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Relationship Work in an Early Childhood Home Visiting Program
Relationship Work in an Early Childhood Home Visiting Program Maureen Heaman, RN, PhD Karen Chalmers, RN, PhD Roberta Woodgate, RN, PhD Judy Brown, MN
A significant component of the work of public health nurses and paraprofessional home visitors who provide home visits to families with young children involves establishing relationships to effectively deliver the visiting program. The purpose of this qualitative and descriptive study was to describe the relationships among participants in a home visiting program in one regional health authority in the Canadian province of Manitoba. Interviews were carried out with 24 public health nurses, 14 home visitors, and 20 parents. The findings related to establishing, maintaining, and terminating relationships as well as factors influencing relationship work are described. Public health nurses and home visitors put significant effort into the work of establishing relationships with each other and their clients and require adequate training, sufficient human resources, and support from the program’s administration to sustain these relationships. n 2007 Elsevier Inc. All rights reserved.
OME VISITING PROGRAMS targeting high-risk families with infants and young children build on a long tradition of child health home visiting services delivered by public health nurses and, more recently, home visitors (paraprofessionals) under the supervision of public health nurses. With the growing number of welldesigned longitudinal studies, there is an increasing body of evidence that home visiting programs contribute to several improved outcomes in young children and parents, including improvement in parenting skills, reduction in behavior problems, and enhancement in the quality of the home environment (Elkan et al., 2000). However, much of the evaluation literature, while describing the program elements (i.e., number of home visits, type of visitor [professional nurse or paraprofessional], and duration of the visiting period), provides little attention to the processes that underpin the program elements. In particular, there is little discussion of the relationships between the network of people involved in the delivery of these programs and how these relationships may influence achieving the program goals. This omission would seem particularly important because the core of child health home visiting programs centers on the interactions between the
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Journal of Pediatric Nursing, Vol 22, No 4 (August), 2007
individuals delivering the program and the individuals receiving the services. This article describes findings related to the relationships among public health nurses, home visitors, and parents who participated in an early childhood home visiting program in one regional health authority in the Canadian province of Manitoba. BACKGROUND LITERATURE Although the importance of developing positive relationships with parents in home visiting programs is espoused in the professional literature, there is little empirical literature documenting how relationships are developed and the outcomes when
From the Faculty of Nursing, University of Manitoba, Winnipeg, MB, Canada, School of Nursing, Midwifery, and Social Work, University of Manchester, Manchester, UK, and Faculty of Nursing, University of Manitoba, Winnipeg, MB, Canada. Address correspondence and reprint requests to Maureen Heaman, RN, PhD, Faculty of Nursing, Room 217, Helen Glass Center for Nursing, University of Manitoba, Winnipeg, MB, Canada R3T 2N2. E-mail: [email protected] 0882-5963/$ - see front matter n 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2007.02.002
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positive relationships with parents are formed. Home visitors, both professional nurses and paraprofessionals, are often hired based on personal attributes that are thought to contribute to helping relationships, such as maturity, warmth, empathy, a nonjudgmental attitude (McGuigan, Katzev, & Pratt, 2003), self-assurance, cultural sensitivity, and good parenting skills (Duggan et al., 1999). In addition, reliability, literacy, residency in the local community, and having a history of volunteering are factors deemed important for nonprofessional visitors (Barnes-Boyd, Fordham, & Nacion, 2001). There is some empirical support that what gets offered by professional nurses in home visiting programs (called health visitors in the United Kingdom) and how the offer is received and acted on by the parents are complex processes that influence relationship development (Chalmers & Luker, 1991; Luker & Chalmers, 1990). The development of relationships with parents who receive visits in the prenatal period has been associated with improved child health outcomes as compared with that of relationships with parents who begin receiving visits postnatally. The study by Larson (1980) concluded that the development of the relationship between the mother and the paraprofessional home visitor was enhanced through early and prolonged involvement and that this contributed in part to the outcomes. The retention of families in programs and more home visits are associated with matching parents and home visitors on the variables of race/ethnicity and parental status (Daro, McCurdy, Falconnier, & Stojanovic, 2003). These researchers concluded that the quality of the relationship may be enhanced when there is more common ground between visitors and parents. In addition, the availability of social support, particularly from friends, has been linked to the quality of the relationship developed between home visitors and mothers (Marcenko & Spence, 1994). The skills found to be important in effective home visiting include relationship building with families under stress, empathic communication, therapeutic use of self, building of trust, and other supportive behaviors (Daro & Harding, 1999; Jack, DiCenso, & Lohfeld, 2002; Kearney, York, & Deatrick, 2000). Relationship building and interviewing skills are frequently included in training programs for home visitors (Marcenko & Spence, 1994). Few studies incorporate parents’ perspectives on home visiting (Byrd, 1997). In one study, mothers reported feeling vulnerable and frequently power-
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less during home visits and valued the development of interpersonal relationships with their public health nurses and family visitors (Jack, DiCenso, & Lohfeld, 2005). Parents also rated home visitors highly on their ability to demonstrate empathy, understanding, respect for the family, trustworthiness, and ability to motivate and guide the family (Duggan et al., 1999)—all of which are qualities needed in developing a trusting relationship with vulnerable families. Although the positive aspects of forming relationships are widely espoused in the professional literature, there is little discussion of the tensions and problems that may arise between professional and paraprofessional home visitors and their clients (Peckover, 2002). There is little empirical literature that compared professional home visitors (usually public health nurses) with paraprofessional home visitors in terms of their capacity to develop successful relationships. Persily (2003), in a review of home visiting programs for young pregnant women, concluded that paraprofessional home visitors may be more acceptable to pregnant women, although the capacity to develop successful relationships was not specifically addressed. Although there is a growing body of evidence that outcomes of children and families are improved when they are visited by either public health nurses or paraprofessional home visitors, the long-term benefits to mothers and children appear to be enhanced when families are visited by professional nurses (Olds et al., 2004). In summary, the development of positive relationships between professional and paraprofessional home visitors and parents is considered to be an important component of effective home visiting programs. Further understanding of those factors underpinning home visiting programs, including relationships, could shed light on why programs or components of programs are effective or not. This understanding could make an important contribution to revising and strengthening current early childhood home visiting programs. BABYFIRST PROGRAM The BabyFirst Program is a community-based early childhood program established in 1998 that provides services to families from the province of Manitoba who live in conditions of risk and who have children up to 3 years old. Conditions of risk include such factors as substance abuse by one or both parents, parents’ own experience of abuse and/or neglect as a child, social isolation, parents’ lack of
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education and basic literacy, unstable housing, and other social and economic hardships. The BabyFirst Program emphasizes positive parenting, enhanced parent–child interaction, improved child health and development, and optimal use of community resources (Children & Youth Secretariat, 1998). The BabyFirst Program is based on Hawaii’s Healthy Start Program (Duggan et al., 1999; Earle, 1995). All families with a newborn are assessed for eligibility for the program by a public health nurse using a universal screening tool. Families identified as being at potential risk (having z3 risk factors) then receive an in-depth family assessment by the public health nurse, and those families who score above a preset point are offered home visitation. The program is available to all families from the province who meet the assessment criteria and agree to participate. Consenting parents are assigned a trained paraprofessional home visitor who has completed secondary school. The home visitor’s role is to work toward the goals of the BabyFirst Program using a standardized curriculum, the Growing Great Kids Curriculumn. This curriculum provides the foundation, structure, and frequency for the visits but also permits flexibility in response to every family’s needs and current situation. Frequency of contact is dependent on the family’s need and developmental progress but is often on a weekly basis. Public health nurses provide the ongoing nursing care and support to the family and supervise the home visitors. The home visitors and the supervising public health nurses receive an orientation to the BabyFirst Program that consists of 4 days of core training (which covers the philosophy and principles of the program, communication strategies, developing a trusting relationship, and goal setting) and 5 days of curriculum training. The public health nurses receive an additional day of training related to providing guidance and support to the home visitors. Ongoing training also occurs (e.g., cultural awareness sessions). METHODOLOGY
Design Data for this project were collected as part of a larger study conducted to provide an evaluation of the BabyFirst Program from the perspective of the providers and recipients of the program. A qualitative and descriptive study that entailed a comprehensive summary in the everyday language of events and the meanings that participants
attributed to those events (in contrast to phenomenology and grounded theory descriptions, which represent events in other terms; Sandelowski, 2000) was conducted. We sought the views of the key participants in the program on a number of program elements, including the strengths and limitations of the program, the assessment and enrollment processes, their experience in working with other participants, the overall effectiveness of the program, and their recommendations for change. Sandelowski noted that qualitative description is especially useful for obtaining straight answers (i.e., minimally theorized or otherwise transformed) to questions of special relevance to practitioners and policymakers. As researchers, we were interested in generating data that would be useful in understanding the interactions among the key participants in the program as well as in gaining an enhanced understanding of the home visiting process, including developing and managing relationships.
Setting and Sample We conducted the study within the largest regional health authority in the province of Manitoba where approximately 65% of the population reside. In 2002, approximately 46% (n = 240) of eligible families participated in the BabyFirst Program, with other families not receiving the program because of their refusal to receive the service or intake being full. The sample consisted of 58 participants (24 public health nurses, 14 home visitors, and 20 parents). The sample size was preset based on the accessible population (102 nurses and 34 home visitors) and estimates of the number of responses needed to ensure sufficient data to inform the interview process. There was no attempt to develop random or systematic sampling procedures in this qualitative evaluation study. All public health nurses had to have a minimum of 2 years of public health experience to ensure familiarity with the role. The criterion of a 2-year work history has been used in previous studies on public health nursing/professional health visiting practice (Chalmers, 1992, 1993, 1994; Chalmers & Luker, 1991; Kristjanson & Chalmers, 1990; Luker & Chalmers, 1990). The inclusion criterion for home visitor and parent participants was having a minimum of 12 months and that of 6 months, respectively, of experience with the BabyFirst Program to ensure sufficient time to be familiar with the program. In addition, parent participants
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had to be receiving regular home visiting services, be English speaking, and have adequate reading capacity to provide informed consent to participate. Public Health Nurses All public health nurse respondents (n = 24) were White women at a mean age of 45.9 years (SD = 8.7 years). Most of the nurse participants were very experienced (M = 20 years, SD = 10.4 years), with an average of 14 years of public health nursing experience. All nurses had a bachelor of nursing degree; several had other degrees (21%) or certificates (21%). Most of these respondents had considerable experience with the BabyFirst Program (M = 56 months, SD = 17 months). Home Visitors The 14 home visitors were all women at an average age of 39 years (SD = 10 years). More than half (57%) were married, and most (79%) had children ranging in age from 3 to 31 years. Four home visitors identified themselves as being of Aboriginal descent, either First Nations or Me´tis, whereas the rest self-described themselves as White. The home visitors had a mean length of education of 15 years; many had various health care certificates, and 2 had university degrees. Home visitors had a mean of 35 months (SD = 19.2 months) of working experience with the BabyFirst Program. Parents Twenty mothers agreed to be interviewed. Occasionally, the father of the child was present during the interviews, but in only three instances did the father become actively involved in the interview. The data subsequently described present the perspectives of the mothers, with those fathers who participated providing responses similar/congruent to those of their partners. The mothers had a mean age of 24.7 years (SD = 5.8 years), had a mean of 12 years of education (SD = 1.6 years), and were either White (80%) or Aboriginal (20%). Fifty percent were single, whereas 45% were married or living in a common law relationship. Most mothers (65%) reported that they were homemakers. The mean age of the children in the program was 14.7 months (SD = 10.6 months).
Data Collection In-depth semistructured interviews were conducted by a master’s-prepared research nurse in
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the parents’ homes and in public health offices or in other areas where private space was ensured. The interview questions were designed by the investigators to elicit information addressing the study goals. Separate interview guides were developed for each group, although similar questions were asked of all participants. Questions asked of the public health nurses and home visitors included the following: ! Tell me about your involvement with the BabyFirst Program. ! What is your understanding of the goals and objectives of the BabyFirst Program? ! What are the program components and how do these relate to the overall goals and objectives of the program? ! In the course of a week, describe your activities related to the BabyFirst Program. ! Tell me about your experience in working with the home visitors/public health nurses. ! Tell me about your experience in working with the client families. (Probe: What works well and why? What does not work so well and why? How do you attempt to create a positive relationship with the family?) ! In your view, what are the strengths and limitations of the BabyFirst Program? ! What is the overall effectiveness of the program? ! What recommendations, if any, do you have for improving the BabyFirst Program? Questions asked of the parents included the following: ! Tell me about how you became involved with the BabyFirst Program. ! How did you think the BabyFirst Program would help you? ! In the course of a week, describe the services you received in the BabyFirst Program. ! What do you like most/like least about being involved in the BabyFirst Program? ! What does the home visitor do that you find helpful? Not helpful? ! What does the public health nurse do that you find helpful? Not helpful? ! In your opinion, what are the overall benefits and weaknesses of the BabyFirst Program? ! What suggestions, if any, do you have for improving the BabyFirst Program? The interviews lasted between three quarters of an hour and an hour and a half. Each participant
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also completed a short demographic form specifically developed for each group of participants to collect data on demographic characteristics and work/program history. Data collection took place over a 5-month period, from October 2003 to February 2004.
Data Analysis Quantitative demographic data were entered and analyzed using Microsoft Exceln. Two transcribers transcribed the taped interviews using Microsoft Word n. The research nurse then checked for accuracy by reviewing audio tapes with the transcripts. Transcribed data were analyzed manually by the three researchers using content analysis techniques (Field & Morse, 1995; Manning & Cullum-Swan, 1994). Data analysis was carried out concurrently with data collection. Each researcher initially read the transcript in full then reread the transcript and began open coding in the margins of the transcripts. After each researcher had reviewed a number of transcripts, discussions of developing codes, categories, and themes among the research team. In total, 20 themes were identified. Several categories relating to each theme were described. Operational definitions were written for each theme and the supporting categories. This joint and individual work occurred until congruence in coding was reached. The categories were also refined through more focused interviewing in subsequent interviews (Sandelowski, 1995; Schatzman & Strauss, 1973; Strauss & Corbin, 1990). Quotations from the data were used to illustrate the findings. Any discrepancy in the data analysis was reviewed, and the data were reexamined until consensus was attained. We also undertook standard measures to enhance the rigor of the qualitative research process, including regular debriefing of the research nurse with the research team and careful line-by-line analysis of the transcripts (Guba & Lincoln, 1994; Schatzman & Strauss, 1973). A major theme uncovered through this analysis process was the work of developing relationships among the participants of the BabyFirst Program. The findings related to the categories within this theme of relationship work are described below.
Ethical Issues We ensured that ethical standards were maintained throughout the project. We maintained careful attention to issues of recruitment, consent,
confidentiality, potential vulnerability, and sensitivity. Before the data collection, we received approval for the project from the University of Manitoba Education/Nursing Research Ethics Board. All participants received written information about the project and were ensured that their participation was voluntary. We obtained written consent from each participant. The two transcribers hired for the project each signed a confidentiality agreement. Parent participants received an honorarium of $20 for their participation in the study, whereas the public health nurses and home visitors did not receive an honorarium, although they were permitted to participate in the interviews during working hours. THE FINDINGS: RELATIONSHIP WORK Central to the implementation of the BabyFirst Program was the network of relationships among participants. The theme of relationship work addressed the active efforts of public health nurses and home visitors to develop and maintain positive connections in their day-to-day work with each other and the parents. It consisted of two main categories: (a) establishing, maintaining, and terminating relationships and (b) factors that influenced the relationship work. Each of these is described in detail below. The goal of facilitating positive relationships was to provide benefits to the clients in the BabyFirst Program. Although relationships were important to parents as well, the work of developing, maintaining, and terminating relationships was, for the most part, carried out by the service providers.
Establishing, Maintaining, and Terminating Relationships Nurses and home visitors had opportunities to develop relationships with parents throughout the course of their BabyFirst Program work. These were evident at the time of establishing, that of maintaining, and, in some cases, that of terminating relationships. Establishing Relationships The work of developing relationships began at the time of initial contact. For the BabyFirst Program work to begin, parents needed to be assessed for eligibility for the program; if eligible, their permission was sought for enrollment in the program. Public health nurses initially screened all new postpartum clients during a home visit. Those
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families with three or more risk factors then received an in-depth family assessment, during which the nurse explored risk factors for parenting and sources of support. Most nurses expressed sensitivity to the assessment process but appeared to deal with this issue in different ways. Most appeared to be quite open with parents in terms of the rationale for the detailed assessment procedure used to determine eligibility for the program (i.e., higher risk for abuse/neglect). For example, one public health nurse stated: I try to be upfront with the in-depth assessment. dThis is the program, I need to ask you these questions, you may feel uncomfortable, sometimes it may be personal, but this is a way of getting a better picture and feel of whether the program is a match for you.T Families are usually okay with that. They want to be honest with you.
Other nurses found the assessment process to be intrusive and potentially damaging to their relationship with the parents. Consequently, albeit not providing false information, they did not disclose much about the rationale for the program or criteria for admission. As one nurse remarked: I do not usually tell them about the [assessment process]. . .to the BabyFirst [program]. I tell them a little bit about it, and when I am doing community resources, I say, dhere is another resource that we have for families to support them with parenting.T
The nurses appeared to have worked out an approach to assessment and enrollment that they were comfortable with. Few parents appeared to know why they specifically were asked to join the BabyFirst Program. Only two mentioned or remembered being questioned extensively by the nurse before signifying their acceptance. Many of the mothers thought that the nurse asked if they would be interested in the program because they were young, single, and/or inexperienced in child care. One mother revealed: We were both really kind of nervous. Neither one of us has raised kids before, so we’re not entirely sure what to do.
Home visitors were introduced to the parents by the public health nurse who was active with the family. They then had to work toward developing their own relationship with the parents. One home visitor explained: I get assigned a family and my number one thing is to be myself—not to go in with an agenda because I
think that puts people off, [I] listen and talk to the family about what their needs are. So then what I would do after that initial visit, I would put together what I feel are the priorities. And then from there on the relationship just naturally occurs.
Maintaining Relationships Some parents reported that they immediately liked the home visitor. It took other parents longer to get to know and like their health visitor. A few parents, at least on some level, reported that they did not like their home visitor. If home visitors could establish an initial connection with the parents, they could usually progress with their work. For example, one parent reported that she was not expecting a weekly visit because she knew bhow to raise a child,Q but once the home visitor came, she found her really bawesome.Q Terminating Relationships Relationships were terminated usually in two ways: when service providers needed to be changed because (a) the public health nurse or home visitor left the program or was reassigned or (b) the parent moved to a new area in the city. Relationships were also terminated when the family had completed the program (i.e., when the child turned 3 years old). Changing home visitors during the course of the BabyFirst Program was more or less problematic for parents. Some parents reported that changing home visitors was difficult but not overwhelming. Others expressed considerable concern about having to end their relationship with and change their visitor, as noted by one parent: If I move to another area, I can’t have my same BabyFirst worker as here. . .we don’t want to get somebody else,
whereas other parents really valued the program and would make the adjustment to a new home visitor, as reflected in one mother’s comment: I really like your program [BabyFirst] and the home visitor, but if I had to have somebody else, I would accept them.
Home visitors also considered the requirement to terminate their relationship with families when they moved to another area to be problematic. Taking on a family from another home visitor entailed establishing a new relationship with the parent in the shadow of the former relationship. In addition, changing home visitors meant severing bonds rather than building consistent trusting
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relationships. One home visitor raised the following concern: If my family moves to a different area, I have at times been where I have to give that family up. . .I feel that it is the failure of the program [that] every time our families move they get a new BabyFirst home visitor. . .I don’t feel that it is appropriate because we are not teaching these families about consistency. And I think that it is about building a bond. Trust does not come overnight, and to keep that trust is important, and that is to continue working with them when they move.
Nurses and home visitors considered that terminating relationships with families was best accomplished when there was a planned exit over a number of visits. A home visitor stated: It is just a weaning process. You wean them off; visits become less. You give them lots of notice.
At the completion of the BabyFirst Program at the child’s third birthday, the home visitor terminated her relationship with the family. Some parents considered this to be a satisfactory time to finish the visiting program, whereas others preferred a shorter or longer period. Parents in this study reported having between one and three home visitors, with just more than half of the parents having one home visitor. However, the average length of time in the BabyFirst Program at the time of data collection was 18 months (SD = 12.6 months). Participants may have additional comments on the changeover of workers and the termination of relationships at the end of the 3-year visiting period.
Factors Influencing the Relationship Work Relationship work was influenced by several factors that could be more or less effective in establishing, maintaining, and potentially terminating relationships based on how each was perceived and received by the other party. These factors included showing respect, providing support and facilitating empowerment, developing trust, working in partnership, working as supervisors/evaluators, and developing and maintaining appropriate boundaries within the relationship. Although presented separately, these factors were not always distinct entities and instead often interconnected. Each is described in detail below. Respect Two central components that home visitors in particular talked about in establishing and maintaining relationships were showing respect and
being shown respect. They frequently commented on the importance of being respected, particularly by public health nurses. This included being respected for their abilities as home visitors and the opinions they brought to case reviews and other professional fora. One home visitor stated: They are all approachable [public health nurses]. Nobody ever makes you feel that dI am a nurse and you are a home visitorT. . .I think my word is appreciated along with everybody else. I often have people tell me, dI appreciate what you are doing with the family, I am happy they are with you.T I find that communication is very open. And nobody is condescending, and they appreciate me and respect me.
Another home visitor commented on being respected by parents: I think they [families] do respect us, they know that we [home visitors] do not make a barrel of money.
Although there were comments in the interviews that suggested that not all home visitors felt respected by nurses or clients, these comments were quite rare. Being shown respect was also important to parents. Respect seemed to entail many qualities such as treating parents as people and making efforts to assist them. One mother stated: She [home visitor] doesn’t make you feel that she is better than you. She doesn’t have an attitude.
Support A core component of relationship work was providing support. This was a key component of public health nurses’ work with the home visitors. One public health nurse said: I see myself really as a support to the home visitor. I am the one [who], when they come back [from a home visit], [would] drop everything.
For some of the home visitors, their work with families triggered unresolved issues in their own lives, and the public health nurses provided them with support in dealing with those issues. Public health nurses and home visitors also worked to provide support to parents. One home visitor related the following example of providing support: I work with a mom who had really low self-esteem and doubted her parenting ability and she lives with her father, and he kept telling her, dOh, you are a bad mother.T. . .But I kept telling her she was a good mother. . .She was like dWow!T And she had a lot of difficulty with her father and the baby, but she had another baby and now she says, dI don’t care what he says, I am a good mother.T
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Parents, for the most part, recognized and valued the support that they were offered by public health nurses and home visitors. Trust Central to creating a supportive relationship was developing trust. Following through with what was expected was an important component of building trust between public health nurses and home visitors, between home visitors and parents, and between public health nurses and parents. This was not always easy when there were conflicting perspectives on situations, workload pressures, or difficulties with contacting families. One public health nurse stated: You really need to watch workload wise that you can, that you are going to deliver something and then not be able to do it—because that can break the trust. Because if your relationship with the home visitor isn’t good, it really shows in your relationship with the family as well.
Public health nurses recognized the importance of trust in the relationships formed between themselves, the home visitors, and the families. As one public health nurse explained: The home visitor forms a relationship with this person. They trust them. . .So when they get a trusting relationship with that home visitor, then it allows them to open up and accept information and accept suggestions and learn and feel positive about themselves, which empowers them to then make changes in their lives.
A mother spoke about trusting the home visitor: As soon as I talked with her [home visitor], I knew she was nice and I could actually trust her. A lot of people I won’t trust about anything.
Partnership Public health nurses and home visitors also valued developing partnerships when working with each other and the families. One public health nurse expressed the following viewpoint: Doesn’t matter whoever you are, I’m your partner to help you. . .,
whereas another nurse stated: The home visitors are part of our monthly public health nurses meeting. They share information from their BabyFirst knowledge with all the staff.
Partnerships in relationships, although valued, were not always perceived as the norm. Demonstrating respect for each other was a key compo-
nent of positive partnerships. Some public health nurses did not consider that home visitors were always treated as partners, and some home visitors felt they were not always treated with respect. A public health nurse commented: On occasion, they [home visitors] feel that they are treated poorly, not as colleagues, not treated as if they have as much knowledge. Or they don’t have as much skill. . .they really need to hear that they are doing a good job, and I don’t think they always hear that from the office group, from the coordinator, from the [nurses].
A home visitor expressed her frustration as follows: We’re [home visitors] way at the bottom of that totem pole, and I feel that [home visitors] are very much left out of things and we are the ones that are, well, working our ass [sic] off, and these public health nurses are sitting back and taking credit for everything and I just get really, really frustrated.
Parents did not specifically talk about partnerships with the public health nurse or home visitor. Their focus within the relationship appeared to be more on the characteristics and behaviors that they valued or did not value. Supervision and Evaluation Public health nurses, although valuing partnerships in their relationships, also functioned as supervisors and evaluators of the home visitors. Nurses expressed varying levels of comfort with their supervisory and evaluative roles. Some nurses saw these as extensions of their original work in working directly with families; others appeared to have greater discomfort with this aspect of their work. Nurses made the following comments: I am your partner as the BabyFirst home visitor, but, at the same time, I am also your supervisor. I do not want anybody to come and go at leisure; you have to come to work [on time]. There needs to be quite an open relationship between the public health nurse and the home visitor as to where the family’s goals are going and a regular reevaluation of that.
Most home visitors considered the supervisory relationship with their public health nurses in a positive light. They valued the public health nurses’ input and guidance, particularly when they detected problems and crises with their families. As one home visitor stated: I love working with my (public health nurse)! She is a very easy person to talk to. . .It is so nice to be
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able to come in and say, dLook, this is what’s happeningT. . .when I have really challenging visits—which I do—and I get a little uptight, then she’s just a good person to bounce it off and, you know, sort of relieve some of that stress.
Maintaining Professional–Client Boundaries Public health nurses talked about the importance of maintaining professional boundaries with home visitors and parents. Nurses both practiced this and attempted to model this for home visitors. One nurse commented on how a professional relationship needs to be maintained with parents: Reaffirming that I am not here to be your best friend. . .it is like you are building a relationship. But it is a professional relationship, and it has to be reaffirmed sometimes.
Another public health nurse explained how she develops relationships with the home visitors: I work with the home visitors exactly how I want them to work with families, recognizing their strengths, building on things and how to problem solve. So I think that I have been able to role model that parallel process.
Home visitors were also required to maintain professional boundaries with clients. In many ways, this was more challenging for home visitors than for the nurses. The nurses had considerable experience in developing and maintaining professional relationships. In addition, their interactions were more likely to be perceived as professional by the parents (e.g., carrying out assessments of babies), whereas home visitors’ interactions with parents were often day-to-day activities, such as talking about child care and taking the bus together to a parent’s group. One home visitor commented on boundaries as follows: I really just let the relationship develop, with proper boundaries. Well, the big thing for me is having proper boundaries. Because a lot of the families want to have you as their friend. So it is the defining line [boundaries].
However, it was not uncommon for parents to consider the home visitor as their friend and invite the home visitor to birthday parties and other family events. It was important for home visitors to negotiate the boundaries carefully with the clients to keep an appropriate role. DISCUSSION Positive relationships were seen as an important mechanism in delivering the BabyFirst Program
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and providing benefits to the families. Findings from this study suggest that public health nurses and home visitors put significant effort into the work of establishing relationships with each other and their clients. Establishing relationships with parents within the context of this child health home visiting program would seem to be particularly critical at two periods. One of these periods has been called the entry phase (Chalmers, 1992). Initially, parents must agree to enroll in the program once their eligibility is established. In the case of the BabyFirst Program, the work of enrolling parents rested with the public health nurses. For the most part, the nurses did not have a prior relationship with the parents. The nurses needed to function as a broker for the program and gain the acceptance of the parents for the BabyFirst Program work to begin. Public health nurses who were not open with prospective clients about their eligibility for the program ran the risk that parents will react negatively once they learned that they are considered to be a high-risk parent. However, most of the nurses interviewed in the study truthfully outlined why parents were eligible for the program and did so in a way that was acceptable to the parents. This approach laid the groundwork for the development of trust that was considered so important by the participants in this study. The home visitors then had to do their own entry work with the families. Consistent with the findings of other research work (Chalmers, 1992), many of the home visitors in this study reported that they initially assessed the key need or problem from the family’s perspective and responded with an offer of help to meet the need or solve the problem. Chalmers referred to this approach to entry work as trying to focus on something that the family considers to be important, which is one of several processes that assists in entering more fully into the client situation (Luker & Chalmers, 1990). The process of entry can be viewed on a continuum from a very easy entry to a very difficult entry (Luker & Chalmers, 1990). A limitation of this study was the lack of knowledge related to factors resulting in a very difficult entry. Because BabyFirst Program participation is voluntary and parents had to agree to be enrolled in the program, we were unable to gain the perspective of families who decided not to accept the program services. Further research is needed to explore reasons why families choose to decline participation in the program. Likewise, we had no knowledge as to the extent of how trust, or lack of
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trust, may have affected parents’ decision not to enroll in the program. The second critical period in relationship work is the ongoing relationship development, particularly between the home visitor and the parent. The factors identified in this study that positively influenced ongoing relationship work included showing respect, developing trust, supporting families, working in partnership, and maintaining appropriate boundaries. These are similar to skills important in effective home visiting that have been identified by other investigators (Daro & Harding, 1999; Jack et al., 2002, 2005; Kearney et al, 2000). Providing training in the development of skills such as empathic communication, development of trust, and other supportive behaviors may enhance the effectiveness of home visiting programs and result in more satisfied staff and clients. In addition, a fundamental component of the helping role is learning to develop positive working relationships while respecting the boundary between clients and service providers. Some home visitors in our study had difficulty with establishing appropriate boundaries with parents. Clearly, this is a very important skill in home visiting work and needs careful attention in the initial orientation and ongoing continuing education. Failure to establish appropriate boundaries may jeopardize the helping relationship and impede the outcomes for parents. Although all nurses and home visitors received an initial orientation and periodic additional workshops, there appears to be a need for systematic and ongoing training in communication and listening skills, relationship development, and sensitivity to clients’ needs. Paying attention to the factors that promote positive relationships may also increase the likelihood that parents will agree to join and remain in the program. The literature on child health home visiting programs concludes that families receive only approximately half of the number of intended visits and that between 20% and 67% of enrolled families leave the program before the intended termination date (Gomby, 1999). Although relationship development is undoubtedly complex and not easy to describe, evaluate, or control, it is likely a key factor influencing the retention of families in home visiting programs. Limiting the size of a home visitor’s caseload has been suggested as important to allow for the establishment of more intense relationships (Daro et al., 2003). Both public health nurses and home visitors in the BabyFirst Program were sensitive to the impact of
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large or frequently changing caseloads. Retention of home visitors in visiting programs is also important to ensure the time needed to develop relationships (Fraser, Armstrong, Morris, & Dadds, 2000). Administrators need to give careful consideration to recruitment and retention strategies to ensure a stable workforce of home visitors. The final phase of the relationship work involves termination, during which home visitors end their contact with the families. Similar to other findings (Chalmers, 1992), termination work appeared to play a fairly minor role for home visitors and families. In the negotiated approach, families were aware that the program services would be terminated when their child turned 3 years old. A more problematic situation arose when the termination was necessitated by the family’s move to another region of the city. Chalmers referred to this as the nonnegotiated approach to termination. Some of the families in this study found changing home visitors to be stressful and counterproductive to strengthening their relationship with the home visitor. For many families, frequent moves are a reality of their lives as they seek safer and better housing. Administrators need to carefully consider if the policies related to changing home visitors when clients move are really in the overall best interests of the families. The benefits of programs cannot occur if parents do not agree to visits or do not stay in the program. Although there may be many reasons for families to discontinue visits, a positive relationship with their home visitor will likely contribute to maintenance in the program for some families. Our findings indicate that a strong relationship with the home visitor was highly valued by the parents. Forming workable and sustained relationships between home visitors and parents requires adequate support. Sufficient human and material resources are needed for public health nurses and home visitors so that they can carry out the program as designed. The home visitors and public health nurses in this study valued the development of supportive relationships with each other to enable them to function at their optimum with parents. Public health nurses also acknowledged the importance of their supervisory role, although this was a challenging part of the work for some. Staff nurses have not traditionally carried out supervisory functions, and the knowledge underpinning this function is not usually part of baccalaureate education programs. However, if public health nurses are to provide helpful super-
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vision to home visitors, they need appropriate knowledge and skills. There is also some evidence that supervision has a positive benefit in the retention of parents in one home visiting program (McGuigan et al., 2003). Despite potential positive gains from home visiting programs reported in the literature and the importance of positive relationships in delivering these services, programs that provide parenting education through limited home visiting cannot ameliorate the severe problems that many parents experience, such as poor housing, low literacy, poor parental role models, and little education (St Pierre & Layzer, 1999). Many of the families in this study had few financial and social resources. These determinants of health likely have a major impact on parenting practices. In addition to attending to their direct service work, public health nurses must also support broad policy initiatives that enhance health. The limitations of this study relate to the voluntary nature of participation in the interviews. The characteristics and perspectives of those public health nurses, home visitors, and parents who volunteered to be interviewed may have differed from those who chose not to participate. The recruitment process for the parents was also a limitation in that the home visitors approached and invited parents to participate; therefore, not all parents had the opportunity to consider participating in the study. Participation was limited to Englishspeaking parents; therefore, the perspectives of non-English-speaking parents were not included.
Although a few fathers participated in the interviews, most parent participants were mothers. Fathers may have differing perspectives on the program. Strengths of the study relate to the qualitative design, which provides rich descriptive data from the perspective of those closely involved with the program. All interviews were carried out by one experienced master’s-prepared research nurse hired for research purposes only, which ensured standardization of the interviewing process and no conflict of interest with a service delivery role. In conclusion, this study makes a contribution to our understanding of the relationships between service providers and parents as uncovered in a qualitative evaluation of an early childhood visiting program. In particular, the findings provide information from the perspectives of all three key participants in the program: public health nurses, home visitors, and parents. The results provide information for ongoing development and improvement of home visiting programs.
ACKNOWLEDGMENTS This research was funded by the Winnipeg Regional Health Authority. Dr. Heaman was supported by a New Investigator Award from the Canadian Institutes of Health Research. Dr. Woodgate was supported by a Canadian Cancer Society Research Scientist Award and a Manitoba Health Research Council Establishment Award. We thank Claire Betker, RN, MN, for her contributions to this project.
REFERENCES Barnes-Boyd, C., Fordham, N. K., & Nacion, K. W. (2001). Promoting infant health through home visiting by a nursemanaged community worker team. Public Health Nursing, 18, 225 – 235. Byrd, M. E. (1997). Child-focused single home visiting. Public Health Nursing, 14, 313 – 322. Chalmers, K. I. (1992). Giving and receiving: An empirically derived theory on health visiting practice. Journal of Advanced Nursing, 17, 1317 – 1325. Chalmers, K. I. (1993). Searching for health needs: The work of health visiting. Journal of Advanced Nursing, 18, 900 – 911. Chalmers, K. I. (1994). Difficult work: Health visitors’ work with clients in the community. International Journal of Nursing Studies, 31, 168 – 182. Chalmers, K. I., & Luker, K. A. (1991). The development of the health visitor–client relationship. Scandinavian Journal of Caring Science, 5, 33 – 41. Children and Youth Secretariat. (1998). BabyFirst implementation paper. Winnipeg, MB: Children and Youth Secretariat Province of Manitoba. Daro, D. A., & Harding, K. A. (1999). Healthy Families
America: Using research to enhance practice. Future Child, 9, 152 – 178. Daro, D., McCurdy, K., Falconnier, L., & Stojanovic, D. (2003). Sustaining new parents in home visitation services: Key participant and program factors. Child Abuse & Neglect, 27, 1101 – 1125. Duggan, A. K., McFarlane, E. C., Windham, A. M., Rohde, C. A., Salkever D. S., Fuddy, L., et al. (1999). Evaluation of Hawaii’s Healthy Start Program. Future Child, 9, 66 – 90. Earle, R. (1995). Helping to prevent child abuse and future criminal consequences: Hawaii Healthy Start. National Institute of Justice: Program Focus. Elkan, R., Kendrick, D., Hewitt, M., Robinson, J. J., Tolley K., Blair, M., et al. (2000). The effectiveness of domiciliary health visiting: A systematic review of international studies and a selective review of the British literature. Health Technology Assessment, 4, i-339. Field, P., & Morse, J. (1995). Qualitative research methods for health professionals. Thousand Oaks, CA: Sage. Fraser, J. A., Armstrong, K. L., Morris, J. P., & Dadds, M. R. (2000). Home visiting intervention for vulnerable families with
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newborns: Follow-up results of a randomized controlled trial. Child Abuse & Neglect, 24, 1399 – 1429. Gomby, D. S. (1999). Understanding evaluations of home visitation programs. Future Child, 9, 27 – 43. Guba, E., & Lincoln, Y. (1994). Competing paradigms in qualitative research. In N. Denzin, Y. Lincoln (Eds.), Handbook of qualitative research (pp. 105 – 117). Thousand Oaks, CA: Sage. Jack, S., DiCenso, A., & Lohfeld, L. (2002). Opening doors: Factors influencing the establishment of a working relationship between paraprofessional home visitors and at-risk families. Canadian Journal of Nursing Research, 34, 59 – 69. Jack, S. M., DiCenso, A., & Lohfeld, L. (2005). A theory of maternal engagement with public health nurses and family visitors. Journal of Advanced Nursing, 49, 182 – 190. Kearney, M. H., York, R., & Deatrick, J. A. (2000). Effects of home visits to vulnerable young families. Journal of Nursing Scholarship, 32, 369 – 376. Kristjanson, L., & Chalmers, K. (1990). Nurse–client interactions in community-based practice: Creating common ground. Public Health Nursing, 7, 215 – 223. Larson, C. P. (1980). Efficacy of prenatal and postpartum home visits on child health and development. Pediatrics, 66, 191 – 197. Luker, K. A., & Chalmers, K. I. (1990). Gaining access to clients: The case of health visiting. Journal of Advanced Nursing, 15, 74 – 82. Manning, P., & Cullum-Swan, B. (1994). Narrative, content, and semiotic analysis. In N. Denzin, & Y. Lincoln, (Eds.) Handbook of qualitative research (pp. 463 – 483). London: Sage.
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Marcenko, M. O., & Spence, M. (1994). Home visitation services for at-risk pregnant and postpartum women: A randomized trial. American Journal of Orthopsychiatry, 64, 468 – 478. McGuigan, W. M., Katzev, A. R., & Pratt, C. C. (2003). Multilevel determinants of retention in a home-visiting child abuse prevention program. Child Abuse & Neglect, 27, 363 – 380. Olds, D. L., Robinson J., Pettitt, L., et al. (2004). Effects of home visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial. Pediatrics, 114, 1560 – 1568. Peckover, S. (2002). Focusing upon children and men in situations of domestic violence: An analysis of the gendered nature of British health visiting. Health & Social Care in the Community, 10, 254 – 261. Persily, C. A. (2003). Lay home visiting may improve pregnancy outcomes. Holistic Nursing Practice, 17, 231 – 238. Sandelowski, M. (1995). Qualitative analysis: What it is and how to begin. Research in Nursing & Health, 18, 371 – 375. Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing & Health, 23, 334 – 340. Schatzman, L., & Strauss, A. (1973). Field research: Strategies for a natural sociology. Englewood Cliffs, NJ: Prentice Hall. St Pierre, R. G., & Layzer, J. I. (1999). Using home visits for multiple purposes: The Comprehensive Child Development Program. Future Child, 9, 134 – 151. Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage.
A significant component of the work of public health nurses and paraprofessional home visitors who provide home visits to families with young children involves establishing relationships to effectively deliver the visiting program. The purpose of this qualitative and descriptive study was to describe the relationships among participants in a home visiting program in one regional health authority in the Canadian province of Manitoba. Interviews were carried out with 24 public health nurses, 14 home visitors, and 20 parents. The findings related to establishing, maintaining, and terminating relationships as well as factors influencing relationship work are described. Public health nurses and home visitors put significant effort into the work of establishing relationships with each other and their clients and require adequate training, sufficient human resources, and support from the program’s administration to sustain these relationships. n 2007 Elsevier Inc. All rights reserved.
OME VISITING PROGRAMS targeting high-risk families with infants and young children build on a long tradition of child health home visiting services delivered by public health nurses and, more recently, home visitors (paraprofessionals) under the supervision of public health nurses. With the growing number of welldesigned longitudinal studies, there is an increasing body of evidence that home visiting programs contribute to several improved outcomes in young children and parents, including improvement in parenting skills, reduction in behavior problems, and enhancement in the quality of the home environment (Elkan et al., 2000). However, much of the evaluation literature, while describing the program elements (i.e., number of home visits, type of visitor [professional nurse or paraprofessional], and duration of the visiting period), provides little attention to the processes that underpin the program elements. In particular, there is little discussion of the relationships between the network of people involved in the delivery of these programs and how these relationships may influence achieving the program goals. This omission would seem particularly important because the core of child health home visiting programs centers on the interactions between the
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individuals delivering the program and the individuals receiving the services. This article describes findings related to the relationships among public health nurses, home visitors, and parents who participated in an early childhood home visiting program in one regional health authority in the Canadian province of Manitoba. BACKGROUND LITERATURE Although the importance of developing positive relationships with parents in home visiting programs is espoused in the professional literature, there is little empirical literature documenting how relationships are developed and the outcomes when
From the Faculty of Nursing, University of Manitoba, Winnipeg, MB, Canada, School of Nursing, Midwifery, and Social Work, University of Manchester, Manchester, UK, and Faculty of Nursing, University of Manitoba, Winnipeg, MB, Canada. Address correspondence and reprint requests to Maureen Heaman, RN, PhD, Faculty of Nursing, Room 217, Helen Glass Center for Nursing, University of Manitoba, Winnipeg, MB, Canada R3T 2N2. E-mail: [email protected] 0882-5963/$ - see front matter n 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2007.02.002
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positive relationships with parents are formed. Home visitors, both professional nurses and paraprofessionals, are often hired based on personal attributes that are thought to contribute to helping relationships, such as maturity, warmth, empathy, a nonjudgmental attitude (McGuigan, Katzev, & Pratt, 2003), self-assurance, cultural sensitivity, and good parenting skills (Duggan et al., 1999). In addition, reliability, literacy, residency in the local community, and having a history of volunteering are factors deemed important for nonprofessional visitors (Barnes-Boyd, Fordham, & Nacion, 2001). There is some empirical support that what gets offered by professional nurses in home visiting programs (called health visitors in the United Kingdom) and how the offer is received and acted on by the parents are complex processes that influence relationship development (Chalmers & Luker, 1991; Luker & Chalmers, 1990). The development of relationships with parents who receive visits in the prenatal period has been associated with improved child health outcomes as compared with that of relationships with parents who begin receiving visits postnatally. The study by Larson (1980) concluded that the development of the relationship between the mother and the paraprofessional home visitor was enhanced through early and prolonged involvement and that this contributed in part to the outcomes. The retention of families in programs and more home visits are associated with matching parents and home visitors on the variables of race/ethnicity and parental status (Daro, McCurdy, Falconnier, & Stojanovic, 2003). These researchers concluded that the quality of the relationship may be enhanced when there is more common ground between visitors and parents. In addition, the availability of social support, particularly from friends, has been linked to the quality of the relationship developed between home visitors and mothers (Marcenko & Spence, 1994). The skills found to be important in effective home visiting include relationship building with families under stress, empathic communication, therapeutic use of self, building of trust, and other supportive behaviors (Daro & Harding, 1999; Jack, DiCenso, & Lohfeld, 2002; Kearney, York, & Deatrick, 2000). Relationship building and interviewing skills are frequently included in training programs for home visitors (Marcenko & Spence, 1994). Few studies incorporate parents’ perspectives on home visiting (Byrd, 1997). In one study, mothers reported feeling vulnerable and frequently power-
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less during home visits and valued the development of interpersonal relationships with their public health nurses and family visitors (Jack, DiCenso, & Lohfeld, 2005). Parents also rated home visitors highly on their ability to demonstrate empathy, understanding, respect for the family, trustworthiness, and ability to motivate and guide the family (Duggan et al., 1999)—all of which are qualities needed in developing a trusting relationship with vulnerable families. Although the positive aspects of forming relationships are widely espoused in the professional literature, there is little discussion of the tensions and problems that may arise between professional and paraprofessional home visitors and their clients (Peckover, 2002). There is little empirical literature that compared professional home visitors (usually public health nurses) with paraprofessional home visitors in terms of their capacity to develop successful relationships. Persily (2003), in a review of home visiting programs for young pregnant women, concluded that paraprofessional home visitors may be more acceptable to pregnant women, although the capacity to develop successful relationships was not specifically addressed. Although there is a growing body of evidence that outcomes of children and families are improved when they are visited by either public health nurses or paraprofessional home visitors, the long-term benefits to mothers and children appear to be enhanced when families are visited by professional nurses (Olds et al., 2004). In summary, the development of positive relationships between professional and paraprofessional home visitors and parents is considered to be an important component of effective home visiting programs. Further understanding of those factors underpinning home visiting programs, including relationships, could shed light on why programs or components of programs are effective or not. This understanding could make an important contribution to revising and strengthening current early childhood home visiting programs. BABYFIRST PROGRAM The BabyFirst Program is a community-based early childhood program established in 1998 that provides services to families from the province of Manitoba who live in conditions of risk and who have children up to 3 years old. Conditions of risk include such factors as substance abuse by one or both parents, parents’ own experience of abuse and/or neglect as a child, social isolation, parents’ lack of
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education and basic literacy, unstable housing, and other social and economic hardships. The BabyFirst Program emphasizes positive parenting, enhanced parent–child interaction, improved child health and development, and optimal use of community resources (Children & Youth Secretariat, 1998). The BabyFirst Program is based on Hawaii’s Healthy Start Program (Duggan et al., 1999; Earle, 1995). All families with a newborn are assessed for eligibility for the program by a public health nurse using a universal screening tool. Families identified as being at potential risk (having z3 risk factors) then receive an in-depth family assessment by the public health nurse, and those families who score above a preset point are offered home visitation. The program is available to all families from the province who meet the assessment criteria and agree to participate. Consenting parents are assigned a trained paraprofessional home visitor who has completed secondary school. The home visitor’s role is to work toward the goals of the BabyFirst Program using a standardized curriculum, the Growing Great Kids Curriculumn. This curriculum provides the foundation, structure, and frequency for the visits but also permits flexibility in response to every family’s needs and current situation. Frequency of contact is dependent on the family’s need and developmental progress but is often on a weekly basis. Public health nurses provide the ongoing nursing care and support to the family and supervise the home visitors. The home visitors and the supervising public health nurses receive an orientation to the BabyFirst Program that consists of 4 days of core training (which covers the philosophy and principles of the program, communication strategies, developing a trusting relationship, and goal setting) and 5 days of curriculum training. The public health nurses receive an additional day of training related to providing guidance and support to the home visitors. Ongoing training also occurs (e.g., cultural awareness sessions). METHODOLOGY
Design Data for this project were collected as part of a larger study conducted to provide an evaluation of the BabyFirst Program from the perspective of the providers and recipients of the program. A qualitative and descriptive study that entailed a comprehensive summary in the everyday language of events and the meanings that participants
attributed to those events (in contrast to phenomenology and grounded theory descriptions, which represent events in other terms; Sandelowski, 2000) was conducted. We sought the views of the key participants in the program on a number of program elements, including the strengths and limitations of the program, the assessment and enrollment processes, their experience in working with other participants, the overall effectiveness of the program, and their recommendations for change. Sandelowski noted that qualitative description is especially useful for obtaining straight answers (i.e., minimally theorized or otherwise transformed) to questions of special relevance to practitioners and policymakers. As researchers, we were interested in generating data that would be useful in understanding the interactions among the key participants in the program as well as in gaining an enhanced understanding of the home visiting process, including developing and managing relationships.
Setting and Sample We conducted the study within the largest regional health authority in the province of Manitoba where approximately 65% of the population reside. In 2002, approximately 46% (n = 240) of eligible families participated in the BabyFirst Program, with other families not receiving the program because of their refusal to receive the service or intake being full. The sample consisted of 58 participants (24 public health nurses, 14 home visitors, and 20 parents). The sample size was preset based on the accessible population (102 nurses and 34 home visitors) and estimates of the number of responses needed to ensure sufficient data to inform the interview process. There was no attempt to develop random or systematic sampling procedures in this qualitative evaluation study. All public health nurses had to have a minimum of 2 years of public health experience to ensure familiarity with the role. The criterion of a 2-year work history has been used in previous studies on public health nursing/professional health visiting practice (Chalmers, 1992, 1993, 1994; Chalmers & Luker, 1991; Kristjanson & Chalmers, 1990; Luker & Chalmers, 1990). The inclusion criterion for home visitor and parent participants was having a minimum of 12 months and that of 6 months, respectively, of experience with the BabyFirst Program to ensure sufficient time to be familiar with the program. In addition, parent participants
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had to be receiving regular home visiting services, be English speaking, and have adequate reading capacity to provide informed consent to participate. Public Health Nurses All public health nurse respondents (n = 24) were White women at a mean age of 45.9 years (SD = 8.7 years). Most of the nurse participants were very experienced (M = 20 years, SD = 10.4 years), with an average of 14 years of public health nursing experience. All nurses had a bachelor of nursing degree; several had other degrees (21%) or certificates (21%). Most of these respondents had considerable experience with the BabyFirst Program (M = 56 months, SD = 17 months). Home Visitors The 14 home visitors were all women at an average age of 39 years (SD = 10 years). More than half (57%) were married, and most (79%) had children ranging in age from 3 to 31 years. Four home visitors identified themselves as being of Aboriginal descent, either First Nations or Me´tis, whereas the rest self-described themselves as White. The home visitors had a mean length of education of 15 years; many had various health care certificates, and 2 had university degrees. Home visitors had a mean of 35 months (SD = 19.2 months) of working experience with the BabyFirst Program. Parents Twenty mothers agreed to be interviewed. Occasionally, the father of the child was present during the interviews, but in only three instances did the father become actively involved in the interview. The data subsequently described present the perspectives of the mothers, with those fathers who participated providing responses similar/congruent to those of their partners. The mothers had a mean age of 24.7 years (SD = 5.8 years), had a mean of 12 years of education (SD = 1.6 years), and were either White (80%) or Aboriginal (20%). Fifty percent were single, whereas 45% were married or living in a common law relationship. Most mothers (65%) reported that they were homemakers. The mean age of the children in the program was 14.7 months (SD = 10.6 months).
Data Collection In-depth semistructured interviews were conducted by a master’s-prepared research nurse in
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the parents’ homes and in public health offices or in other areas where private space was ensured. The interview questions were designed by the investigators to elicit information addressing the study goals. Separate interview guides were developed for each group, although similar questions were asked of all participants. Questions asked of the public health nurses and home visitors included the following: ! Tell me about your involvement with the BabyFirst Program. ! What is your understanding of the goals and objectives of the BabyFirst Program? ! What are the program components and how do these relate to the overall goals and objectives of the program? ! In the course of a week, describe your activities related to the BabyFirst Program. ! Tell me about your experience in working with the home visitors/public health nurses. ! Tell me about your experience in working with the client families. (Probe: What works well and why? What does not work so well and why? How do you attempt to create a positive relationship with the family?) ! In your view, what are the strengths and limitations of the BabyFirst Program? ! What is the overall effectiveness of the program? ! What recommendations, if any, do you have for improving the BabyFirst Program? Questions asked of the parents included the following: ! Tell me about how you became involved with the BabyFirst Program. ! How did you think the BabyFirst Program would help you? ! In the course of a week, describe the services you received in the BabyFirst Program. ! What do you like most/like least about being involved in the BabyFirst Program? ! What does the home visitor do that you find helpful? Not helpful? ! What does the public health nurse do that you find helpful? Not helpful? ! In your opinion, what are the overall benefits and weaknesses of the BabyFirst Program? ! What suggestions, if any, do you have for improving the BabyFirst Program? The interviews lasted between three quarters of an hour and an hour and a half. Each participant
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also completed a short demographic form specifically developed for each group of participants to collect data on demographic characteristics and work/program history. Data collection took place over a 5-month period, from October 2003 to February 2004.
Data Analysis Quantitative demographic data were entered and analyzed using Microsoft Exceln. Two transcribers transcribed the taped interviews using Microsoft Word n. The research nurse then checked for accuracy by reviewing audio tapes with the transcripts. Transcribed data were analyzed manually by the three researchers using content analysis techniques (Field & Morse, 1995; Manning & Cullum-Swan, 1994). Data analysis was carried out concurrently with data collection. Each researcher initially read the transcript in full then reread the transcript and began open coding in the margins of the transcripts. After each researcher had reviewed a number of transcripts, discussions of developing codes, categories, and themes among the research team. In total, 20 themes were identified. Several categories relating to each theme were described. Operational definitions were written for each theme and the supporting categories. This joint and individual work occurred until congruence in coding was reached. The categories were also refined through more focused interviewing in subsequent interviews (Sandelowski, 1995; Schatzman & Strauss, 1973; Strauss & Corbin, 1990). Quotations from the data were used to illustrate the findings. Any discrepancy in the data analysis was reviewed, and the data were reexamined until consensus was attained. We also undertook standard measures to enhance the rigor of the qualitative research process, including regular debriefing of the research nurse with the research team and careful line-by-line analysis of the transcripts (Guba & Lincoln, 1994; Schatzman & Strauss, 1973). A major theme uncovered through this analysis process was the work of developing relationships among the participants of the BabyFirst Program. The findings related to the categories within this theme of relationship work are described below.
Ethical Issues We ensured that ethical standards were maintained throughout the project. We maintained careful attention to issues of recruitment, consent,
confidentiality, potential vulnerability, and sensitivity. Before the data collection, we received approval for the project from the University of Manitoba Education/Nursing Research Ethics Board. All participants received written information about the project and were ensured that their participation was voluntary. We obtained written consent from each participant. The two transcribers hired for the project each signed a confidentiality agreement. Parent participants received an honorarium of $20 for their participation in the study, whereas the public health nurses and home visitors did not receive an honorarium, although they were permitted to participate in the interviews during working hours. THE FINDINGS: RELATIONSHIP WORK Central to the implementation of the BabyFirst Program was the network of relationships among participants. The theme of relationship work addressed the active efforts of public health nurses and home visitors to develop and maintain positive connections in their day-to-day work with each other and the parents. It consisted of two main categories: (a) establishing, maintaining, and terminating relationships and (b) factors that influenced the relationship work. Each of these is described in detail below. The goal of facilitating positive relationships was to provide benefits to the clients in the BabyFirst Program. Although relationships were important to parents as well, the work of developing, maintaining, and terminating relationships was, for the most part, carried out by the service providers.
Establishing, Maintaining, and Terminating Relationships Nurses and home visitors had opportunities to develop relationships with parents throughout the course of their BabyFirst Program work. These were evident at the time of establishing, that of maintaining, and, in some cases, that of terminating relationships. Establishing Relationships The work of developing relationships began at the time of initial contact. For the BabyFirst Program work to begin, parents needed to be assessed for eligibility for the program; if eligible, their permission was sought for enrollment in the program. Public health nurses initially screened all new postpartum clients during a home visit. Those
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families with three or more risk factors then received an in-depth family assessment, during which the nurse explored risk factors for parenting and sources of support. Most nurses expressed sensitivity to the assessment process but appeared to deal with this issue in different ways. Most appeared to be quite open with parents in terms of the rationale for the detailed assessment procedure used to determine eligibility for the program (i.e., higher risk for abuse/neglect). For example, one public health nurse stated: I try to be upfront with the in-depth assessment. dThis is the program, I need to ask you these questions, you may feel uncomfortable, sometimes it may be personal, but this is a way of getting a better picture and feel of whether the program is a match for you.T Families are usually okay with that. They want to be honest with you.
Other nurses found the assessment process to be intrusive and potentially damaging to their relationship with the parents. Consequently, albeit not providing false information, they did not disclose much about the rationale for the program or criteria for admission. As one nurse remarked: I do not usually tell them about the [assessment process]. . .to the BabyFirst [program]. I tell them a little bit about it, and when I am doing community resources, I say, dhere is another resource that we have for families to support them with parenting.T
The nurses appeared to have worked out an approach to assessment and enrollment that they were comfortable with. Few parents appeared to know why they specifically were asked to join the BabyFirst Program. Only two mentioned or remembered being questioned extensively by the nurse before signifying their acceptance. Many of the mothers thought that the nurse asked if they would be interested in the program because they were young, single, and/or inexperienced in child care. One mother revealed: We were both really kind of nervous. Neither one of us has raised kids before, so we’re not entirely sure what to do.
Home visitors were introduced to the parents by the public health nurse who was active with the family. They then had to work toward developing their own relationship with the parents. One home visitor explained: I get assigned a family and my number one thing is to be myself—not to go in with an agenda because I
think that puts people off, [I] listen and talk to the family about what their needs are. So then what I would do after that initial visit, I would put together what I feel are the priorities. And then from there on the relationship just naturally occurs.
Maintaining Relationships Some parents reported that they immediately liked the home visitor. It took other parents longer to get to know and like their health visitor. A few parents, at least on some level, reported that they did not like their home visitor. If home visitors could establish an initial connection with the parents, they could usually progress with their work. For example, one parent reported that she was not expecting a weekly visit because she knew bhow to raise a child,Q but once the home visitor came, she found her really bawesome.Q Terminating Relationships Relationships were terminated usually in two ways: when service providers needed to be changed because (a) the public health nurse or home visitor left the program or was reassigned or (b) the parent moved to a new area in the city. Relationships were also terminated when the family had completed the program (i.e., when the child turned 3 years old). Changing home visitors during the course of the BabyFirst Program was more or less problematic for parents. Some parents reported that changing home visitors was difficult but not overwhelming. Others expressed considerable concern about having to end their relationship with and change their visitor, as noted by one parent: If I move to another area, I can’t have my same BabyFirst worker as here. . .we don’t want to get somebody else,
whereas other parents really valued the program and would make the adjustment to a new home visitor, as reflected in one mother’s comment: I really like your program [BabyFirst] and the home visitor, but if I had to have somebody else, I would accept them.
Home visitors also considered the requirement to terminate their relationship with families when they moved to another area to be problematic. Taking on a family from another home visitor entailed establishing a new relationship with the parent in the shadow of the former relationship. In addition, changing home visitors meant severing bonds rather than building consistent trusting
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relationships. One home visitor raised the following concern: If my family moves to a different area, I have at times been where I have to give that family up. . .I feel that it is the failure of the program [that] every time our families move they get a new BabyFirst home visitor. . .I don’t feel that it is appropriate because we are not teaching these families about consistency. And I think that it is about building a bond. Trust does not come overnight, and to keep that trust is important, and that is to continue working with them when they move.
Nurses and home visitors considered that terminating relationships with families was best accomplished when there was a planned exit over a number of visits. A home visitor stated: It is just a weaning process. You wean them off; visits become less. You give them lots of notice.
At the completion of the BabyFirst Program at the child’s third birthday, the home visitor terminated her relationship with the family. Some parents considered this to be a satisfactory time to finish the visiting program, whereas others preferred a shorter or longer period. Parents in this study reported having between one and three home visitors, with just more than half of the parents having one home visitor. However, the average length of time in the BabyFirst Program at the time of data collection was 18 months (SD = 12.6 months). Participants may have additional comments on the changeover of workers and the termination of relationships at the end of the 3-year visiting period.
Factors Influencing the Relationship Work Relationship work was influenced by several factors that could be more or less effective in establishing, maintaining, and potentially terminating relationships based on how each was perceived and received by the other party. These factors included showing respect, providing support and facilitating empowerment, developing trust, working in partnership, working as supervisors/evaluators, and developing and maintaining appropriate boundaries within the relationship. Although presented separately, these factors were not always distinct entities and instead often interconnected. Each is described in detail below. Respect Two central components that home visitors in particular talked about in establishing and maintaining relationships were showing respect and
being shown respect. They frequently commented on the importance of being respected, particularly by public health nurses. This included being respected for their abilities as home visitors and the opinions they brought to case reviews and other professional fora. One home visitor stated: They are all approachable [public health nurses]. Nobody ever makes you feel that dI am a nurse and you are a home visitorT. . .I think my word is appreciated along with everybody else. I often have people tell me, dI appreciate what you are doing with the family, I am happy they are with you.T I find that communication is very open. And nobody is condescending, and they appreciate me and respect me.
Another home visitor commented on being respected by parents: I think they [families] do respect us, they know that we [home visitors] do not make a barrel of money.
Although there were comments in the interviews that suggested that not all home visitors felt respected by nurses or clients, these comments were quite rare. Being shown respect was also important to parents. Respect seemed to entail many qualities such as treating parents as people and making efforts to assist them. One mother stated: She [home visitor] doesn’t make you feel that she is better than you. She doesn’t have an attitude.
Support A core component of relationship work was providing support. This was a key component of public health nurses’ work with the home visitors. One public health nurse said: I see myself really as a support to the home visitor. I am the one [who], when they come back [from a home visit], [would] drop everything.
For some of the home visitors, their work with families triggered unresolved issues in their own lives, and the public health nurses provided them with support in dealing with those issues. Public health nurses and home visitors also worked to provide support to parents. One home visitor related the following example of providing support: I work with a mom who had really low self-esteem and doubted her parenting ability and she lives with her father, and he kept telling her, dOh, you are a bad mother.T. . .But I kept telling her she was a good mother. . .She was like dWow!T And she had a lot of difficulty with her father and the baby, but she had another baby and now she says, dI don’t care what he says, I am a good mother.T
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Parents, for the most part, recognized and valued the support that they were offered by public health nurses and home visitors. Trust Central to creating a supportive relationship was developing trust. Following through with what was expected was an important component of building trust between public health nurses and home visitors, between home visitors and parents, and between public health nurses and parents. This was not always easy when there were conflicting perspectives on situations, workload pressures, or difficulties with contacting families. One public health nurse stated: You really need to watch workload wise that you can, that you are going to deliver something and then not be able to do it—because that can break the trust. Because if your relationship with the home visitor isn’t good, it really shows in your relationship with the family as well.
Public health nurses recognized the importance of trust in the relationships formed between themselves, the home visitors, and the families. As one public health nurse explained: The home visitor forms a relationship with this person. They trust them. . .So when they get a trusting relationship with that home visitor, then it allows them to open up and accept information and accept suggestions and learn and feel positive about themselves, which empowers them to then make changes in their lives.
A mother spoke about trusting the home visitor: As soon as I talked with her [home visitor], I knew she was nice and I could actually trust her. A lot of people I won’t trust about anything.
Partnership Public health nurses and home visitors also valued developing partnerships when working with each other and the families. One public health nurse expressed the following viewpoint: Doesn’t matter whoever you are, I’m your partner to help you. . .,
whereas another nurse stated: The home visitors are part of our monthly public health nurses meeting. They share information from their BabyFirst knowledge with all the staff.
Partnerships in relationships, although valued, were not always perceived as the norm. Demonstrating respect for each other was a key compo-
nent of positive partnerships. Some public health nurses did not consider that home visitors were always treated as partners, and some home visitors felt they were not always treated with respect. A public health nurse commented: On occasion, they [home visitors] feel that they are treated poorly, not as colleagues, not treated as if they have as much knowledge. Or they don’t have as much skill. . .they really need to hear that they are doing a good job, and I don’t think they always hear that from the office group, from the coordinator, from the [nurses].
A home visitor expressed her frustration as follows: We’re [home visitors] way at the bottom of that totem pole, and I feel that [home visitors] are very much left out of things and we are the ones that are, well, working our ass [sic] off, and these public health nurses are sitting back and taking credit for everything and I just get really, really frustrated.
Parents did not specifically talk about partnerships with the public health nurse or home visitor. Their focus within the relationship appeared to be more on the characteristics and behaviors that they valued or did not value. Supervision and Evaluation Public health nurses, although valuing partnerships in their relationships, also functioned as supervisors and evaluators of the home visitors. Nurses expressed varying levels of comfort with their supervisory and evaluative roles. Some nurses saw these as extensions of their original work in working directly with families; others appeared to have greater discomfort with this aspect of their work. Nurses made the following comments: I am your partner as the BabyFirst home visitor, but, at the same time, I am also your supervisor. I do not want anybody to come and go at leisure; you have to come to work [on time]. There needs to be quite an open relationship between the public health nurse and the home visitor as to where the family’s goals are going and a regular reevaluation of that.
Most home visitors considered the supervisory relationship with their public health nurses in a positive light. They valued the public health nurses’ input and guidance, particularly when they detected problems and crises with their families. As one home visitor stated: I love working with my (public health nurse)! She is a very easy person to talk to. . .It is so nice to be
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able to come in and say, dLook, this is what’s happeningT. . .when I have really challenging visits—which I do—and I get a little uptight, then she’s just a good person to bounce it off and, you know, sort of relieve some of that stress.
Maintaining Professional–Client Boundaries Public health nurses talked about the importance of maintaining professional boundaries with home visitors and parents. Nurses both practiced this and attempted to model this for home visitors. One nurse commented on how a professional relationship needs to be maintained with parents: Reaffirming that I am not here to be your best friend. . .it is like you are building a relationship. But it is a professional relationship, and it has to be reaffirmed sometimes.
Another public health nurse explained how she develops relationships with the home visitors: I work with the home visitors exactly how I want them to work with families, recognizing their strengths, building on things and how to problem solve. So I think that I have been able to role model that parallel process.
Home visitors were also required to maintain professional boundaries with clients. In many ways, this was more challenging for home visitors than for the nurses. The nurses had considerable experience in developing and maintaining professional relationships. In addition, their interactions were more likely to be perceived as professional by the parents (e.g., carrying out assessments of babies), whereas home visitors’ interactions with parents were often day-to-day activities, such as talking about child care and taking the bus together to a parent’s group. One home visitor commented on boundaries as follows: I really just let the relationship develop, with proper boundaries. Well, the big thing for me is having proper boundaries. Because a lot of the families want to have you as their friend. So it is the defining line [boundaries].
However, it was not uncommon for parents to consider the home visitor as their friend and invite the home visitor to birthday parties and other family events. It was important for home visitors to negotiate the boundaries carefully with the clients to keep an appropriate role. DISCUSSION Positive relationships were seen as an important mechanism in delivering the BabyFirst Program
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and providing benefits to the families. Findings from this study suggest that public health nurses and home visitors put significant effort into the work of establishing relationships with each other and their clients. Establishing relationships with parents within the context of this child health home visiting program would seem to be particularly critical at two periods. One of these periods has been called the entry phase (Chalmers, 1992). Initially, parents must agree to enroll in the program once their eligibility is established. In the case of the BabyFirst Program, the work of enrolling parents rested with the public health nurses. For the most part, the nurses did not have a prior relationship with the parents. The nurses needed to function as a broker for the program and gain the acceptance of the parents for the BabyFirst Program work to begin. Public health nurses who were not open with prospective clients about their eligibility for the program ran the risk that parents will react negatively once they learned that they are considered to be a high-risk parent. However, most of the nurses interviewed in the study truthfully outlined why parents were eligible for the program and did so in a way that was acceptable to the parents. This approach laid the groundwork for the development of trust that was considered so important by the participants in this study. The home visitors then had to do their own entry work with the families. Consistent with the findings of other research work (Chalmers, 1992), many of the home visitors in this study reported that they initially assessed the key need or problem from the family’s perspective and responded with an offer of help to meet the need or solve the problem. Chalmers referred to this approach to entry work as trying to focus on something that the family considers to be important, which is one of several processes that assists in entering more fully into the client situation (Luker & Chalmers, 1990). The process of entry can be viewed on a continuum from a very easy entry to a very difficult entry (Luker & Chalmers, 1990). A limitation of this study was the lack of knowledge related to factors resulting in a very difficult entry. Because BabyFirst Program participation is voluntary and parents had to agree to be enrolled in the program, we were unable to gain the perspective of families who decided not to accept the program services. Further research is needed to explore reasons why families choose to decline participation in the program. Likewise, we had no knowledge as to the extent of how trust, or lack of
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trust, may have affected parents’ decision not to enroll in the program. The second critical period in relationship work is the ongoing relationship development, particularly between the home visitor and the parent. The factors identified in this study that positively influenced ongoing relationship work included showing respect, developing trust, supporting families, working in partnership, and maintaining appropriate boundaries. These are similar to skills important in effective home visiting that have been identified by other investigators (Daro & Harding, 1999; Jack et al., 2002, 2005; Kearney et al, 2000). Providing training in the development of skills such as empathic communication, development of trust, and other supportive behaviors may enhance the effectiveness of home visiting programs and result in more satisfied staff and clients. In addition, a fundamental component of the helping role is learning to develop positive working relationships while respecting the boundary between clients and service providers. Some home visitors in our study had difficulty with establishing appropriate boundaries with parents. Clearly, this is a very important skill in home visiting work and needs careful attention in the initial orientation and ongoing continuing education. Failure to establish appropriate boundaries may jeopardize the helping relationship and impede the outcomes for parents. Although all nurses and home visitors received an initial orientation and periodic additional workshops, there appears to be a need for systematic and ongoing training in communication and listening skills, relationship development, and sensitivity to clients’ needs. Paying attention to the factors that promote positive relationships may also increase the likelihood that parents will agree to join and remain in the program. The literature on child health home visiting programs concludes that families receive only approximately half of the number of intended visits and that between 20% and 67% of enrolled families leave the program before the intended termination date (Gomby, 1999). Although relationship development is undoubtedly complex and not easy to describe, evaluate, or control, it is likely a key factor influencing the retention of families in home visiting programs. Limiting the size of a home visitor’s caseload has been suggested as important to allow for the establishment of more intense relationships (Daro et al., 2003). Both public health nurses and home visitors in the BabyFirst Program were sensitive to the impact of
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large or frequently changing caseloads. Retention of home visitors in visiting programs is also important to ensure the time needed to develop relationships (Fraser, Armstrong, Morris, & Dadds, 2000). Administrators need to give careful consideration to recruitment and retention strategies to ensure a stable workforce of home visitors. The final phase of the relationship work involves termination, during which home visitors end their contact with the families. Similar to other findings (Chalmers, 1992), termination work appeared to play a fairly minor role for home visitors and families. In the negotiated approach, families were aware that the program services would be terminated when their child turned 3 years old. A more problematic situation arose when the termination was necessitated by the family’s move to another region of the city. Chalmers referred to this as the nonnegotiated approach to termination. Some of the families in this study found changing home visitors to be stressful and counterproductive to strengthening their relationship with the home visitor. For many families, frequent moves are a reality of their lives as they seek safer and better housing. Administrators need to carefully consider if the policies related to changing home visitors when clients move are really in the overall best interests of the families. The benefits of programs cannot occur if parents do not agree to visits or do not stay in the program. Although there may be many reasons for families to discontinue visits, a positive relationship with their home visitor will likely contribute to maintenance in the program for some families. Our findings indicate that a strong relationship with the home visitor was highly valued by the parents. Forming workable and sustained relationships between home visitors and parents requires adequate support. Sufficient human and material resources are needed for public health nurses and home visitors so that they can carry out the program as designed. The home visitors and public health nurses in this study valued the development of supportive relationships with each other to enable them to function at their optimum with parents. Public health nurses also acknowledged the importance of their supervisory role, although this was a challenging part of the work for some. Staff nurses have not traditionally carried out supervisory functions, and the knowledge underpinning this function is not usually part of baccalaureate education programs. However, if public health nurses are to provide helpful super-
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vision to home visitors, they need appropriate knowledge and skills. There is also some evidence that supervision has a positive benefit in the retention of parents in one home visiting program (McGuigan et al., 2003). Despite potential positive gains from home visiting programs reported in the literature and the importance of positive relationships in delivering these services, programs that provide parenting education through limited home visiting cannot ameliorate the severe problems that many parents experience, such as poor housing, low literacy, poor parental role models, and little education (St Pierre & Layzer, 1999). Many of the families in this study had few financial and social resources. These determinants of health likely have a major impact on parenting practices. In addition to attending to their direct service work, public health nurses must also support broad policy initiatives that enhance health. The limitations of this study relate to the voluntary nature of participation in the interviews. The characteristics and perspectives of those public health nurses, home visitors, and parents who volunteered to be interviewed may have differed from those who chose not to participate. The recruitment process for the parents was also a limitation in that the home visitors approached and invited parents to participate; therefore, not all parents had the opportunity to consider participating in the study. Participation was limited to Englishspeaking parents; therefore, the perspectives of non-English-speaking parents were not included.
Although a few fathers participated in the interviews, most parent participants were mothers. Fathers may have differing perspectives on the program. Strengths of the study relate to the qualitative design, which provides rich descriptive data from the perspective of those closely involved with the program. All interviews were carried out by one experienced master’s-prepared research nurse hired for research purposes only, which ensured standardization of the interviewing process and no conflict of interest with a service delivery role. In conclusion, this study makes a contribution to our understanding of the relationships between service providers and parents as uncovered in a qualitative evaluation of an early childhood visiting program. In particular, the findings provide information from the perspectives of all three key participants in the program: public health nurses, home visitors, and parents. The results provide information for ongoing development and improvement of home visiting programs.
ACKNOWLEDGMENTS This research was funded by the Winnipeg Regional Health Authority. Dr. Heaman was supported by a New Investigator Award from the Canadian Institutes of Health Research. Dr. Woodgate was supported by a Canadian Cancer Society Research Scientist Award and a Manitoba Health Research Council Establishment Award. We thank Claire Betker, RN, MN, for her contributions to this project.
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