Strategies to Improve Client Retention in Home Visitation Programs

Saturday, 28 October 2017

Marilyn A. Smith, BSN
Maternal Child, Le Bonheur Children's Hospital, Memphis, TN, USA
Linda R. Tuggle, MSN
Labor and Delivery Services, Methodist Healthcare-Olive Branch, Olive Branch, MS, USA
Billie E. Bitowski, MSN
Northwestern State University, Retired, Keithville, LA, USA
August C. Marshall
Maternal Child Health, Le Bonheur Community Health and Well-Being, Memphis, TN, USA
Angela R. Rainey, BSN
Maternal Child Department/ Nurse-Family Partnership, LeBonheur Community Health and Well Being, Memphis, TN, USA

BACKGROUND: Nurse-Family Partnership (NFP) is an evidence-based home visitation program implemented nationwide that serves first-time, low income mothers and their children enrolled before the 2nd trimester and ends when the child turns two years old. Nurses carry an average caseload of 25 mothers, and work with these mothers on a regular basis. Nurses engage their clients with preventative health practices, including linking to prenatal care, improving diet, and encouraging the reduction or abstinence of tobacco, alcohol, and illegal substances. Nurses use an evidence-based curriculum to educate the mothers on responsible and competent child care to improve the baby’s health and development. Finally, the nurses improve the client’s economic self-sufficiency by working with the client on goals for the future, including proper birth spacing, education continuation, and finding gainful employment. Families who leave these programs prematurely decrease the efficacy of the curriculum, miss opportunities to model a trusting relationship for the mother to the infant, and overall have fewer positive outcomes than families who stay enrolled for the full two years. Le Bonheur has been an implementing agency for NFP since 2009, and has served more than 660 clients in Memphis, TN.

More than 30 years of research anchored on three well-designed randomized, controlled trials documents lasting and significant benefits for both mother and child, including an increased number of babies born full term, more mothers initiating breastfeeding, more children current on immunization, and increased economic self-sufficiency. However, these positive effects correlate with the amount of time that mothers remain in the program and receive these intensive home visitation services. Le Bonheur NFP - along with NFP sites nationwide - has experienced a high level of client attrition, especially during the infancy stage. Secondary data analysis reveals that two of the most common reasons for client attrition are a.) the client’s nurse left the program and b.) Program model inflexibility (e.g. having to meet a certain number of times per month to stay enrolled ). Clients form close emotional bonds with their nurse home visitors. When a nurse leaves the program, the clients are often reluctant to engage with a new nurse and subsequently opt to leave the program prematurely. Nurses report leaving home visitation programs for any number of reasons but frequently state that they leave for better pay and works schedules available in the hospital settings, and because of compassion fatigue also known as burn out. Burn out is the state of physical, mental and emotional exhaustion and/or dissatisfaction with one’s work situation. NFP’s national service office have made changes to the program’s critical elements that allow for more flexibility regarding the frequency of the visits, the location of the visits and even allowing the use of electronic media such as face-time to conduct a certain percentage of visits . Nurse turnover continues to present problems for home visitation programs that are financially unable to complete with the salaries of bedside nurses and the level of burnout that comes with daily interactions with families facing poverty generated obstacles and unhealthy family dynamics.

PURPOSE: The purpose of this project was to improve client retention in the Le Bonheur NFP program, with the focus from birth to 1 years old by: 1) Improving the nurse home visitor’s knowledge of proven, effective client retention strategies. 2) Training the nurses to recognize early signs of client dis-engagement and nurse burnout amongst themselves and co-workers and ways to use reflective supervision and self-care to manage burnout symptoms. 3) Implementing allowable changes to the NFP model elements. 4) Investigate reasons why clients and nurses leave NFP prematurely/ This project was selected and facilitated through the STTI Maternal-Child Leadership Academy in participation with Johnson & Johnson.

PROJECT DESIGN/ACTIVITES/METHODS: A level of knowledge change was conducted with 6 nurses working in an evidence-based home visitation program using pre-and post-test utilizing an established client retention training module designed specifically for NFP. The sampling of this correlational study included research of past studies for identified reasons why clients leave the NFP programs prematurely and a sampling of 44 clients that left Le Bonheur NFP early in 2016. Trending cumulative data from Le Bonheur NFP quarterly reports was used to monitor change in the client retention rate from birth to 1 year and linked with annotation of dates that nurses resigned from the program. The data collection tools were the Pre-and post-test given with the client retention training module and the Client Retention Survey. The cumulative report used was quarterly client attrition during the infancy stage for reporting periods; 4th qtr. 2016, 1st quarter and 2nd quarter 2017.

FINDINGS: NFP’s client retention from birth to 1 year prior to this intervention averaged 67% which was comparable with the NFP national rate. Post intervention, this rate decreased slightly to. There was a direct correlation with the number of clients that left the program early and the recent turnover of 3 nurses. Responses from the survey mailed to clients was low, with almost 40% of the surveys being returned as undeliverable due to the client relocation. To date, the reasons for leaving indicated by the few that have responded to the survey align with the reasons for leaving commonly found in literature. Respondent # 1 selected visits conflict with work and school schedule; respondent # 2 selected my nurse left the program. Six nurse home visitors were educated using the client retention model and offered a pre-and post-test. Pre-test scores averaged 12/20, and rose by 6 points to 18/20 on the post-test, showing a marked knowledge gain in several critical areas.

Outcomes from this project indicate a strong need to reduce nurse turnover as a strategy to improve client retention. As shown in past research and in the current NFP’s experience, clients when made to change nurses, are much likelier to leave these programs early rather than engage with a new nurse. Survey of the 4 nurses that have been in the program the longest identified that weekly reflective supervision sessions along with a regular routine of practicing self- care has been most helpful with avoiding burnout.

CONCLUSIONS: The results of this study demonstrated that nurse retention directly correlates to client retention in long-term home visitation programs. Home visiting nurses should be trained on recognizing and managing the signs of compassion fatigue and client disengagement annually and encouraged to practice self-care that results in resiliency. Training the nurses how to utilize the allowed flexibility of the program model and how to ensure that services are client centered will improve client retention. The tenured nurses should share effective strategies with the newer nurses and with the NFP model developers to improve approaches that reduce nurse turnover and client attrition. The NFP leaders should advocate for tangible and intangible benefits that will add value this nurse home visitor position that will support longevity in this role.