clients English speaking Aged 18-34 Risk to warrant additional nurse contact Diverse backgrounds Nurses Recommended by supervisor Expert PHNs

11. 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)

12. 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

13. 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

14. 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

15. Characteristics of ‘Open’ Clients Overwhelming needs Multiple needs Anxiety - sought relief via nurse Shared personal information Friends: positive experience with PHNs

16. Characteristics of Nurses Supporting Relationship Addressed client anxiety Adapted to client needs Did not take control

17. Characteristics of ‘Closed’ Client Multiparous Mother present at home visits Rescheduled home visits Possibly had intact support system

18. 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

19. Problems Solved Less Complicated Need for baby clothes Adding protein to diet Transportation More Complicated Maternal life course Immigration Poor social support Lack of knowledge: pregnancy, childbirth Partner relationships

20. 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

21. Client Outcomes Maternal life-course Use of health services Health indicators Use of resources Health behavior

22. Summary Relationships are unique Clients control home visits Client problems complex, not easily solved Other problems were priority over pregnancy

23. Similarities to Previous Research Therapeutic alliance: relationship shifts between 3rd and 5th encounters Nursing: relationships develop in phases, all relationships are not mutual

24. 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

25. Nursing Education Foster communication skills Importance of psych knowledge Cross-cultural communication skills Supporting families with multiple, complex problems

26. 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