Introduction/Problem: Nurse-client relationships have been considered the foundation of successful home visiting programs. It is within the context of relationships that clients reveal health concerns to nurses, receive information and act on a plan developed with the nurse. Although nurse-client relationships are considered important to home visiting, little is known about how relationships develop and the amount of time needed to develop a relationship that supports problem solving, client’s use of resources and changes in health behavior.
Objective: The purpose of this study is to: 1) explore relationship development between Mexican immigrant mothers and advanced practice school nurses during home visits, and 2) to determine the amount of time needed for mothers to enter a working relationship with nurses.
Design: This study is a secondary data analysis from a larger, experimental study that tests the effectiveness of home visits on mother’s mental health and family functioning. The study focuses on providing decisional control (Cox, 1982) to mothers in letting them decide the frequency or nursing contact and topics for problem solving. The design of the secondary data analysis reported here is a descriptive, multiple case study design that examines development of nurse-client relationships and problem solving over 10 home visits.
Population, Sample, Setting, Years: The sample for this study (n=23) is drawn from the Mexican immigrant population of Chicago. All research participants were born in Mexico and are mothers of 4th or 5th grade children who attend Chicago Public Schools. Data were collected during Fall, 2001.
Conceptual Framework: The conceptual framework guiding this analysis is Peplau’s Theory of Interpersonal Relations. Peplau’s theory posits that relationships develop in interlocking and overlapping phases of Orientation, Working and Resolution. Adding to the work of Peplau, Forchuk and Westwell (2000) identify relationship phases of Grappling and Mutual Withdrawal that occur in cases when relationships do not develop and frustration and distance occur between the nurse and client. Determining the length of time needed to enter the Working Phase is significant for health promotion because it is in this phase that clients identify and solve problems with nurses, use resources and change health behavior.
Methods: The research consisted of a multiple case study design. Data analyzed were The Relationship Form (Forchuk and Brown, 1989; Forchuk & Westwell, 2000), which includes empirical indicators of relationship development reflective of Peplau’s theory, Problem Solving Forms and Case Summaries developed for this study. Scores on the Relationship Form can be compared over time within a nurse-client relationship to track relationship development.
Findings: Dyads entered the Working Phase of the relationship at different times during the 16 week period. Of the 23 nurse-client dyads, seven dyads entered the Working Phase at the second and third home visits. Seven dyads entered the Working Phase in the 4th, 5th, or 6th home visits and one relationship entered the Working Phase in home visit 7 or later. One dyad remained in the Orientation Phase through out the study period. For the remaining seven dyads, two relationships experienced Mutual Withdrawal after four home visits and five participants dropped from home visiting program after one home visit. The length of the Orientation Phase was not influenced by the type of problems presented by the mothers.
Problems solved during this brief period of home visiting (7-10 home visits over 16 weeks) included finding health care resources for family members, dealing with an unintended pregnancy, finding employment, securing child care, learning computer skills, and exploring options for returning to school. Problems that were discussed, but were not resolved in the allotted for the intervention included: martial problems, parenting, children’s academic problems, family substance abuse, and domestic violence. Although difficult problems were not resolved, mothers used nurses as confidants and discussed options for problem solving and use of community resources that could be utilized after the nurse-client relationship ended.
Conclusions: Nurse-client relationships developed at varying rates during home visits. Future research should explore the amount of time and number of nursing contacts needed to solve more difficult and complex problems.
Implications for home visiting interventions. Monitoring relationship development is an important component of determining the nursing dosage needed to assist multi-problem families in meeting their needs. Limited nursing contact (10 home visits or less) is adequate for some mothers to develop relationships with nurses and to solve some problems.
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