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0207 403 9827, why do nurseries do home visits here’s what you need to know.

If you’re thinking about finding a nursery for your child or children, you may have wondered why some nurseries do home visits. For us at Little Angels, it’s an easy question to answer.

We carry out home visits for children starting nursery as it makes it easier, more enjoyable and less stressful for your child to settle in when they join us.

We also sometimes find that parents and guardians themselves can be anxious about sending their child to nursery and that a home visit can reassure them and help them worry less about taking this step.

A Nursery Home Visit Helps Build Relationships

The team at Little Angels prides itself on being an extension of your family and we strive to build genuine, meaningful relationships with you. This helps us to better understand your parenting style and adapt the way we nurture your child and meet their individual needs whilst they’re in our care.

A nursery home visit is a big part of this as it helps both us and you form a partnership and establish trust from the very moment that you register your child with us. It also allows you and your child to meet with us in the place you feel most comfortable – your home

In Little Angels’ case, why nurseries do home visits is to provide your family with the opportunity to meet Azi Alamani , our owner and director, before your child joins us. This helps us and you to get to know one another and also share knowledge about your child.

For example, knowing whether they have siblings or pets, what they like and dislike, what they’re interested in, what foods they enjoy or refuse to eat! ) – these all help us build a relationship with your child that allows us to support you in your role as their primary caregiver and educator.  

The Benefits of Nursery Home Visits

One of the biggest benefits of home visits for children starting nursery is that your child will see a familiar face when they first join Little Angels.

Having said that, there are a number of other benefits, both for the parent or guardian, as well as for us and our staff.

For example:

– You have the chance to meet Azi, the owner of Little Angels, in the comfort of your own home.

– When your child first meets us at home, they are in a safe environment in which they feel confident. This creates a positive first contact.

– Knowing who they will spend their days with helps your child transition more easily to a nursery environment. 

– We gain insight into your child’s home life which helps us understand them and see when and where they feel settled and in control.

– You get to ask us any questions you may have about our nurseries, staff, facilities and extra curricular activities , and find out what your child will be learning while they’re with us.

– We are better able to understand, and address, any anxiety you or your child may have about starting nursery. 

– You also get to talk about your child and their needs, or your hopes for their growth and learning.

How Do Home Visits for Children Starting Nursery Work?

At Little Angels we recommend a nursery home visit for each child before they join us. However, this is a free optional extra service and we understand that not all parents or guardians will be able to arrange an appointment. 

We strongly believe that our home visits for children going to nursery are a unique part of our 

settling in policy, so if you are able to take advantage of the service, we are more than happy to accommodate you.  

Our nursery home visits are scheduled for a time and date that is both convenient for you and Azi. We also follow our Little Angels Code of Conduct which ensures that the home visit is both safe and professional, with a copy of this then being held on file.

You will also be asked to complete a questionnaire when you register your child for Little Angels in which you can express your views and feelings about the transition to nursery. We can then use this information to better support you and tailor our nursery home visit to you individually as a family.

Starting Your Child’s Journey with Little Angels

We hope that answered your question as to why nurseries do home visits, but if you’d like to know anything else about Little Angels before registering your baby or toddler at our Perkins Square nursery, we are always happy to oblige.

For example, we offer both in-person and video tours of our facilities , as well as nursery open days and our informative brochure is also available to prospective parents and guardians.

Download your copy of our brochure today and we hope to be a valuable part of your child’s journey through their early years very soon.

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Best Visiting Nurse Services

AccentCare is the best visiting nurse service, with performance ratings above industry standards

One day you or a loved one might need a visiting nurse for medical care in your home. In the United States, it’s a relatively common experience. According to the Centers for Disease Control and Prevention (CDC), about 4.5 million Americans are treated in their homes every year by more than 12,000 home healthcare agencies. Many people prefer the ease of having medical care in their own home, rather than having to travel to a hospital or doctor's office.

When the time comes, you’ll need to do some research to find a visiting nurse service that fits your personal needs. With that in mind, we reviewed over 40 home healthcare companies to find the best visiting nurse services available.

Best Visiting Nurse Services of 2024

• Best Overall: AccentCare
• Best for Post-Operative Assistance: Elara Caring
• Best Technology: Enhabit Home Health & Hospice
• Best for Specialized Care: Interim HealthCare
• Best for Hospice (End-of-Life Care): ProMedica Hospice
• Our Top Picks

Elara Caring

• Enhabit Home Health & Hospice
• Interim HealthCare
• ProMedica Hospice
• See More (2)

Final Verdict

• How to Choose

Methodology

Best overall : accentcare.

• Services offered : Personal care, behavioral health, rehabilitation, medical assistance, hospice and palliative care, care management, health alert systems
• Number of locations : 260 locations across 31 states

We selected AccentCare as the best overall provider of skilled home health care based on its accessibility (there are over 260 locations) and performance ratings that are above industry standards.

Programs for chronic conditions

Specialized programs, including behavioral health and stroke

Tele-monitoring program for early intervention

Some locations have different names, which can be confusing

Website’s location search page is hard to find

All of AccentCare's agencies are accredited by Community Health Accreditation Partners (CHAP) and have earned an overall 4.6-star quality rating and recognition from the We Honor Veterans program. AccentCare treats over 140,000 patients a year. Along with skilled home health care and private duty nursing, it offers hospice care, personal care services, and care management.

AccentCare also uses technology to supplement visiting nurse home care visits with tele-monitoring that can deliver biometric data (blood pressure, pulse, blood glucose, etc.) in close to real-time to keep the medical support team informed and ready to take action if necessary. AccentCare is the fifth largest provider of skilled home health in the U.S.

Best for Post-Operative Assistance : Elara Caring

• Services offered : Home health care, hospice care, rehabilitation, recovery care, personal care, behavioral care
• Number of locations : 200+ locations across 16 states

Elara Caring focuses on recovery and rehabilitation, excelling in nursing, physical therapy (PT) , occupational therapy (OT), and speech therapy . 

Also offers hospice care and behavioral health services

Delivers proactive customized care (CAREtinuum)

Only available in 16 states

Elara Caring's CAREtinuum program, a system that uses predictive analytics to identify patients at risk, sets it apart from other companies for post-operative assistance. For example, Elara’s CAREtinuum Fall Risk Program patients are 72% less likely to return to the hospital due to falling.

Elara Caring offers a wide range of in-home clinical services, treating more than 65,000 patients a day. Along with skilled home health, Elara Caring offers hospice care, personal care, and behavioral care. Its behavioral care supports a wide range of conditions, including depressive/anxiety disorders, schizophrenia, bipolar, and other disorders.

Even though Elara only has locations in about one-third of the states in the U.S., it is the ninth largest provider of skilled home health in the country.

Best Technology : Enhabit Home Health & Hospice

• Services offered : Home health care, hospice care, post-operative care, transition program from hospital to home, long-term care
• Number of locations : 355 locations across 34 states

We chose Enhabit Home Health & Hospice for its easy-to-use technology that makes a customer’s online experience simple, with comprehensive information quickly available.

Locations in 34 states

Variety of programs to enhance skilled nursing, including skilled therapy, balance and fall prevention, and orthopedics

Not all locations offer hospice

Website offers Spanish translation, but only portions of the site are available in Spanish

The online software at Enhabit streamlines each step, from referral processing to scheduling to management of physician orders, in order to optimize patient care and attention. This connection between patients, doctors, and in-home care providers makes processes easier and more transparent.

In addition, Enhabit’s web portal provides one-stop access to manage diagnoses, patient history, medications, and plan of care. Enhabit is also able to deliver better care for patients through predictive analysis, to identify potential risks.

Best for Specialized Care : Interim HealthCare

Interim Healthcare

• Services offered : Home health care, senior care, in-home nursing services, respite care, transitional care; at-home physical therapy, occupational therapy, and speech therapy.
• Number of locations : 300+ locations across 41 states

We chose Interim HealthCare for its focus on home care for adults or children with special needs due to an injury or illness.

Promotes a more engaged existence at home for patients and their families

Offers caregivers more than 300 continuing education units

Available in nearly 50 states

Independently owned franchises mean inconsistencies in customer satisfaction

Interim HealthCare's services include care for adults and children who are developmentally delayed or need to use a feeding tube. Specialized offerings include home care for arthritis, multiple sclerosis , joint replacement, hypertension , paraplegia and quadriplegia, and traumatic brain injury (TBI).

Interim also offers many specialized interactive online training courses and live webinars for specific needs, such as dementia care. Interim HealthCare University provides extensive training resources available for free to employees, including over 300 lessons for both clinical and non-clinical staff and management in areas such as fall prevention, home care technology, and transitioning from a facility.

Interim’s HomeLife Enrichment program looks beyond basic needs to address the mind, spirit, and family as well as the body. The focus is to add purpose, dignity, and self-worth to basic safety and independence.

Interim HealthCare has a network of more than 300 independently owned franchises (employing nurses, aides, therapists, and other healthcare personnel) serving about 173,000 people every year.

Best for Hospice (End-of-Life Care) : ProMedica Hospice

• Services offered : Home hospice care, pain management, spiritual support, comforting treatments, bereavement services
• Number of locations : In 26 states

ProMedica Hospice provides the comfort and quality of life that hospice is known for, with fast and effective responses to patient discomforts such as pain, shortness of breath, and anxiety.

Advance directive not required for hospice care

Fully accredited

Provides employees with training, continuing education, and tuition assistance

Only available in 26 states across the U.S.

ProMedica Hospice has locations in 26 states, offering services such as pain and symptom management therapies. Heartland can provide hospice care in any “home”—including a private home, an assisted living facility, or a skilled nursing center.

While some hospices require a do not resuscitate (DNR) order before providing care, ProMedica (formerly Heartland Hospice Care) doesn’t. In situations where Medicare will be paying for the care, a DNR is not required because the care is considered palliative (providing comfort, instead of a cure or treatment).

ProMedica Hospice develops talent by offering its employees training and education opportunities at many of its locations. For example, its nursing assistant training programs include assistance with the cost of taking a state certification exam.

ProMedica Hospice also offers bereavement services, advanced planning services, and the possibility to grant funds to help offset financial burdens created by terminal illness.

While each visiting nurse service on this list has its strengths, AccentCare is our top pick due to its wide variety of specialized programs and high quality rating. The caretakers at AccentCare are skilled and experienced. Plus, home care visits are supplemented with an advanced tele-monitoring system.

Guide to Choosing a Visiting Nurse Service

When it comes to selecting the best visiting nurse services for you or a loved one, there are several factors you should look for to help inform your decision.

• Accreditation : Home healthcare agencies and companies must be licensed in order to operate in a state. As you research the best visiting nurse services, ensure that the agency you select is licensed in the state you live. Consult with the Centers for Medicare & Medicaid Services (CMS) or the Joint Commission, which offers accreditation to home health providers.
• Insurance : Check your available coverage and what potential out-of-pocket costs may be by asking any potential visiting nurse service if it accepts your insurance. Often, services take Medicare, Medicaid, private insurance, or Veterans Administration benefits.
• Services needed : Depending on your needs, you may require more specialized nursing care. For example, visiting nurse services can be tailored to the patient if they need after-surgery care, rehabilitation therapy, medication administration, or personal care and companionship.
• Visiting hours : Many visiting home nurses operate between the hours of 8 a.m. and 5 p.m. However, depending on the needs of the patient, in-home hours can often be adjusted. Ask a home healthcare provider if they also arrange for evening or overnight visits, should you need them.

Frequently Asked Questions

What are the duties of a visiting nurse.

A visiting nurse is a skilled medical professional, usually a registered nurse, who oversees all aspects of the medical care you receive at home, as ordered by a physician. This might include evaluating your medical condition and health needs, monitoring your vital signs and assessing risk factors, and administering medication. A visiting nurse is also trained to care for specific conditions such as COPD, diabetes, dementia, and Alzheimer’s. They can change dressings for surgical incisions or wounds and provide hospice care .

When your visiting nurse leaves, they make sure that you and your caregivers have the necessary information and supplies to support the plan of care.

Is a Visiting Nurse the Same as a Home Health Aide?

A visiting nurse is a skilled medical professional, while a home aide typically has limited formal medical training and provides services such as help with personal hygiene, meals, and transportation. A home health aide may stay in your home for several hours providing care, while a visiting nurse will stay for a shorter time to perform specific tasks.

Does Medicare Cover Visiting Nurse Services?

If you have Medicare, home health care, such as that provided by a visiting nurse, is covered 100% by Medicare when your doctor certifies that you meet the required guidelines. If you do not have Medicare, consult with your healthcare insurance to determine your policy parameters for coverage, including necessary copayments, if any.

Hospice (including a visiting nurse, if one is on your team) is covered by Medicare, Medicaid, the Veteran’s Health Administration, and private insurance. Although most hospice care is provided at home, it is also available at hospitals, assisted living facilities, nursing homes, and dedicated hospice facilities.

Always double-check coverage with your insurance provider and ask the visiting nurse service if it accepts your insurance plan.

For this ranking, we looked at more than 40 home health providers. The primary criteria were the number of locations and national footprint, so the ranking would be useful to a large number of people. In addition to reviewing companies' areas of expertise, we also looked at their website interface, navigation, and usability and how they are ranked in areas such as quality care and patient satisfaction by services such as the U.S. government’s Centers for Medicare and Medicaid Services (CMS) Home Health Star and Home Health Compare .

AE Pictures / Getty Images

Centers for Disease Control and Prevention, National Center for Health Statistics. Home health care .

LexisNexis Risk Solutions. LexisNexis Risk Solutions ranks top home health and hospice providers .

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History and Development of Home Visiting in the United States

Social justice movements before 1950, the war on poverty and prevention of child maltreatment, expansion of home visiting in recent decades, home visiting outside the united states, poverty, child health, and home visiting, national evaluation and evidence of effectiveness, home visiting and the medical home, recommendations and position statement, community pediatricians, large health systems, managed care organizations, and accountable care organizations, researchers, the aap endorses and promotes the following general policy positions and advocacy strategies:, conclusions.

• Lead Authors
• Council on community Pediatrics Executive Committee, 2016–2017
• Council on Early Childhood Executive Committee, 2016–2017
• Committee on Child abuse and Neglect, 2016–2017

Early Childhood Home Visiting

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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James H. Duffee , Alan L. Mendelsohn , Alice A. Kuo , Lori A. Legano , Marian F. Earls , COUNCIL ON COMMUNITY PEDIATRICS , COUNCIL ON EARLY CHILDHOOD , COMMITTEE ON CHILD ABUSE AND NEGLECT , Lance A. Chilton , Patricia J. Flanagan , Kimberley J. Dilley , Andrea E. Green , J. Raul Gutierrez , Virginia A. Keane , Scott D. Krugman , Julie M. Linton , Carla D. McKelvey , Jacqueline L. Nelson , Emalee G. Flaherty , Amy R. Gavril , Sheila M. Idzerda , Antoinette “Toni” Laskey , John M. Leventhal , Jill M. Sells , Elaine Donoghue , Andrew Hashikawa , Terri McFadden , Georgina Peacock , Seth Scholer , Jennifer Takagishi , Douglas Vanderbilt , Patricia G. Williams; Early Childhood Home Visiting. Pediatrics September 2017; 140 (3): e20172150. 10.1542/peds.2017-2150

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High-quality home-visiting services for infants and young children can improve family relationships, advance school readiness, reduce child maltreatment, improve maternal-infant health outcomes, and increase family economic self-sufficiency. The American Academy of Pediatrics supports unwavering federal funding of state home-visiting initiatives, the expansion of evidence-based programs, and a robust, coordinated national evaluation designed to confirm best practices and cost-efficiency. Community home visiting is most effective as a component of a comprehensive early childhood system that actively includes and enhances a family-centered medical home.

Recent advances in program design, evaluation, and funding have stimulated widespread implementation of public health programs that use home visiting as a central service. This policy statement is an update of “The Role of Preschool Home-Visiting Programs in Improving Children’s Developmental and Health Outcomes” (2009) and summarizes salient changes, emphasizes practical recommendations for community pediatricians, and outlines important national priorities intended to improve the health and safety of children, families, and communities. 1 By promoting child development, early literacy, school readiness, informed parenting, and family self-sufficiency, home visiting presents a valuable strategy to buffer the effects of poverty and adverse early childhood experiences that influence lifelong health.

The term “home visiting” refers to an evidence-based strategy in which a professional or paraprofessional renders a service in a community or private home setting. Home visiting also refers to the variety of programs that employ home visitors as a central component of a comprehensive service plan. 2 Early childhood home-visiting programs may be focused on young children, children with special health care needs, parents of young children, or the relationship between children and parents, and they can use a 2-generational strategy to simultaneously address parental and family social and economic challenges. 3  

Home-visiting programs vary widely with regard to target populations and goals. Many successful home-visiting models are directed toward mothers and infants in high-risk groups, such as adolescent mothers and single-parent families. Other models concentrate on specific populations, such as recently incarcerated adolescents, children with special needs, or immigrants. Some programs are designed to identify risk factors, such as environmental hazards and maternal mental health, but others include mentoring, coaching, and other therapeutic interventions. Many employ independently licensed health professionals, but others depend on trained paraprofessionals (including community health workers) drawn from the communities they serve. Community-based care coordination (including housing, transportation, and nutritional support) often are service components. Integration with the family-centered medical home (FCMH) has been a recent focus for program improvement and medical education. 4  

Home visiting began in the United States in the 1880s as an activity of each of 3 social justice movements. Derived from the British models developed a few decades earlier, home visitors were deployed to promote universal kindergarten, improve maternal-infant health through public health nursing, and support impoverished immigrant communities as part of the philanthropic settlement house movement. From the late 19th through the early 20th century, teachers and public health nurses visited communities and families to provide in-home education and health care to urban women and children. These efforts were based on the assumptions still held that education is the most powerful strategy to lift children out of poverty and that the lifelong health of families in immigrant and poor neighborhoods is improved by addressing the social and economic aspects of health and disease. 5  

From the Great Depression through World War II, funding for social initiatives decreased and philanthropic support for home visitors declined. After the relatively prosperous postwar period, renewed interest developed in antipoverty activities, including home visiting, especially in the context of the Civil Rights Movement. In the 1960s, home visiting became an important component of the government’s so-called War on Poverty. Home visiting was and remains integral to programs such as Head Start, although it is applied on a limited basis compared with Early Head Start, for which home visiting is a central service component. A decade later, many home-visiting programs shifted to include case management, intending to help families achieve self-sufficiency and link them to other broad community support services. 6 Improving school readiness, moderating poverty-related social risk determinants, reducing environmental safety hazards, and promoting population-based health remain core goals of contemporary home visiting.

In the last quarter of the 20th century, home visiting gained renewed attention as a strategy for the prevention of child abuse and neglect, promotion of child development, and improvement of parental effectiveness. C. Henry Kempe, MD, called for a home visitor for every pregnant mother and preschool-aged child in his 1978 Abraham Jacobi Memorial Award address. 7 He suggested that integral to every child’s right to comprehensive care is the assignment of a home health visitor to work with the family until each child began school. The visionary pediatrician who developed the concept of the medical home, Cal Sia, MD, reiterated Kempe’s call to action in his 1992 Jacobi Award address 8 based on his experience with Hawaii’s Healthy Start Program, which is an innovative, statewide home-visiting initiative to prevent child abuse and neglect. Another pioneer in modern home visiting, David Olds, PhD, initiated the Nurse-Family Partnership (NFP) with families at risk in Elmira, New York, in 1978. 1  

Before 2009, at least 22 states recognized the critical role of home visitors within statewide systems for at-risk pregnant mothers, infants, and toddlers from birth to 5 years old. States legislated funding for home-visiting programs while insisting on proof of effectiveness, fiscal accountability, and continuous quality improvement. Even during the Great Recession that followed the US financial crisis of 2007 to 2008, some state governments enacted home-visiting legislation to ensure long-term sustainability through innovative financing mechanisms and the strategic allocation of limited public resources.

In 2009, the American Recovery and Reinvestment Act (Public Law Number 111-5) included $2.1 billion for the expansion of Head Start and Early Head Start (including the home-visiting components of Early Head Start) to benefit young children in low-resource communities. The next year, the Patient Protection and Affordable Care Act of 2010 (ACA) (Public Law Number 111-148) designated $1.5 billion, allocated over 5 years, for the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV). The Health Resources and Services Administration currently administers the MIECHV in collaboration with the Administration for Children and Families. The allocations to states, territories, and tribal entities are designed to support the implementation and evaluation of evidence-based home-visiting programs regarding specified goals and objectives. All 50 states, the District of Columbia, and 5 US territories have home-visiting programs. 9 In addition, ACA funding provides support for home-visiting initiatives to serve American Indian and Alaskan native children through the Tribal MIECHV program. 10  

Nineteen home-visiting models have met the criteria of the US Department of Health and Human Services (HHS) for evidence of effectiveness through the Home Visiting Evidence of Effectiveness (HomVEE) review. Supported by federal grants through the MIECHV, states receive funding to implement 1 or more evidence-based models designated eligible by the MIECHV that best meet the needs of particular at-risk communities. The program objectives must improve outcomes that are statutorily defined and must include increased family economic self-sufficiency, improved health indicators (eg, a reduction in health disparities) in target populations, and improved school readiness. After 2013, potential program outcomes were expanded to include reductions in family violence, juvenile delinquency, and child maltreatment. 11 A review of 4 common programs illustrates the range of measurable outcomes. Healthy Families America identifies family self-sufficiency as a principal objective measured by a reduction of dependence on public assistance. 12 Early Head Start and other home-visiting programs focus on the promotion of child development and positive family relationships. NFP is designed to improve prenatal health, maternal life course development, and positive parenting. 13 Parents as Teachers promotes child development and school readiness. 14  

Home visiting for families with young children is an early intervention strategy in many industrialized nations outside of the United States. In several European countries, home health visiting is provided at no cost to the family, participation is voluntary, and the service is embedded in a comprehensive maternal and child health system. 3 While visiting young mothers at home, public health nurses in other countries provide many child health-promotion services that are provided by pediatricians in the United States. For instance, Denmark established home visiting in 1937 after a pilot program showed lower infant mortality rates linked with the services of home visitors. France provides universal prenatal care and home visits by midwives and nurses, who educate families about smoking, nutrition, drug use, housing, and other health-related issues.

The Early Start program in New Zealand targets families with 2 or more risk factors on an 11-point screening measure that includes parent and family functioning. Randomized controlled trials showed improvement in access to health care, lower hospitalization rates for injuries and poisonings, longer enrollment in early childhood education, and more positive and nonpunitive parenting. 15 , 16 The Dutch NFP program, VoorZorg, was found to reduce victimization and perpetration of self-reported intimate partner violence during pregnancy and 2 years after birth among low-educated, pregnant young women, 17 and there were fewer reports of child abuse. At 24 months, measurable improvements were evident in the home environments of participating families, and the children exhibited a significant reduction in internalizing symptoms. 18  

Paraprofessionals (ie, trained but unlicensed lay people) are often employed as home visitors in low-resource areas of the world. In Haiti, for example, community health workers trained by Partners in Health improve the care of those with HIV, multidrug-resistant tuberculosis, and such waterborne illnesses as cholera. In southern Mexico and other areas in Central America, “promotoras de salud,” or community health workers, coordinate with lay midwives to care for expectant mothers in rural, isolated, and other low-resource regions. Promotoras are deployed in many regions in the United States and have been recognized by HHS for their ability to reduce barriers and improve access to culturally informed and linguistically appropriate health care. 19  

More than 1 in 5 young children in the United States live in families with incomes below the federal poverty level, and more than 2 in 5 live at less than twice that level. 20 Living at or below 200% of the federal poverty level places children, 21 especially infants and toddlers, at high risk for adverse early childhood experiences that lead to lifelong detrimental effects on health, education, and vocational success. 22 Home visitors can help families attain economic self-sufficiency by linking them to community support services (such as quality preschool) while encouraging parents to enroll in training opportunities that lead to employment. Although they differ in structure, targeted populations, and intended outcomes, high-quality home-visiting programs deliver family support and child development services that provide a foundation for physical health, academic success, and economic stability in vulnerable families that are at risk for the adverse effects of poverty and other negative social determinants of health.

By applying multigenerational interventions, home visiting may improve child health and family wellbeing in many domains. Individual neuroendocrine-immune function, behavioral allostasis, and relational health are all established in the first 3 years of life, 23 when home visiting is most often applied. 24 The emerging science of toxic stress indicates that poverty and its accompanying problems, such as food insecurity, may disrupt the architecture and function of the developing brain. 25 , 26 Home visitors have the opportunity to assess risk and protective factors in families, identify potential adversity, and intervene at the earliest opportunity. By promoting supportive relationships, reducing parental stress, and increasing the likelihood of positive experiences, home visiting may help avoid the deleterious behavioral and medical health outcomes associated with child poverty. 27 , – 31  

Young mothers in poverty disproportionately suffer moderate to severe symptoms of maternal depression, elevating the risk of poor developmental and educational outcomes for their children. 32 Almost 1 in 4 mothers who are near or below the federal poverty level experience significant depression, but few obtain appropriate treatment. In-home cognitive behavioral therapy is a novel treatment modality for maternal depression that has proved to be effective in early trials. 33 Combining in-home cognitive behavioral therapy with other home-visiting programs, such as Early Head Start, that promote positive parenting and infant development provides a model of 2-generational care that has the potential to mitigate the effects of poverty and improve both family financial stability and school readiness. 34  

Home-visiting programs are most effective when they are components of a community-level, comprehensive early childhood system that reaches families as early as possible with needed services, accommodates children with special needs, respects the cultures of the families in the communities, and ensures continuity of care in a continuum from prenatal life to school entry. 35 , 36 An early childhood system may include safety-net resources (such as supplemental food and subsidies for housing, heating, and child care), adult education, job training, cash assistance, quality child care, early childhood education, and preventive health services. 37 Communicating the strengths and risk factors of individual families to the FCMH may further increase the coordination of care and efficient use of services. 38  

When the MIECHV program was established by the ACA, HHS established the HomVEE review of the research literature on home visiting. 11 Results of that review are used to identify home-visiting service delivery models that meet HHS criteria for evidence of effectiveness because, by statute, at least 75% of the funds available from the ACA are to be used for programs that use service delivery models that are evidence based. The HomVEE conducts a yearly literature search to identify promising studies of home-visiting models. It includes only studies that are considered to meet quality standards on the basis of overall design (only randomized controlled trials or quasiexperimental studies are included) and design-specific criteria. Studies that meet criteria for entry are then assessed for outcomes in the following 8 domains, as defined by HHS:

Child health;

Maternal health;

Child development and school readiness;

Reductions in child maltreatment;

Reductions in juvenile delinquency, family violence, and crime;

Positive parenting practices;

Family economic self-sufficiency; and

Linkages and referrals.

To meet HHS criteria for evidence of effectiveness, home-visiting models must demonstrate favorable outcomes in either 1 study with results in 2 or more domains or 2 studies with significant benefits in the same domain. To be included, study designs must meet evaluation quality standards, and outcomes need to show statistically significant benefits using nonoverlapping analytic samples. As of April 2017, the 18 models that meet these standards (along with 2 programs that do not meet criteria for implementation) with target populations, ages of participants, and outcomes for which there is evidence are listed in Table 1 . 11  

Home-Visiting Programs Meeting HHS Criteria for Evidence of Effectiveness (as of April 2017)

Reference: https://www.mathematica-mpr.com/our-publications-and-findings/publications/home-visiting-evidence-of-effectiveness-review-executive-summary-april-2017 . Descriptions of specific home-visiting programs by state can be accessed at: https://homvee.acf.hhs.gov/models.aspx .

Outcomes: (1) child health; (2) maternal health; (3) child development and school readiness; (4) reductions in child maltreatment; (5) reductions in juvenile delinquency, family violence, and crime; (6) positive parenting practices; (7) family economic self-sufficiency; and (8) linkages and referrals.

A rapidly expanding evidence base documents the benefits of high-quality home-visiting programs, especially when they are integrated in a comprehensive early childhood system of care. 39 Home visiting has been shown to increase children’s readiness for school, promote child health (such as vaccine rates), and enhance parents’ abilities to promote their children’s overall development. There is evidence that home visiting reduces the risk of both child abuse and unintended injury. 16 , 40 Maternal health is improved by more frequent prenatal care, better birth outcomes, and early detection and treatment of depression. 41 Outcome studies have established the effectiveness of home visiting by nurses or community health workers in reducing child maltreatment, 42 improving birth outcomes, 43 and increasing school readiness. 44  

A close examination of the evidence of effectiveness published in 2015 by the HomVEE review provides additional insights about the potential benefits and limitations of current models of home visiting. 11 Of the 44 models assessed in 2015, 19 showed improvements in at least 1 primary outcome measure, and 15 had favorable effects on secondary measures. These results are consistent with both the broad scope of many of the models as well as the likelihood that improvements in 1 domain sometimes lead to benefits in another (eg, positive parenting improving child development). All 19 models that showed positive results had evidence of sustained benefits for at least 1 year after enrollment.

In addition to the 19 models approved in 2015, 8 of the 25 that were not approved had evidence of benefit, perhaps because of stringent criteria for study quality and number. Even among programs showing positive outcomes, there was not a high level of consistency across domains. For example, only 7 of 19 models demonstrated benefits in the same domain across 2 or more studies. Many effect sizes were fairly small (approximately 0.2 SDs) but comparable to those seen in many studies of programs located in other settings (eg, early child education). 45 However, modest effect sizes in studies concerning developmental delay can result in important population-level effects given the high proportion of children in low-income families (nearly 20%) meeting criteria for early intervention services. 46 , 47  

Longitudinal studies within the HomVEE review of the NFP have shown improvements in adolescent mental health, in middle school achievement, over substance use and/or criminality immediately after high school, as well as in overall maternal and child mortality. 48 , – 50 Other studies document the persistence of beneficial outcomes after population-level scaling. A study of Durham Connects (also known as Family Connects) showed more than 80% participation and 84% adherence among all mothers delivering in Durham, North Carolina, during an 18-month period. 51 Researchers in this study, using rigorous methodology, documented important and beneficial effects on child health, including a 59% reduction in emergency medical care, an increase in positive parenting, successful linkages to community services, and improved maternal mental health. In addition, a large-scale study of SafeCare home-based services showed reductions in reports to child protective services after a scale-up of the program in Oklahoma. 52 These beneficial outcomes of rigorous program evaluation counterbalance other studies that found little or no benefit after a scale-up, such as the finding of reduced implementation fidelity and limited benefit after scaling up Hawaii’s Healthy Start Program. 53  

Other studies document the capacity of home visiting to successfully target specific high-risk populations and implement interventions of varying intensity specific to the intended outcome. For example, Computer-Assisted Motivational Intervention, when applied in combination with home visiting, successfully reduced subsequent pregnancies among pregnant teenagers. 54 Other 2-generational interventions, including Family Spirit (which targets American Indian teen-aged mothers) and Family Check-Up (which targets young mothers with depression), improved behavioral problems in infants and young children as well as the mental health of the young mothers. 55 , – 57  

Finally, the outcomes documented by the HomVEE need to be considered in the context of a number of meta-analyses and systematic reviews that have been conducted other than the HomVEE. One of the most cited is a meta-analysis that documented significant benefits across 4 broad domains, including child development, child abuse prevention, childrearing, and maternal life course. 58 Benefits were maximized when specific rather than general populations were targeted, when interventions used professionals versus paraprofessionals, and when interventions were more specifically focused on parental rather than child wellbeing. 59 , – 61  

Integration of home visiting with the medical home expands the multidisciplinary team into the community, enhancing the goals of communication, coordination of care, and comprehensive care. With effective leadership, the pediatric or FCMH may become a community hub that connects early education and child development activities with health promotion to support maximum outcomes for children and families. The Institute for Healthcare Improvement has described the triple aim as improvement of the health of populations, improvement of the quality of care and experience of each patient, and the reduction of per capita cost. The history of home visiting also reveals another triple aim of improving health, preparing children for education, and reducing poverty. An advanced medical home that reaches out to the community by collaborating with or integrating a high-quality home-visiting program has the potential of meeting both sets of triple aims. 62 , 63  

Some important factors that are common among home-visiting programs that are also characteristic of an FCMH include an emphasis on relationships, the provision of culturally informed care, coordination with other community support agencies, an emphasis on strength-based assessments, and collaboration with families to support self-identified goals. Of particular importance is the relationship that develops between the visitor and the family engaging in a natural environment and the consequent improvement in the relationships among family members. 64 As more has been learned about toxic stress and its negative effect on the life trajectory, close and nurturing relationships have emerged as a most important protective factor. The home visitor can extend the support of the medical home into the community and provide an important link for the family to the relationship with a compassionate pediatric practitioner while improving family relational health. 65  

The integration or colocation of home visiting with the medical home presents many opportunities for synergy and collaboration. The joint statement from the Academic Pediatric Association and the American Academy of Pediatrics (AAP) regarding integration of the FCMH with home visiting emphasizes the potential for coordinated anticipatory guidance, improved early detection, and enhanced community involvement. 66 Recommendations in the joint statement include integrated, computerized record systems; the creation of a joint registry; coverage of home visiting by payers, including Medicaid and the Children’s Health Insurance Program; and supporting the evaluation of coordination between an FCMH and home visiting. In a collaborative model, referrals between a pediatric practitioner and the home visitor may constitute a warm handoff (face-to-face introduction), increasing the likelihood that family concerns are communicated and addressed. For example, a home visitor has the opportunity to complete developmental screening with the parent in a child’s natural environment. The results of screening may be communicated to the pediatric practitioner for use and comparison with the developmental assessment during health-promotion visits. A shared chronic condition care plan facilitates common therapeutic goals, linkages to community resources, and follow-up on referrals. Particularly helpful have been home-visiting strategies for children with diabetes or asthma. Researchers have associated home visiting with improvements in symptoms, urgent care use, and family quality of life. 67  

Home visiting may be used effectively as an adjunctive strategy in comprehensive community-based programs serving children. Although not approved for MIECHV funding, Healthy Steps for Young Children is a comprehensive primary-care model that may include on the treatment team a home visitor who supports positive parenting, provides in-home developmental assessment, and links the family more strongly to the medical home. 68 The example of Healthy Steps illustrates the significant potential benefits from improved collaboration between the medical home and community home-visiting programs. These include common documentation, centralized intake services, strength-based assessments, colocation of home visitors in the pediatric practice, and multidisciplinary team meetings convened by the practice. Through these coordinated activities, home visitors are in partnership with the medical home to build parental resilience, promote child development, and support healthy family relationships. 66 , 69 Other models that similarly employ home visiting as an adjunctive strategy, such as the Health Resources and Services Administration’s Bridging the Word Gap Research Network 70 , 71 and the New York City Council’s City’s First Readers program, exemplify systematic linkages among the medical home, home-visiting programs, and other community-based services with early childhood education. 63 , 72  

Because home-visiting models and programs cross many health systems and involve many funding sources, this policy divides recommendations into the following 3 levels: community pediatricians, large health systems, and researchers. The section concludes with AAP-supported federal and state advocacy strategies.

Provide community-based leadership to promote home-visiting services to at-risk young mothers, children, and families;

Be familiar with state and local home-visiting programs and develop the capacity to identify and refer eligible children and pregnant mothers;

Consider opportunities to integrate or colocate home visitors in the FCMH;

Recognize home-visiting programs as an evidence-based method to enhance school readiness and reduce child maltreatment;

Recognize home visiting as a promising strategy to buffer the effects of stress related to the social determinants of health, including poverty; and

Serve as a referral source to home-visiting programs as a strategy to engage families in services and strengthen the connection between home visiting and the medical home.

Develop a continuum of early childhood programs that intersects or integrates with the FCMH;

Ensure that home-visiting programs are culturally responsive, linguistically appropriate, and family centered, emphasizing collaboration and shared decision-making;

Ensure that all home-visiting programs incorporate evidence-based strategies and achieve program fidelity to ensure effectiveness;

Support the use of trained community health workers, especially in lower-resourced, tribal, and immigrant communities; and

Develop training and certification programs for community health workers to ensure quality and fidelity to program expectations.

Improve understanding of how to engage difficult-to-reach and high-risk communities and populations, including immigrant families, families with low literacy and/or health literacy and limited English proficiency, families that are socially isolated, and families living in poverty in evidence-based home-visiting programs;

Improve understanding of how to take successful programs to scale while maintaining fidelity;

Improve understanding of how to optimize links between evidence-based home-visiting programs and the medical home;

Determine the degree to which the medical home and strategies using multidisciplinary and integrated interventions can provide added value to and synergy with evidence-based home-visiting programs;

Determine the degree to which home-visiting programs can augment the medical home in the prevention or mitigation of chronic disease, such as asthma and obesity, and associated morbidities;

Improve understanding of how to tailor the implementation of evidence-based home-visiting programs to diverse populations with heterogeneous strengths and challenges; and

Investigate and establish the cost-effectiveness and return on investment of home-visiting programs as well as program components.

The continuation and expansion of federal funding for evidence-based home-visiting programs;

Public support for the dissemination of home-visiting programs that meet the HomVEE criteria for evidence of effectiveness as well as other programs with early and promising evidence of potential effectiveness;

The establishment of state systems that integrate home-visiting infrastructure (such as data collection and evaluation) into a comprehensive early childhood service system;

Coordination across state agencies and health systems that serve young children to build an efficient and effective infrastructure for home-visiting programs;

The simplification and standardization of referral processes in and among states to improve the coordination of care and integration of home-visiting services with the medical home; and

The inclusion of home-visiting experience in community pediatrics education and exposure by residents and medical students to the evidence of effectiveness of home-visiting models.

The objectives of contemporary home-visiting programs have strong roots in public health, early childhood education, and antipoverty efforts. Home visiting has expanded rapidly in the recent past, with the current generation of programs providing strong evidence of effectiveness in many domains of family life. Rigorous national outcome evaluations substantiate that home-visiting programs are effective in the promotion of healthy family relationships, improvement of overall child development, prevention of child maltreatment, advancement of school readiness, and improvement of maternal physical and mental health. By linking families to opportunities such as employment and continuing education, home visiting increases family economic stability and thereby is a successful antipoverty strategy. Home-visiting programs have shown the most effectiveness when they are components of community-wide, early childhood service systems. With pediatrician leadership, the FCMH can serve as the hub for coordinating community-based, family support programs at the intersection of early education with public health promotion designed to help children avoid the lifelong effects of early childhood adversity.

American Academy of Pediatrcs

Patient Protection and Affordable Care Act

family-centered medical home

US Department of Health and Human Services

Home Visiting Evidence of Effectiveness

Maternal, Infant, and Early Childhood Home Visiting Program

Nurse-Family Partnership

Dr Duffee was intimately involved with the concept, organization, and design during the early phases of writing, he reviewed the contributions of the other authors, consolidated the contributions (along with his own) into the final product, took responsibility for responding to comments and direction from staff and the Board of Directors, and reviewed the references in detail to ensure that the evidence supports the recommendations; and Drs Kuo, Legano, Mendelsohn, and Earls assisted with revisions; and all authors approve the final manuscript as submitted.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

FUNDING: No external funding.

L ead A uthors

James H. Duffee, MD, MPH, FAAP

Alan L. Mendelsohn, MD, FAAP

Alice A. Kuo, MD, PhD, FAAP

Lori Legano, MD, FAAP

Marian F. Earls, MD, MTS, FAAP

Council on c ommunity Pediatrics Executive Committee , 2016–2017

Lance A. Chilton, MD, FAAP, Chairperson

Patricia J. Flanagan MD, FAAP, Vice Chairperson

Kimberley J. Dilley, MD, MPH, FAAP

Andrea E. Green, MD, FAAP

J. Raul Gutierrez, MD, MPH, FAAP

Virginia A. Keane, MD, FAAP

Scott D. Krugman, MD, MS, FAAP

Julie M. Linton, MD, FAAP

Carla D. McKelvey, MD, MPH, FAAP

Jacqueline L. Nelson, MD, FAAP

Jacqueline R. Dougé, MD, MPH, FAAP – Chairperson, Public Health Special Interest Group

Kathleen Rooney-Otero, MD, MPH – Section on Pediatric Trainees

Camille Watson, MS

Council on Early Childhood Executive Committee , 2016– 20 17

Jill M. Sells, MD, FAAP, Chairperson

Elaine Donoghue, MD, FAAP

Marian Earls, MD, FAAP

Andrew Hashikawa, MD, FAAP

Terri McFadden, MD, FAAP

Alan Mendelsohn, MD, FAAP

Georgina Peacock, MD, FAAP

Seth Scholer, MD, FAAP

Jennifer Takagishi, MD, FAAP

Douglas Vanderbilt, MD, FAAP

Patricia Gail Williams, MD, FAAP

Laurel Murphy Hoffmann, MD – Section on Pediatric Trainees

Barbara Sargent, PNP – National Association of Pediatric Nurse Practitioners

Alecia Stephenson – National Association for the Education of Young Children

Dina Lieser, MD, FAAP – Maternal and Child Health Bureau

David Willis, MD, FAAP – Maternal and Child Health Bureau

Rebecca Parlakian, MA – Zero to Three

Lynette Fraga, PhD – Child Care Aware

Charlotte Zia, MPH, CHES

Committee on Child a buse and Neglect , 2016–2017

Emalee G. Flaherty, MD, FAAP

Amy R Gavril, MD, FAAP

Sheila M. Idzerda, MD, FAAP

Antoinette “Toni” Laskey, MD, MPH, MBA, FAAP

Lori A. Legano, MD, FAAP

John M. Leventhal, MD, FAAP

Harriet MacMillan, MD – American Academy of Child and Adolescent Psychiatry

Elaine Stedt, MSW – Department of Health and Human Services Office on Child Abuse and Neglect

Beverly Fortson, PhD – Centers for Disease Control and Prevention

Tammy Hurley

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Nursing Home Visit

Description

A nursing  home visit is a family- nurse contact which allows the health worker to assess the home and family situations in order to provide the necessary nursing care and health related activities. In performing  home visits, it is essential to prepare a plan of visit to meet the needs of the client and achieve the best results of desired outcomes .

• To give care to the sick, to a postpartum mother and her newborn with the view teach a responsible family member to give the subsequent care.
• To assess the living condition of the patient and his family and their health  practices in order to provide the appropriate health teaching.
• To give health teachings regarding the prevention and control of diseases.
• To establish close relationship between the health agencies and the public for the promotion of health.
• To make use of the inter-referral system and to promote the utilization of community services

The following principles are involved when performing a home visit :

• A home visit must have a purpose or objective.
• Planning for a home visit should make use of all available information about the patient and his family through family records.
• In planning for a home visit, we should consider and give priority to the essential needs if the individual and his family.
• Planning and delivery of care should involve the individual and family.
• The plan should be flexible.

The following guidelines are to be considered regarding the frequency of home visits:

• The physical needs psychological needs and educational needs of the individual and family.
• The acceptance of the family for the services to be rendered, their interest and the willingness to cooperate.
• The policy of a specific agency and the emphasis given towards their health programs.
• Take into account other health agencies and the number of health personnel already involved in the care of a specific family.
• Careful evaluation of past services given to the family and how the family avails of the nursing services.
• The ability of the patient and his family to recognize their own needs, their knowledge of available resources and their ability to make use of their resources for their benefits.
• Greet the patient and introduce yourself.
• State the purpose of the visit
• Observe the patient and determine the health needs.
• Put the bag in a convenient place and then proceed to perform the bag technique .
• Perform the nursing care needed and give health teachings.
• Record all important date, observation and care rendered.
• Make appointment for a return visit.
• Bag Technique
• Primary Health Care in the Philippines

2 thoughts on “Nursing Home Visit”

Thanks alots for the impressive lessons learnt from the principal of community health care and nursing home

Home visit nursing

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Nursing Home Visit – Tips & What To Expect

If you are preparing for your first nursing home visit, read this guide. This is packed with helpful tips so you can be prepared.

Reasons Nurses Do Home Visits

There are lots of reasons that a nurse might visit someone’s home. Before I share some of my tips, it’s important to understand the purpose of the visit. Each type of home visit will have different goals and outcomes, so you’ll do different things when you arrive.

These are the main reasons that nurses might do home visits:

• Care for a sick patient as a home-care nurse
• Teach care techniques to a postpartum family
• Assess the living condition of a patient and/or their family members for upcoming care
• Teach people about prevention and control of diseases from within their homes
• To promote the utilization of community services

7. Make Another Appointment

Your chances of doing a home visit as a nurse will depend on where you work. Typically, community outreach organizations and home health care agencies will do the most frequent home visits.

How To Decide Whether To Do A Home Visit

If you are a new nurse, you probably won’t be the one making the decision about whether to visit a patient’s home, but it is still good to know how the decision is made.

Typically, these are the main guidelines that health care providers use to decide whether nurses should visit a patient in their home:

• The needs of the patient and their family – including physical, psychological, and educational
• Patient and family’s acceptance and willingness to cooperate
• Patient and family’s ability to recognize their needs and their ability to use the resources for their benefits
• How many health personnel are already involved in the care of this specific family
• The policy of the agency in regards to the home visits

How To Do A Home Visit

When it comes time to do your first home visit, just follow these steps in order. This will help you have a pleasant experience and make sure you don’t forget something important.

1. Greet The Patient

Arrive with a smile and introduce yourself. Remember to state where you are coming from and your role in the agency. Make sure you ask them their name and what they prefer to be called (if they have a nickname).

2. Tell Them The Purpose Of The Visit

Go into detail about why you are there and what you are hoping to accomplish. This part should be detailed so that they know what to expect.

3. Assess The Patient

Next you will do a quick observation and assessment. This is a silent and mental one so that you know what you will have to do while on your visit.

4. Set Your Bag In A Clean Place

Make sure your bag is sitting on a table that is lined with clean paper. Then, wash your hands with soap and water. Take out all the tools you will need for your visit so they are easy to access. Put on an apron, close the bag, and you are ready for your nursing care treatment.

5. Perform Your Nursing Care

After you are all prepared, you can do the care which you came to do. One of the most important things you will do on these visits is educate the patient and/or their family. Listen to their questions attentively and answer them the best you can. Direct them to any community services if you cannot help them right away.

6. Keep Excellent Records

Write everything down. Record the date, what you observed, and all the care you gave the patient. Also write down everything you told the family for caring for the patient at home.

If necessary, make an appointment to return and give more care. This is always needed, but don’t leave until you verified whether they need a follow up.

Nursing Home Visit: Final Thoughts

It might be nerve-wracking to think about visiting a patient or their family at their home. If you are really nervous, you can ask a friend or family member to help you prepare. Do a few practice runs as you introduce yourself and go through the motions of the assessment and care.

Set realistic expectations for yourself. If you need notes to remember what to ask, then take them along. Always ask for help when you need it. These can be very valuable and give the education and support that the patient and/or their family

More Nursing Tips

If you enjoyed these nursing home visit tips, then here are some more tips and advice about life as a nurse.

• How To Get ACLS Certified
• How To Write A Cover Letter
• The Best Accelerated Nursing Programs

About The Author

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EYFS: How to get home visits right

Many settings carry out home visits before children and families start with them. 

But whether you work in a playgroup, private nursery, school nursery or Reception class, there are some important considerations to take into account before making these visits part of your practice.  

If home visiting is already part of your role, take some time to reflect and review with your team.

Quick read:  Five questions we need to ask about EYFS

Quick listen:  What you need to know about the problems with ‘school readiness’ 

Want to know more?  My year in teaching: adventures with my early years class

We must be clear and consistent about what we do and why we do it.  There are dos and don’ts that must be regarded to make sure that a visit is successful and comfortable for all involved.

Be flexible

Remember that a visit to a family’s home is a privilege. You are their guest. In this way, the visit must take place on their terms, and at their convenience.

It can be very difficult for many parents or carers to get time off to see you during the day, and their child may be at nursery during this time, making it disruptive for everyone and hardly an ideal start.  

Rather than send appointments to the families, put up a chart at your introductory sessions for new families and ask them to sign up for a convenient time.

As a teacher, I met my youngest son’s new nursery teacher at my childminder’s house during my lunch break, a mutually convenient time for us all.

Allow refusals

Remember that there is no obligation to have a visit, it is not a statutory requirement.

If a family does not want a visit for any reason this must be respected, and reasons must not be expected. 

An informal meeting at a different venue may be more acceptable. I have met families in a local coffee shop, and some of my families preferred to come to school for a private cup of tea and a chat.

The core purpose of these visits must be to build up relationships founded on two-way trust and respect.

Don’t be judgemental

In order to build up this trust and respect, the home visit must not to be viewed as a time for form filling or cross examination. 

It is not an assessment or test - remember that some families will have had other agencies involved in their lives which may not have been such a pleasant experience.

Home visits are not judgemental, and should not be perceived as such. In this way, writing any kind of notes is inappropriate; don’t go armed with a clipboard and forms to fill in as this could easily be perceived as threatening.

Your visit is an opportunity to meet each other in an informal way, play with the children and feel relaxed in each other’s company. Building up trust and respect will help families to share things in confidence if they wish.

That is not to say that forms cannot be left with the parents to be filled in after the visit. Remember that visitors with clipboards are intimidating and this will damage any relationship.

Be sensitive to timings

Think about how long each visit needs to be, and be sure that the family knows how long you will be there. It is important that these aren’t rushed, but also that the welcome is not outstayed.

The family must feel relaxed. It is fine to accept or decline a drink or something to eat just as you would when visiting a friend. 

Bring resources 

Take a resource from the setting to share with the child. I always take a story sack as they enable interaction with the child, the family can join in, and the same resource will be available for them when they start at the setting.

Stay relaxed

Keeping relaxed can help families to share very private information with you. For example medical matters, special needs or family circumstances.

This must be respected as confidential and any paperwork given must be treated securely at the setting; the information should only be shared with those who need to know.

A relaxed home visit is about your team too. If you know that a colleague has specific allergies, it is always a good idea to check if a family has pets when arrangements are made.

Go in pairs

Finally, home visits must always be done in pairs. This is a safeguard for all concerned, but is also very practical - with two adults visiting there will be time for play and conversation and for everyone to feel relaxed. 

Dr Sue Allingham is an EYFS researcher

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Nurses Registry Home Health

The Art Of Aging At Home

New orleans.

What does a home health nurse do on the first home visit?

The proper home health nurse can help make independent living more achievable while still closely monitoring and managing your health condition. Well-organized health experts with lots of experience, home health nurses are there to make you feel at ease and make sure your treatment goes according to plan. They can also help you to understand the intended outcomes of your treatment and provide a listening ear. 

If you’re planning your first home health nurse visit, here are a few things to expect (and ask) to help make the most of the experience. 

Before the visit 

Before their first visit, you’ll be contacted by a representative or a nurse, who will help you get to grips with what to expect. This representative is there to smooth the transition between hospital care and home care. 

You should be notified of when they’ll be visiting and anything you may need to do to prepare. 

Evaluation 

One of the first steps your nurse will undertake is to evaluate your current condition. This will help them to organize a plan of care that suits your needs. The evaluation process will differ, depending on your condition and your medical team’s needs. You should be fully involved in this process and leave the session with more information about what to expect in the coming weeks and months. 

Your home health nurse will be responsible for helping to plan your care from other applicable healthcare professionals – for instance, dietitians or physical therapists – ensuring a well-rounded and effective treatment schedule that works for you. 

If anything seems unclear or any of the treatment dates scheduled aren’t workable for you, let your home health nurse know. 

Discussion 

This is also a great time to chat with your home health nurse about any questions or concerns you might have. Remember, you’ll be seeing them often – so this is an opportunity to find out about anything you’ve not yet been able to ask and to establish open lines of communication. 

Your home health nurse is likely to ask you a few questions, too – making sure you know exactly how things will progress as you move forward with treatment and helping to put your mind at rest. If anything is unclear or you have any worries, this is a great time to make sure your home health nurse knows. They’ll be happy to talk you through the way your visits will develop and find solutions to your queries or concerns.  

Medication 

Your home health nurse will also take the time to plan and administer any medication you’re currently taking, whether post-operatively or in the long term. They’ll help devise a schedule for medication that has to be taken outside of their visiting hours. They will likely either give or show you how to provide yourself with any injections, tablets, or tests that you need to carry out throughout the day, week, or week month of your treatment. 

As with every other stage of their first visit, be sure to flag any questions or concerns you have. You must know when to take your medication and understand the aims of the treatment you’ve been given. Be sure your home health nurse also provides you with information on any side effects that may occur.  

Monitoring 

One of the main aims of a home health visit is to monitor your condition and help keep you out of the hospital. Home care is a fantastic solution for many diverse conditions – and can often be both less costly and more comfortable for patients. 

Expect your vital signs to be taken during the visit and jotted down so that the nurse can keep a close eye on your progress throughout treatment. 

How long is the visit? 

The length of your first home health nurse visit will differ, depending on your condition and the complexity of the treatment plan which is being developed. 

The first visit could take as long as three hours or much less time if your needs are not as comprehensive. Please don’t feel like you have to rush this stage, as it’s necessary to get to know the person who will be helping you manage your health at home.

At Nurses Registry, we can schedule a free personalized in-home health care assessment with just a few clicks. Head to the official website and get in touch for more information. 

• Black Children
• Indigenous Children

5 Things to Know About Early Childhood Home Visiting

• Lauren Supplee

Early childhood home visiting is a type of family support targeted to expectant parents and parents of children birth to age 5. Trained home visitors provide services and support for parents and their children in their homes, where they may feel most comfortable. Parents who choose to participate in home visits may receive information on child development, health, and well-being, and on sources of support for parents themselves. Parents also learn about available services such as developmental screenings, and enrollment in any benefits they—or their children—may need.

States use a mix of federal, state, and foundation funding to support home visiting programs, and expenditures nationally may now exceed $1 billion. [1] Maternal, Infant, and Early Childhood Home Visiting ( MIECHV ) is one federal effort that facilitates the implementation of evidence-based home visiting programs. In fiscal year 2015, MIECHV-supported home visiting programs served 165,500 parents and children in every U.S. state, the District of Columbia, five territories, and 25 tribal entities.

There has been a great deal of research , over many decades, examining the use of home visiting to reach vulnerable children and families. Based on this research, here are five things to know:

1 Evidence shows that home visiting programs benefit children and families.

Research on early childhood models has demonstrated impacts for children and families across different outcome areas . There are many different home visiting models, serving children of different ages or targeting different outcomes (e.g., health, education, child abuse, employment, etc.). Some models target only one outcome while others try to improve a wide range of outcomes. Improving many outcomes versus one is not necessarily better or worse, in terms of effectiveness. Most evidence-based home visiting models (i.e., those with evidence of effectiveness) demonstrate favorable impacts on child development, school readiness, and positive, supportive parenting practices. Evidence-based home visiting models have shown positive long-term impacts on children in the long term, via increased school readiness , reduced child maltreatment , and reduced lifetime arrests and convictions . Evidence-based home visiting programs also show positive impacts for families, such as increased parental income and increased percentages of parents who live together .

2 Frequency of home visits vary by program.

Evidence-based home visiting programs use a wide range of recommended numbers of visits over different time span s . Models such as Family Connects and Family Check Up recommend three visits with a family. Other models, such as Healthy Families America and Nurse Family Partnership , begin seeing families in pregnancy or early infancy and may continue for multiple years. The frequency of visits may vary by the age of the child and the needs of the family. However, more research is needed on the optimal number and length of visits, generally.

3 Some models require rigid implementation, while others are more flexible.

Some home visiting models have a specific curriculum or specific measures they want home visitors to use with families. Some models specify staffing requirements, such as level of education or experience. Other models allow for flexibility in all or some of the program elements. Some implementing agencies (which may be nonprofits, hospitals, universities, county health departments, etc.) find it helpful to have everything packaged and ready to begin implementing, while others want more flexibility. However, there is currently little research on the extent to which giving implementing agencies the ability to be flexible and tailor their programs is related to greater impacts for families.

4 Fathers benefit from participation in home visiting programs.

Dads have reported home visiting programs helped them with their parenting skills and ability to co-parent, and with information about services to help them find jobs and participate in job training. However, research has shown that it is not always easy to include dads . Staff who work in home visiting programs may not have training on the best ways to include fathers in home visits. Sometimes dads are seen as less involved because they may not be present at the visits . However, if dads see the benefits of participating to learn about child development and ways to be better parents, this way of serving families may be a great way to reach fathers.

5 Home visiting models should account for community needs and resources.

Research suggests that in the process of choosing a home visiting model , there are benefits to assessing your community’s needs, goals, and available resources, and the fit of the evidence-based model you are considering. If the chosen model is not a good fit for a community, it may not achieve the outcomes desired , even if it has been effective in other settings. There is growing research examining model selection, the fit of a model to a community, and adaptations of models to meet unique program or community needs.

[1] Congressional Research Service estimate in 2009 suggested $750 million to 1 billion, and the MIECHV Program is now up to $400 million annually.

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• v.2021; 2021

The Practice of Home Visiting by Community Health Nurses as a Primary Healthcare Intervention in a Low-Income Rural Setting: A Descriptive Cross-Sectional Study in the Adaklu District of the Volta Region, Ghana

Kennedy diema konlan.

1 Department of Public Health Nursing, School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana

2 College of Nursing, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea

Nathaniel Kossi Vivor

Isaac gegefe, imoro a. abdul-rasheed, bertha esinam kornyo, isaac peter kwao, associated data.

The data used to support the findings of this study are included within the article.

Home visit is an integral component of Ghana's PHC delivery system. It is preventive and promotes health practice where health professionals render care to clients in their own environment and provide appropriate healthcare needs and social support services. This study describes the home visit practices in a rural district in the Volta Region of Ghana. Methodology . This descriptive cross-sectional study used 375 households and 11 community health nurses in the Adaklu district. Multistage sampling techniques were used to select 10 communities and study respondents using probability sampling methods. A pretested self-designed questionnaire and an interview guide for household members and community health nurses, respectively, were used for data collection. Quantitative data collected were coded, cleaned, and analysed using Statistical Package for Social Sciences into descriptive statistics, while qualitative data were analysed using the NVivo software. Thematic analysis was engaged that embraces three interrelated stages, namely, data reduction, data display, and data conclusion.

Home visit is a routine responsibility of all CHNs. The factors that influence home visiting were community members' education and attitude, supervision challenges, lack of incentives and lack of basic logistics, uncooperative attitude, community inaccessibility, financial constraint, and limited number of staff. Household members (62.3%) indicated that health workers did not adequately attend to minor ailments as 78% benefited from the service and wished more activities could be added to the home visiting package (24.5%).

There should be tailored training of CHNs on home visits skills so that they could expand the scope of services that can be provided. Also, community-based health workers such as community health volunteers, traditional birth attendants, and community clinic attendants can also be trained to identify and address health problems in the homes.

1. Introduction

Home visit practice is a healthcare service rendered by trained health professionals who visit clients in their own home to assess the home, environment, and family condition in order to provide appropriate healthcare needs and social support services. The home environment is where health is made and can be maintained to enhance or endanger the health of the family because individuals and groups are at risk of exposure to health hazards [ 1 , 2 ]. At home visit, conducted in a familiar environment, the client feels free and relaxed and is able to take part in the activity that the health professional performs [ 1 ]. It is possible to assess the client's situation and give household-specific health education on sanitation, personal hygiene, aged, and child care. The important role the health professional plays during home visits (HV) cannot be overemphasized, and this led Ghana to adopt HV as a cardinal component of its preventive healthcare delivery system. This role is largely conducted by community health nurses (CHN) [ 2 ]. Health education given during HVs is more effective, resulting in behavioural change than those given through other sources such as the mass media [ 3 ].

In the home, the health professionals, mostly CHN monitor the growth, development, and immunization status of children less than 5 years and carry out immunization for defaulters. Care is given to special groups such as the elderly, discharged tuberculosis, and leprosy patients as well as malnourished children [ 1 , 2 ]. It is also possible to carry out contact tracing during HVs [ 2 ]. These services may prevent, delay, or be a substitute for temporary or long-term institutional care [ 4 , 5 ]. HV has potential for bringing health workers into contact with individuals and groups in the community who are at risk for diseases and who make ineffective or little use of preventive health services [ 2 ]. Several factors influence the conduct of HVs. These factors include location of practice, general practitioners age, training status, and the number of older patients on the list and predicts home visiting rate [ 6 ].

The concept of HV has remained in Ghana over the decades, and yet, its very essence is imperative [ 3 ]. In Ghana, home visiting is one of the major activities of CHN. The health visitors, as CHNs were then called, went from house to house, giving education on sanitation and personal hygiene [ 3 ]. These nurses attempt to promote positive health and prevent occurrence of diseases by increasing people's understanding of healthy ways of living and their knowledge of health hazards [ 7 ]. HVs remain fundamental to the successful prevention of deaths associated with women and children under five; yet, there still remain certain gaps in the successful implementation of this innovative intervention in Ghana [ 4 ]. In Sekyere West district in Ashanti Region of Ghana, although nurses had knowledge of home visiting and had a positive opinion of the practice, they could not perform their home visiting tasks or functions up to standard [ 8 ]. Home visiting practice in that district among nurses was found to be very low, even though community members desired more [ 8 ]. The findings indicate that there is a need for HV [ 9 ]. Also identified were several health hazards, such as uncovered refuse containers, open fires, misplaced sharp objects, open defecation, and other unhygienic practices that a proper home visiting regiment can address [ 8 ]. At the service level, lack of publicity about the service, the cost of the service, failure to provide services that meet clients' felt needs, rigid eligibility criteria, inaccessible locations, lack of public transport, limited hours of operation, inflexible appointment systems, lack of affordable child care, poor coordination between services, and not having an outreach capacity were identified as the challenges associated with this kind of service [ 9 – 13 ].

Home visiting is a crucial tool for enhancing family healthcare and the health of every community. Ghana Health Service through home visiting services has supported essential community health actions and address gaps in knowledge and community practices such as reproductive behaviour, nutritional support for pregnant women and young children, recognition of illness, home management of sick children, disease prevention, and care seeking behaviours [ 4 ]. As many interventions are implemented by stakeholders in health to ensure that home visiting practices actually benefit community members, recent studies have not delved into the practices of home visiting in poor rural communities especially in the Volta Region of Ghana. This study assessed the home visiting practices in the Adaklu district (AD) of the Volta Region.

This study assessed the practice of home visiting as a primary healthcare (PHC) intervention in a poor rural district in the Volta Region of Ghana.

2. Methodology

2.1. study design.

This mixed method study employed a descriptive cross-sectional study design as the study involved a one-time interaction with the CHNs and the community members to assess the practice of HVs.

2.2. Study Setting

The AD is one of the districts in the Volta Region of Ghana and has about 40 communities. The district capital and administrative centre is Adaklu Waya. The estimated population of the district was 36391 representing 1.7% of the Volta Region's population before the Oti Region was carved out [ 14 ]. The district is described as a rural district [ 14 ] as no locality has a population above 5000 people. The economically active population (aged 15 and above) represents 67% of the population [ 14 ]. The economically inactive population is in full-time education (55.1%), performed household duties (20.6%), or disabled or too sick to work (4.6%), while the employed population engages in skilled agricultural, forestry, and fishery workers (63.1%), service and sales (12.6%), craft and related trade (14.6%), and 3.4% other professional duties [ 14 ]. The private, informal sector is the largest employer in the district, employing 93.9% [ 14 ]. There are 15 health facilities in the district government health centres [ 4 ], one health centre by Christian Health Association of Ghana, and 10 community health-based planning services (CHPS) of which 5 are functional [ 15 ]. The housing stock is 5629 representing 1.4% of the total number of houses in the Volta Region. The average number of persons per house was 6.5 [ 14 ], and the houses are mostly built with mud bricks [ 15 ]. The most common method of solid waste disposal by households is public dumping in the open space (47.5%). Some households dump solid waste indiscriminately (17.3%), while other households dispose of burning (13.3%) [ 14 ].

2.3. Study Population, Sample, and Sampling Technique

There are about 36391 inhabitants with 6089 households in AD [ 14 ]. This study mainly involved adult members of the household and CHNs from randomly sampled communities in the district. These sampled communities included Abuadi, Anfoe, Ahunda, Dawanu, Goefe, Helekpe, Hlihave, Tsrefe, Waya, and Wumenu. An adult member of the household is a person above the age of 18 years who has the capacity to represent the household. CHN [ 11 ] from the selected communities in the district was recruited. A CHN is a certified health practitioner who combines prevention and promotion health practices, works within the community to improve the overall health of the area, and has a role to play in home visiting.

Estimating for a tolerable error of 5%, with a confidence interval of 95%, and a study population of 6089 households, with a margin of error of 0.05 using Yamane's formula for calculating sample for finite populations, a sample of 375 households were computed. The sample size was increased to 390 to take into consideration the possible effect of nonresponse from participants. Multistage sampling technique was adopted to eventually select study participants. Each community was stratified into four geographical locations: north, south, east, and west with respondents being selected from every second house using a systematic sampling approach. In each household, an adult member of the household responded to the questionnaire.

A whole population sampling method was used to select eleven [ 11 ] CHNs from the specific communities [ 10 ] where the study took place in the district. The CHN that served the 10 selected communities were selected. The numbers selected from each community were Helekpe (18.2%), Waya (18.2%), Anfoe (9.1%), Tsrefe (27.3%) and Wumenu (27.3%). This represented 42.3% of the total CHN community of the district at the time of the study.

2.4. Pretesting

The questionnaire and interview guide were piloted using 30 adult household members and 5 CHNs, respectively, at Klefe CHPS in the Ho municipality. The data collected through the questionnaire were subjected to a reliability test on SPSS (version 22). The pretesting ascertained the respondent's general reaction and particularly, interest in answering the questionnaire. The questionnaire was modified until it produced a Cronbach alpha coefficient of 0.790. It can therefore be concluded that the questionnaire had a high reliability in measuring the objectives of the study. The pretesting helped in identifying ambiguous questions and revising them appropriately. It also helped to structure and estimate the time the respondents used to answer the questionnaires and to respond to the interview.

2.5. Data Collection

Researchers from the University of Health and Allied Sciences School of Nursing and Midwifery were involved in data collection. Five researchers received two days training in data collection, the study tools, and research ethics for social sciences prior to the commencement of data collection. All researchers had a minimum of a bachelor degree in CHN with at least three years' data collection experience.

Respondents were assisted to respond to a questionnaire within their homes. The household questionnaire had four [ 4 ] sections comprising personal details and how HV practice is carried out in the home such as frequency of visit, duration, and activities. Subsequent sections had respondents answer questions on the challenges, benefits, and factors that could promote the HV practice. It took an average of about 15 minutes to complete a single questionnaire.

A semistructured interview guide was used to interview CHNs. This guide was in four sections; the first section was personal details with subsequent sections on practice of home visits, constraints to the practice, the benefits, and promotion factors to HVs. An interview section lasted 20–25 minutes to complete.

2.6. Data Analysis

2.6.1. quantitative data.

Each individual questionnaire was checked for completeness and appropriateness of responses before it was entered into Microsoft Excel, cleaned, and transferred to the Statistical Package for Social Sciences (version 22) for analysis. The data were basically analysed into descriptive statistics of proportions. There were also measures of central tendencies for continuous variables.

2.6.2. Qualitative Data

In data analysis, thematic analysis was engaged that embraces three interrelated stages, namely, data reduction, data display, and data conclusion [ 16 ]. CHNs views were summarised based on the conclusions driven and collated as frequencies and proportions. Guest, Macqueen, and Namey summarised the process of thematic analysis as construing through textual data, identifying data themes, coding the themes, and then interpreting the structure and content of the themes [ 17 ]. In using this scheme, a codebook was first established, discussed, and accepted by the authors. The nodes were then created within NVivo software using the codebook. Line-by-line coding of the various transcripts was performed as either free or tree nodes. Double coding of each transcript was carried out by two of the researchers. Coding comparison query was used to compare the coding, and a kappa coefficient (the measurement of intercoder reliability) was generated to compare the coding that was conducted by the two authors. The matrix coding query was performed to compare the coding against the nodes and attributes using NVivo software that made it possible for the researchers to compare and contrast within-group and between-group responses.

2.7. Ethical Consideration

Ethical clearance was obtained on the 19th September, 2018, from the Research and Scientific Ethics Committee of the Institute of Health Research, University of Health and Allied Sciences (UHAS-REC A.2 [13] 18-19). Permission was sought from the district health authorities, chiefs, and assembly members of each study community. Preliminary to the administration of the questionnaires, an informed consent was obtained as respondents signed/thumb printed a consent form before they were enrolled into the study. Participants could withdraw from the study anytime they wished to do so.

3.1. Household Members' Views regarding Home Visit

The household representatives surveyed (375) had a mean age of 41.24 ± 16.88 years. The majority (26.5%) of household members were aged between 30 and 39 years. Most (75.1%) were females. The majority (97.1%) of people in households were Christians, while 38% was farmers. The majority (69.9%) of household members were married as 47.2% had schooled only up to the JHS level as at the time of this survey as given in Table 1 .

Demographic characteristics of household members.

The majority (73.3%) of adult household members had ever been visited by a health worker for the purpose of conducting HVs as a significant number (26.7%) of household members had never been visited by health workers in the community. Most (52.6%) household members had had their last visit from a health worker during the past month. Within the past three months, some (48.2%) community members were visited only once by a health worker. The majority (93.4%) of community members were usually visited between the time periods of 9am and 2pm as given in Table 2 . The community members contend that home visiting was beneficial to the disease prevention process (65%). The people that need to be visited by CHNs include children under five (25%), malnourished children's homes (14%), children with disabilities (14%), mentally ill people (11%), healthcare service defaulters (22%), people with chronic diseases (9%), and every member of the community (5%).

Practice of home visits in AD (household members).

Most (87.9%) community members were given health education during HVs conducted by the CHN. In describing the nature of health education that is most frequently given by CHNs during HVs, household members indicated fever management (14%), malaria prevention (20%), waste disposal (11%), prevention and management of diarrhoea (22%), nutrition and exclusive breastfeeding (14%), hospital attendance (14%), and prevention of worm infestations (5%). The majority (62.3%) of community members did not receive a minor ailment management during HVs as most (66.5%) of community members received vaccination during HVs by CHNs. Describing the type of minor ailment treatment given during the HV include care of home accidents (13%), management of minor pains (22%), management of fever (45%), and management of diarrhoea (20%). Household members (24.5%) did identify bad timing as a barrier for home visiting, while some (13.1%) did identify the attitude of health workers as a barrier to home visiting. However, most (67.3%) of the household members attributed their dislike for home visiting to the duration of the visit. The majority (95.2%) of household members indicated health workers were friendly. Some household members (78%) indicated they benefited from HVs conducted in their homes. The majority (91.4%) of household members showed that time for home visiting was convenient. Indicating if household members will wish for the conduct of the HV to be a continuous activity of CHNs in their community, the respondents (82%) were affirmative.

3.2. CHNs Views on Home Visit in AD

The mean age of CHNs was 30.44 ± 4.03 years as some (33.3%) were aged 32 years as the modal age. The CHNs (90.9%) were females with the majority (81.8%) being Christians as given in Table 3 .

Demographic characteristics of CHN.

In assessing the home visiting practices of CHNs, the researchers had some thematic areas. These thematic areas that were discussed include but not limited to the concept of HV by CHN, factors that influence the conduct of HVs, ability to visit all homes within CHN catchment area, reasons for conducting or not able to conduct HV, frequency of conducting home visits by CHN, and activities undertaken during HVs. This view that was expressed was simply summarised based on the thematic areas and presented in Table 4 as descriptive statistics related to the CHN conduct of HVs.

Summary of CHNs home visit practice in AD.

3.2.1. Concept of Home Visit by CHN

CHNs have varied descriptions of the concept of HV as it is conducted within the district. The description of HV was basically related to the nature and objective that is associated with the concept. The central concept expressed by participants included a health worker visiting a home in their place of abode or workplace, providing service to the family during this visit, and this service is aimed at preventing disease, promoting health, and maintaining a positive health outcome. These views were summarised when they said

“HVs are a service that we (CHNs) rendered to the client and his family in their own home environment to promote their health and prevent diseases. The central idea is that during the HV, the CHN is able to engage the family in education and services that eventually ensure that diseases are prevented and health is promoted.”

“HV is the art when the CHNs visit community members' homes to provide some basic curative and largely preventive healthcare services to clients within their own homes or workplaces. During this visit, the CHN helps the entire family to live a healthy life and give special attention or care to the vulnerable members of the society.”

“It is the processes when at-risk populations are identified; then, the CHN provides services to this cadre within their own home environment and sometimes workplaces as the case may be. Essentially, the CHN assists the family to adopt positive behaviours that will ensure they live with the vulnerable person in a more comfortable way.”

3.2.2. Factors that Influence the Conduct of Home Visits

The CHNs enumerated a cluster of factors that influence the conduct of HVs within the district. These factors ranged from community members education, attitude, supervision challenges, lack of incentives, and lack of basic logistics to conduct HVs. The uncooperative attitude of community members was identified by CHNs (36.4%) as a barrier to HVs. As they indicate, some community members did not support the continued visit to their homes or did not give them the necessary attention needed for the provision of services.

“Some community members do not understand the importance of HVs in the prevention of disease and for that matter are less receptive to the conduct of HVs. They just do not see the need for the service provider to come to their homes to provide services.”

“The client is the master of his own home; when you get into a home for a HV, the owner should be willing to talk or attend to you. Sometimes, you get into a home and even if you are not offered a seat, or you are just told we are busy, come next time. You know community service is not a paid job, so because the community members do not directly pay for the services we provide, essentially less premium is placed on the activities we conduct.”

“There is some resistance to HVs by some community members. Sometimes, you come to a house and can feel that you are not wanted; meanwhile, the home is part of the home that needs and has to get a HV because of the special needs they have. This is particularly specific in homes that believe that the particular problem is a result of supernatural causes.”

3.2.3. The Ability to Visit All Homes within CHN Catchment Area

The conduct of HVs is a basic responsibility for all CHNs as they remain as an integral part of the PHC delivery system in Ghana. Based on the nature and problems in the community, CHNs strategizes various means that will aid them to provide this essential service efficiently. CHNs (81.8%) are able to visit all homes in the catchment areas during a quarter. Some of the responses included the following:

“We do organise HVs, this is part of our routine schedule. As a community health nurse, to enjoy your work, you will need to organise HVs from time to time.”

“As for the HV, it depends on the strategies a particular CHPS compound is using. Irrespective of the community that one works in, you can always provide full and adequate care and service to the community if you plan well. First, you have to identify the “at need people” then the distance to their homes and put this in your short-term strategic plan for execution.”

“HVs are basic responsibilities of community health nurses, and we ought to execute it. In spite of the challenges, we cannot let those particularly hinder on our ability to conduct our very core mandate.”

Some CHNs were not able to visit all homes in their catchment areas, citing “hard to reach areas” and “Inadequate equipment” as the reasons for not being able to visit all households.

“Sometimes it is the distance to the clients' homes that makes it impossible to visit them. There are some homes if you actually intend to visit them, then you must be willing to spend the whole day doing only that activity.”

“Some clients' problems are such that you will need to have special tools before you visit them. For example, what use will it be to a diabetic client if you visit him/her and you are unable to monitor the blood sugar level or to a hypertension patient, you are not able to check the blood pressure because you do not have the required equipment?”

“To have a successful HV practice, I think the authorities should be willing to provide the basic logistics that will aid us to work. Without this basic logistics, we cannot.”

3.2.4. The Reasons for Conducting or Not Able to Conduct Home Visits

CHNs (72.7%) carried out both routine and special HVs. For those community health nurses who were not able to conduct HVs, several reasons were ascribed. Some of the reasons described included the lack of basic amenities to conduct HVs. The majority (18.2%) of CHNs also did attribute inaccessible geographical areas as a barrier to HV. Also, CHNs (63.6%) identified inadequate logistics and financial constraints as barriers to HV. All of the CHNs report on their activities regarding home visiting to the district health authorities.

“We basically lack the simple logistics that will assist us to conduct HVs. We do not have simple movable equipment like weight scales, thermometers, sphygmomanometers, and stethoscopes.”

“We do not have functionally equipped home visiting bags, so even if we decide to visit the homes, how much help will we be to the client?”

The other reasons included large catchment areas and lack of reliable transportation for the conduct of HVs in the AD.

“The catchment area is quite wide and practically impossible to visit every home. Looking from here to the end of our catchment area is more than 5 kilometers, without a means of transport, one cannot be able to visit all those homes.”

“I remember in those days; community health nurses were given serviceable motor cycles to aid in their movement and especially the conduct of HVs. Today, since our motorbike broke down 5 years ago, it has since not been serviced, yet we are expected to conduct HVs.”

“To conduct home visits, whose money will be used for transportation? The meagre salary I earn? Or the families or beneficiaries of the service have to pay?”

“The number of staff here is woefully inadequate, we are only two people here, how can we do home visiting and who will be left in the facility to conduct the other activities. For this reason, we are not able to conduct HVs.”

CHNs tried to visit the homes at various times depending on the occupation of the significant other of the homes, so that they can provide services in the presence of the significant others. CHNs (63.6%) visit 6–10 homes in a week as 90.9% CHNs conduct HVs in the morning. The reasons given for conducting some HVs in the evenings included the following:

“This place is largely a farming community, most people visit their farms during the mornings, so if you visit the home in the morning, you may not meet the significant others of the vulnerable person to conduct health education.”

“We do HVs because of the clients, so anytime it is possible, we will meet them at home, we conduct the visits at that time. For me, even if the case is that I can only meet the important people regarding the client at night, I visited them at that time. For community health nursing work, it is a 24-hour work and we must be found doing it at all time.”

3.2.5. Frequency of Conducting Home Visits by CHN

Various schedule periods were used based on health facilities for the purpose of HVs. Most (45.5%) conducted HVs three times in a week. CHNs (90.9%) had conducted HVs the week preceding the interview. Indicating that the last time HV was conducted, CHNs conducted a HV at least within the last week:

“HV is a weekly schedule in this facility; for every week, we have a specific person who is assigned to do HV just as all other activities that are conducted in this facility”.

“Yes, last week, we had a number of HVs; we made one routine HV and the other was a scheduled HV from a destitute elderly woman who was accused as a witch by some of her family members.”

Indicating if they sometimes get fatigued for conducting HVs weekly because of the limited number of staff, a community health nurse indicated that,

“I think it is about the plan we have put in place. There are about four people in this facility. We plan our activities that we all conduct HVs. In a month, one may only have one or two HVs, so it is unlikely that you will be fatigued in conducting HVs.”

“Yes, sometimes, it is really tedious, but we cannot let that be a setback. We have a responsibility to execute and we must be doing so to the best of our ability.”

3.2.6. Activities Undertaken during Home Visits

CHNs conducted health education (90.9%), management of minor ailments (54.6%), and vaccination/contact tracing (63.6%) during HVs. Describing if they are able to conduct the management of small ailments and home accidents at home, CHNs were divided in their ability to do this. Those were not able to do so indicated,

“…. And who will pay? Since the introduction of the national health insurance, we are not able to provide management of minor ailments during HVs. In those days, we were supplied with the medicines to use from the district, so we could provide such free services. But with the insurance now in place, we do not get medicine from the district, so whose medicine will you use to conduct such treatment?”

“I think our major goal is on preventive care. We have a lot to do with preventing diseases. Let us leave disease treatment to the clinical people. When we get ailments, we refer them to the next level of care to use their health insurance to access service.”

Identification of cases, defaulter tracing, and health education were identified as benefits and promotion factors of HVs. Identification of cases and defaulter tracing were both mentioned by CHNs as benefits and promotion factors of HVs.

“I think HVs should be continued and encouraged to be able to achieve universal, sustainable PHC coverage for all. Not only do we visit the homes, we also identify vaccination defaulters, tuberculosis treatment defaulters, and prevention of domestic violence against women and children and health education on specific diseases and sometimes we do immunisation.”

“In the home, we have a varied responsibility, treatment of minor ailments, immunization and vaccination, contact tracing, education on prevention of home accidents, etc.” It will be a disservice, therefore, if anyone tries to downplay the importance of HVs in our PHC dispensation.”

“Through HVs, we have provided very essential services that cannot be quantified mathematically, but the community members know the role of the services in their everyday lives. Even the presence of the community health nurse in the home is a factor that promotes girl child education and leads to woman empowerment.”

4. Discussion

This study assessed the home visiting practices in the AD of the Volta Region of Ghana. The concept of home visiting has been enshrined in Ghana's health history and executed by the CHN or public health nurses (PHN). In AD, only CHNs among all the various cadres of health professionals conducted HVs. This was contrary to the practice in the past when both CHN and PHN conducted HVs [ 18 ]. Notwithstanding the limited numbers of CHNs in the district, the majority of households (73.3 %) have a history of visits from a CHN. Home visiting is central in preventive healthcare services, especially among the vulnerable population. In children under five years, it is plausible that nurse home visiting could lead to fewer acute care visits and hospitalization by providing early recognition of and effective intervention for problems such as jaundice, feeding difficulties, and skin and cord care in the home setting [ 19 ]. Home visiting emphasizes prevention, education, and collaboration as core pillars for promoting child, parent, and family well-being [ 20 ].

In Ghana, under the PHC initiative, communities are zoned or subdivided and have a CHN to manage each zone by conducting HVs, including a cluster of responsibilities mainly in the preventive care sectors [ 4 ]. As rightly identified, HV is one of the core mandates of the CHN. Most of the community members who had received more than one visit in a week lived close to the health facilities indicating that there are homes which have never been visited, and CHNs are not able to cover all homes in their catchment areas. Factors that deter the conduct of HVs by CHN ranged from community members' level of education, attitude, supervision challenges, lack of incentives, and lack of basic logistics to conduct HVs. It is imperative that CHNs HVs especially those with newborn children to assess the home environment and provide appropriate care interventions and education as it was reported that 2.8% of 2641 newborns who did not receive a HV were readmitted to the hospital in the first 10 days of life with jaundice and/or dehydration compared with 0.6% of 326 who did receive a HV [ 21 ]. CHNs need to be provided with the right tools including means of transport to reach “hard to reach” communities and homes to provide services.

In rural Ghana such as the AD, community members leave the home to their places of work or farms during the morning sessions and only return home in the evening or late afternoon. HVs (93.4%) were conducted between 9am and 2pm, while some homes (6.6%) were visited between 3pm and 6pm. One problem faced by this timing difference is further expressed when CHNs indicated that they did not meet people at home during HVs. It is important for CHNs to be wary of their safety in client's homes as they show enthusiasm to visit homes at any time, and they could meet significant others. Therefore, to ensure safety, it is important to cooperate with clients and their families [ 22 ] in providing these services especially outside the conventional working hours. The need to use alternative timing of visits is essential as it is known that client participation is required to determine the scope of quality and safety improvement work; in reality, it is difficult for them to participate [ 23 ]. Also, some respondents indicated the time spent during HVs was too short (32.7%), and others (24.5%) wished the CHNs could spend more time with them. Community members have problems they wished could be addressed by the CHNs during HVs, but because of the number of households compared to the limited number of CHNs available, the CHNs could not spend much time during HVs and the respondents were not satisfied with the services rendered. It is likely that services will be better implemented by households if the CHN spends much time with the household and together implements thought health activities. Amonoo-Lartson and De Vries reported that community clinic attendants who spent more time in consultation performed better [ 24 ].

CHNs (8.2%) indicated they could not visit all households that needed the home visiting services in their catchment areas. Home visiting nurses are required to be mindful of the time and environment where they are performing care [ 22 ], so that they can allow for maximum benefit to the community. This notwithstanding, some community members (26.7 %) were not available during the HVs. The determination of suitable time between the CHN and the client is critical in ensuring that a positive relationship is established for their mutual benefit. The interval associated with HVs varied from one community or a health centre to another, and this was planned based on the specific needs of each community or CHPS catchment zone. There is actually no one-size-fits-all approach to home visiting [ 20 ] as several strategies can be adopted in providing services. The number of weeks or months elapsing between the visits ranged from one week to four months. The ministry of Health Ghana per the PHC system encourages CHN to conduct at least one contact tracing and/or HV session within a week within their communities [ 25 ]. All CHNs indicated that in their catchment area, they conducted at least one HV in a week and sometimes even more depending on the exigencies of the time.

Various activities are expected to be conducted by CHNs during HVs. These activities include the provision of basic healthcare services such as prevention of diseases and accidents, disease surveillance, tracing of contacts of infectious disease, tracing of treatment defaulters such as tuberculosis, diabetes mellitus, and hypertension and management of minor ailments at home. Community members (62.3%) did not receive a minor ailment management during HVs. CHNs are expected to be equipped with requisite knowledge, tools, and skills to be able to conduct these services in the homes. Also, the level of care that can be identified as a minor ailment as per the guidelines of the Ministry of Health needs to be specific as community members had varied classification of minor ailments and the level of care to be provided. Home visitors have varying levels of formal education and come from a variety of educational backgrounds marked by different theoretical traditions and content knowledge [ 20 ]. Other jurisdiction HV nurses drew blood for bilirubin checks and set up home phototherapy if indicated; they provided breastfeeding promotion and teaching on feeding techniques and skin and cord care [ 19 ]. Also, CHNs are expected to be able to provide baby friendly home-based nursing care services during a visit to the clients' home. HV nurses should also discuss the schedule of well-baby visits and immunizations [ 19 ] with families.

Important challenges associated with the conduct of HVs were identified as a large catchment area, lack of basic logistics, lack of the reliable transportation system, uncooperative community members, inadequate staff, and “hard to reach” homes due to geographical inaccessibility. Health education, management of minor ailment, and vaccination or contact tracing were the activities carried out in the homes. Home visiting nurses are under pressure to complete a job within an allotted time frame, as determined by the contract or terms of employment [ 22 ]. Time pressure significantly contributes to fatigue and depersonalization, and adjustments to interpersonal relationships with nurse administrators can have notable alleviating effects in relation to burnout caused by time pressure [ 26 ]. CHNs (63.6%) identified inadequate equipment and financial constraints as challenges to HV. Given evidence suggesting that relationship-based practices are the core of successful home visiting [ 27 – 29 ], with a natural harmony between the home visitor and the community members to the home, she renders her services [ 20 ]. A report published by the National Academy of Sciences (1999) also identified staffing, family involvement, language barrier, and cultural diversities as some of the barriers to a HV [ 30 ].

Health education (87.9%) dominated the home visiting activities. Health education helps to provide a safe and supportive environment and also build a strong relationship that leads to long lasting benefits to the entire family [ 5 ]. Face to face teaching in the privacy of the home is an excellent environment for imparting health information [ 31 ]. The CHNs stated that health education, tracing of defaulters, and identification of new cases are the benefits and promotion factors for conducting HVs. This implies that there are other critical aspects of HV that CHNs neglect such as prevention of home accidents and ensuring a safe home environment and care for the aged. Early detection of potential health concerns and developmental delays, prevention of child abuse, and neglect are also other benefits and promotive factors of HV. HV helps to increase parents' knowledge, parent-child interactions, and involvement [ 5 ]. The conduct of HV was not reported among all community members as some community members (22.0%) in the AD indicated their homes have never been visited. This is, however, an improvement over the rate of HVs that was reported in the Assin district in Ghana [ 32 ]. In the Assin district, about 84% of the respondents said they gained benefits from HVs [ 32 ]. In this study, respondents who were visited indicated the CHNs just inspected their weighing card while giving them no feedback. CHNs should implement various interventions to ensure that community members directly benefit from health interventions that are implemented during HVs to reduce the consequences that are usually associated with poor access to healthcare services especially in poor rural communities such as the AD.

5. Conclusion

The activities carried out in the homes were mainly centred on health education, contact tracing, and vaccination. Health workers faced many challenges such as geographical inaccessibility, financial constraints, and insufficient equipment and medications to treat minor ailments. If HV is carried out properly and as often as expected, one would expect the absence of home accidents, child abuse, among others in the homes, and a reduction in hospital admissions.

The need for strengthening HV as a tool for improving household health and addressing home-based management of minor ailment in the district cannot be over emphasized. It is important to forge better intersectoral collaboration at the district level. The District Assembly could assist the District Health Management Team with transport to support HVs. In addition, community-based health workers such as community health volunteers, traditional birth attendants, and community clinic attendants should also be trained to identify and address health problems in the homes to complement that which is already conducted by healthcare professionals.

Acknowledgments

The authors wish to express their profound gratitude to the staff and district health management team of the AD of the Volta Region of Ghana for providing them with the necessary support and assisting in diverse ways to make this study possible. They thank their participants for the frank responses.

Abbreviations

Data availability, conflicts of interest.

The authors declare that they have no conflicts of interest.

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Home Visit: Opening the Doors for Family Health

Chapter 11 Home Visit Opening the Doors for Family Health Claudia M. Smith Chapter Outline Home Visit Definition Purpose Advantages and Disadvantages Nurse–Family Relationships Principles of Nurse–Client Relationship with Family Phases of Relationships Characteristics of Relationships with Families Increasing Nurse–Family Relatedness Fostering a Caring Presence Creating Agreements for Relatedness Increasing Understanding through Communication Skills Reducing Potential Conflicts Matching the Nurse’s Expectations with Reality Clarifying Nursing Responsibilities Managing the Nurse’s Emotions Maintaining Flexibility in Response to Client Reactions Clarifying Confidentiality of Data Promoting Nurse Safety Clarifying the Nurse’s Self-Responsibility Promoting Safe Travel Handling Threats during Home Visits Protecting the Safety of Family Members Managing Time and Equipment Structuring Time Handling Emergencies Promoting Asepsis in the Home Modifying Equipment and Procedures in the Home Postvisit Activities Evaluating and Planning the Next Home Visit Consulting and Collaborating with the Team Making Referrals Legal Documentation The Future of Evidence-Based Home-Visiting Programs Focus Questions Why are home visits conducted? What are the advantages and disadvantages of home visits? How is the nurse–client relationship in a home similar to and different from nurse–client relationships in inpatient settings? How can a nurse’s family focus be maximized during a typical home visit? What promotes safety for community/public health nurses? What happens during a typical home visit? How can client participation be promoted? Key Terms Agreement Collaboration Consultation Empathy Family focus Genuineness Home visit Positive regard Presence Referral Nurses who work in all specialties and with all age groups can practice with a family focus , that is, thinking of the health of each family member and of the entire family per se and considering the effects of the interrelatedness of the family members on health. Because being family focused is a philosophy, it can be practiced in any setting. However, a family’s residence provides a special place for family-focused care. Community/public health nurses have historically sought to promote the well-being of families in the home setting ( Zerwekh, 1990 ). Community/public health nurses seek to promote health; prevent specific illnesses, injuries, and premature death; and reduce human suffering. Through home visits, community/ public health nurses provide opportunities for families to become aware of potential health problems, to receive anticipatory education, and to learn to mobilize resources for health promotion and primary prevention ( Kristjanson & Chalmers, 1991 ; Raatikainen, 1991 ). In clients’ homes, care can be personalized to a family’s coping strategies, problem-solving skills, and environmental resources (see Chapter 13 ). During home visits, community/public health nurses can uncover threats to health that are not evident when family members visit a physician’s office, health clinic, or emergency department ( Olds et al., 1995 ; Zerwekh, 1991 ). For example, during a visit in the home of a young mother, a nursing student observed a toddler playing with a paper cup full of tacks and putting them in his mouth. The student used the opportunity to discuss safety with the mother and persuaded her to keep the tacks on a high shelf. The quality of the home environment predicts the cognitive and social development of an infant ( Engelke & Engelke, 1992 ). Community/public health nurses successfully assist parents in improving relations with their children and in providing safe, stimulating physical environments. All levels of prevention can be addressed during home visits. Research has demonstrated that home visits by nurses during the prenatal and infancy periods prevent developmental and health problems ( Kitzman et al., 2000 ; Norr et al., 2003 ; Olds et al., 1986 ). Olds and colleagues demonstrated that families who received visits had fewer instances of child abuse and neglect, emergency department visits, accidents, and poisonings during the child’s first 2 years of life. These results were true for families of all socioeconomic levels but greater for low-income families. The health outcomes for families who received home visits were better than those of families that received care only in clinics or from private physicians. Furthermore, the favorable results were still apparent 15 years after the birth of the first child ( Olds et al., 1997 ), and the home visits reduced subsequent pregnancies ( Kitzman et al., 1997 ; Olds et al., 1997 ). The U.S. Advisory Board on Abuse and Neglect advocates such home-visiting programs as a means to prevent child abuse and neglect ( U.S. Department of Health and Human Services, 1990 ). Other research shows that home visits by nurses can reduce the incidence of drug-resistant tuberculosis and decrease preventable deaths among infected individuals ( Lewis & Chaisson, 1993 ). This goal is achieved through directly observing medication therapy in the individual’s home, workplace, or school on a daily basis or several times a week (see Chapter 8 ). Several factors have converged to expand opportunities for nursing care to adults and children with illnesses and disabilities in their homes. The American population has aged, chronic diseases are now the major illnesses among older persons, and attempts are being made to limit the rising hospital costs. As the average length of stay in hospitals has decreased since the early 1980s, families have had to care for more adults and children with acute illnesses in their homes. This increased demand for home health care has resulted in more agencies and nurses providing home care to the ill and teaching family members to perform the care (see Chapter 31 ). The degree to which families cope with a member with a chronic illness or disability significantly affects both the individual’s health status and the quality of life for the entire family ( Burns & Gianutsos, 1987 ; Harris, 1995 ; Whyte, 1992 ). Family members may be called on to support an individual family member’s adjustment to a chronic illness as well as take on tasks and roles that the ill member previously performed. This adjustment occurs over time and often takes place in the home. Community/public health nurses can assist families in making these adjustments. Since the late 1960s, deinstitutionalization of mentally ill clients has shifted them from inpatient psychiatric settings to their own homes, group homes, correctional facilities, and the streets (see Chapter 33 ). Nurses in the fields of community mental health and psychiatry began to include the relatives and surrogate family members in providing critical support to enable the person with a psychiatric diagnosis to live at home ( Mohit, 1996 ; Stolee et al., 1996 ). The hospice movement also recognizes the importance of a family focus during the process of a family member’s dying ( American Nurses Association [ANA], 2007a ). Care at home or in a homelike setting is cost effective under many circumstances. As the prevalence of acquired immunodeficiency syndrome (AIDS) increases and the number of older adults continues to increase, providing care in a cost-effective manner is both an ethical and an economic necessity. Nurses in any specialty can practice with a family focus. However, the specific goals and time constraints in each health care service setting affect the degree to which a family focus can be used. A home visit is one type of nurse–client encounter that facilitates a family focus. Home visiting does not guarantee a family focus. Rather, the setting itself and the structure of the encounter provide an opportunity for the nurse to practice with a family focus. A nurse visiting a client in his home listens to the man’s heart while his daughter looks on. Nurses who graduate from a baccalaureate nursing program are expected to have educational experiences that prepare them for beginning practice in community/public health nursing. Family-focused care is an essential element of community/public health nursing. One of the ways to improve the health of populations and communities is to improve the health of families ( ANA, 2007b ). Home visits may be made to any residence: apartments for older adults, group homes, boarding homes, dormitories, domiciliary care facilities, and shelters for the homeless, among others. In these residences, the family may not be related by blood, but, rather, they may be significant others: neighbors, friends, acquaintances, or paid caregivers. Nurses who are educated at the baccalaureate level are one of a few professional and service workers who are formally taught about making home visits. Some social work students, especially those interested in the fields of home health and protective services, also receive similar education. The American Red Cross and the National Home Caring Council have developed training programs for homemakers and home health aides; not all aides have received such extensive training, however. Agricultural and home economic extension workers in the United States and abroad also may make home visits ( Murray, 1968 ; World Health Organization, 1987 ). Home visit Definition A home visit is a purposeful interaction in a home (or residence) directed at promoting and maintaining the health of individuals and the family (or significant others). The service may include supporting a family during a member’s death. Just as a client’s visit to a clinic or outpatient service can be viewed as an encounter between health care professionals and the client, so can a home visit. A major distinction of a home visit is that the health care professional goes to the client rather than the client coming to the health care professional. Purpose Almost any health care service can be accomplished on a home visit. An assumption is that—except in an emergency—the client or family is sufficiently healthy to remain in the community and to manage health care after the nurse leaves the home. The foci of community/public health nursing practice in the home can be categorized under five basic goals: 1.  Promoting support systems that are adequate and effective and encouraging use of health-related resources 2.  Promoting adequate, effective care of a family member who has a specific problem related to illness or disability 3.  Encouraging normal growth and development of family members and the family and educating the family about health promotion and illness prevention 4.  Strengthening family functioning and relatedness 5.  Promoting a healthful environment The five basic goals of community/public health nursing practice with families can be linked to categories of family problems ( Table 11-1 ). A pilot study to identify problems common in community/public health nursing practice settings revealed that problems clustered into four categories: (1) lifestyle and living resources, (2) current health status and deviations, (3) patterns and knowledge of health maintenance, and (4) family dynamics and structure ( Simmons, 1980 ). Home visits are one means by which community/public health nurses can address these problems and achieve goals for family health. Table 11-1 Family Health-Related Problems and Goals Problem * Goal Lifestyle and resources Promote support systems and use of health-related resources Health status deviations Promote adequate, effective family care of a member with an illness or disability Patterns and knowledge of health maintenance Encourage growth and development of family members, health promotion, and illness prevention Promote a healthful environment Family dynamics and structure Strengthen family functioning and relatedness * Problems from Simmons, D. (1980). A classification scheme for client problems in community health nursing (DHHS Pub No. HRA 8016). Hyattsville, MD: U.S. Department of Health and Human Services. Advantages and Disadvantages Advantages of home visits by nurses are numerous. Most of the disadvantages relate to expense and concerns about unpredictable environments ( Box 11-1 ). Box 11-1 Advantages and Disadvantages of Home Visiting Advantages •  Home setting provides more opportunities for individualized care. •  Most people prefer to receive care at home. •  Environmental factors impinging on health, such as housing condition and finances, may be observed and considered more readily. •  Collecting information and understanding lifestyle values are easier in family’s own environment. •  Participation of family members is facilitated. •  Individuals and family members may be more receptive to learning because they are less anxious in their own environments and because the immediacy of needing to know a particular fact or skill becomes more apparent. •  Care to ill family members in the home can reduce overall costs by preventing hospitalizations and shortening the length of time spent in hospitals or other institutions. •  A family focus is facilitated. Disadvantages •  Travel time is costly. •  Home visiting is less efficient for the nurse than working with groups or seeing many clients in an ambulatory site. •  Distractions such as television and noisy children may be more difficult to control. •  Clients may be resistant or fearful of the intimacy of home visits. •  Nurse safety can be an issue. Nurse–family relationships How nurses are assigned to make home visits is both a philosophical and a management issue. Some community/public health nurses are assigned by geographical area or district . The size of the geographical area for home visits varies with the population density. In a densely populated urban area, a nurse might visit in one neighborhood; in a less densely populated area, the nurse might be assigned to visit in an entire county. With geographical assignments, the nurse has the potential to work with the entire population in a district and to handle a broad range of health concerns; the nurse can also become well acquainted with the community’s health and social resources. The potential for a family-focused approach is strengthened because the nurse’s concerns consist of all health issues identified with a specific family or group of families. The nurse remains a clinical generalist, working with people of all ages. Other community/public health nurses are assigned to work with a population aggregate in one or more geopolitical communities. For example, a nurse may work for a categorical program that addresses family planning or adolescent pregnancy, in which case the nurse would visit only families to which the category applies. This type of assignment allows a nurse to work predominantly with a specific interest area (e.g., family planning and pregnancy) or with a specific aggregate (e.g., families with fertile women). Principles of Nurse–Client Relationship with Family Regardless of whether the community/public health nurse is assigned to work with an aggregate or the entire population, several principles strengthen the clarity of purpose: •  By definition, the nurse focuses on the family. •  The health focus can be on the entire spectrum of health needs and all three levels of prevention. •  The family retains autonomy in health-related decisions. •  The nurse is a guest in the family’s home. Family Focus To relate to the family, the community/public health nurse does not have to meet all members of the household personally, although varying the times of visits might allow the nurse to meet family members usually at work or school. Relating to the family requires that the nurse be concerned about the health of each member and about each person’s contribution to the functioning of the family. One family member may be the primary informant; in such instances, the nurse should realize that the information received is being filtered by the person’s perceptions. The community/public health nurse should take the time to introduce herself or himself to each person present and address each person by name. Building trust is an essential foundation for a continued relationship ( Heaman et al., 2007 ; McNaughton, 2000 ; Zerwekh, 1992 ). The nurse should use the clients’ surnames unless they introduce themselves in another way or give permission for the nurse to be less formal. Interacting with as many family members as possible, identifying the family member most responsible for health issues, and acknowledging the family member with the most authority are important. The nurse should ask for an introduction to pets and ask for permission before picking up infants and children unless it is granted nonverbally. A nurse enters the home of a client with a young child. All Levels of Prevention Through assessment, the community/public health nurse attempts to identify what actual and potential problems or concerns exist with each individual and, thematically, within the family (see Chapter 13 ). Issues of health promotion (diet) and specific protection (immunization) may exist, as may undiagnosed medical problems for which referral is necessary for further diagnosis and treatment. Home visits also can be effective in stimulating family members to seek appropriate services such as prenatal care ( Bradley & Martin, 1994 ) and immunizations ( Norr et al., 2003 ). Actual family problems in coping with illness or disability may require direct intervention. Preventing sequelae and maximizing potential may be appropriate for families with a chronically ill member. Health-related problems may appear predominantly in one family member or among several members. A thematic family problem might be related to nutrition. For example, a mother may be anemic, a preschooler may be obese, and a father may not follow a low-fat diet for hypertension. Family Autonomy A few circumstances exist in our society in which the health of the community, or public, is considered to have priority over the right of individual persons or families to do as they wish. In most states, statutes (laws) provide that health care workers, including community/public health nurses, have a right and an obligation to intervene in cases of family abuse and neglect, potential suicide or homicide, and existence of communicable diseases that pose a threat of infection to others. Except for these three basic categories, the family retains the ultimate authority for health-related decisions and actions . In the home setting, family members participate more in their own care. Nursing care in the home is intermittent, not 24 hours a day. When the visit ends, the family takes responsibility for their own health, albeit with varying degrees of interest, commitment, knowledge, and skill. This role is often difficult for beginning community/public health nurses to accept; learning to distinguish the family’s responsibilities from the nurse’s responsibilities involves experience and consideration of laws and ethics. Except in crises, taking over for the family in areas in which they have demonstrated capability is usually inappropriate. For example, if family members typically call the pharmacy to renew medications and make their own medical appointments, beginning to do these things for them is inappropriate for the nurse. Taking over undermines self-esteem, confidence, and success. Nurse as Guest Being a guest as a community/public health nurse in a family’s home does not mean that the relationship is social. The social graces for the community and culture of the family must be considered so that the family is at ease and is not offended. However, the relationship is intended to be therapeutic. For example, many older persons believe that offering something to eat or drink is important as a sign that they are being courteous and hospitable. Because your refusal to share in a glass of iced tea may be taken as an affront, you may opt to accept the tea. However, you certainly have the right to refuse, especially if infectious disease is a concern. Validate with the client that the time of the visit is convenient. If the client fails to offer you a seat, you may ask if there is a place for you and the family to sit and talk. This place may be any room of the house or even outside in good weather. Phases of Relationships Relatedness and communication between the nurse and the client are fundamental to all nursing care. A nurse–client relationship with a family (rather than an individual) is critical to community/public health nursing. The phases of the nurse–client relationship with a family are the same as are those with an individual. Different schemes have been developed for naming phases of relationships. All schemes have (1) a preinitiation or preplanning phase, (2) an initiation or introductory phase, (3) a working phase, and (4) an ending phase (Arnold & Boggs, 2011). Some schemes distinguish a power and control or contractual phase that occurs before the working phase. The initiation phase may take several visits. During this phase, the nurse and the family get to know one another and determine how the family health problems are mutually defined. The more experience the nurse has, the more efficient she or he will become; initially, many community/public health nursing students may require four to six visits to feel comfortable and to clarify their role ( Barton & Brown, 1995 ). The nursing student should keep in mind that the relationship with the family usually involves many encounters over time—home visits, telephone calls, or visits at other ambulatory sites such as clinics. Several encounters may occur during each phase of the relationship ( Figure 11-1 ). Each encounter also has its own phases ( Figure 11-2 ). Figure 11-1 A series of encounters during a relationship. (Redrawn from Smith, C. [1980]. A series of encounters during a relationship [Unpublished manuscript]. Baltimore, MD: University of Maryland School of Nursing.) Figure 11-2 Phases of a home visit. (Redrawn from Smith, C. [1980]. Phases of a home visit [Unpublished manuscript]. Baltimore, MD: University of Maryland School of Nursing.) Preplanning each telephone call and home visit is helpful. Box 11-2 lists activities in which community/public health nurses usually engage before a home visit. The list can be used as a guide in helping novice community/public health nurses organize previsit activities efficiently. Box 11-2 Planning Before a Home Visit   1.  Have name, address, and telephone number of the family, with directions and a map. 2.  Have telephone number of agency by which supervisor or faculty can be reached. 3.  Have emergency telephone numbers for police, fire, and emergency medical services (EMS) personnel. 4.  Clarify who has referred the family to you and why. 5.  Consider what is usually expected of a nurse in working with a family that has been referred for these health concerns (e.g., postpartum visit), and clarify the purposes of this home visit. 6.  Consider whether any special safety precautions are required. 7.  Have a plan of activities for the home visit time (see Box 11-3 ). 8.  Have equipment needed for hand-washing, physical assessment, and direct care interventions, or verify that client has the equipment in the home. 9.  Take any data assessment or permission forms that are needed. 10.  Have information and teaching aids for health teaching, as appropriate. 11.  Have information about community resources, as appropriate. 12.  Have gasoline in your automobile or money for public transportation. 13.  Leave an itinerary with the agency personnel or faculty. 14.  Approach the visit with self-confidence and caring. The visit begins with a reintroduction and a review of the plan for the day; the nurse must assess what has happened with the family since the last encounter. At this point, the nurse may renegotiate the plan for the visit and implement it. The end of the visit consists of summarizing, preparing for the next encounter, and leave-taking. Box 11-3 describes the community/public health nurse’s typical activities during a home visit. Box 11-3 Nursing Activities During Three Phases of a Home Visit Initiation Phase of Home Visit 1.  Knock on door, and stand where you can be observed if a peephole or window exists. 2.  Identify self as [name], the nurse from [name of agency]. 3.  Ask for the person to whom you were referred or the person with whom the appointment was made. 4.  Observe environment with regard to your own safety. 5.  Introduce yourself to persons who are present and acknowledge them. 6.  Sit where family directs you to sit. 7.  Discuss purpose of visit. On initial visits, discuss services to be provided by agency. 8.  Have permission forms signed to initiate services. This activity may be done later in the home visit if more explanation of services is needed for the family to understand what is being offered. Implementation Phase of Home Visit 9.  Complete health assessment database for the individual client. 10.  On return visits, assess for changes since the last encounter. Explore the degree that family was able to follow up on plans from previous visit. Explore barriers if follow-up did not occur. 11.  Wash hands before and after conducting any physical assessment and direct physical care. 12.  Conduct physical assessment, as appropriate, and perform direct physical care. 13.  Identify household members and their health needs, use of community resources, and environmental hazards. 14.  Explore values, preferences, and clients’ perceptions of needs and concerns. 15.  Conduct health teaching as appropriate, and provide written instructions. Include any safety recommendations. 16.  Discuss any referral, collaboration, or consultation that you recommend. 17.  Provide comfort and counseling, as needed. Termination Phase of Home Visit 18.  Summarize accomplishments of visit. 19.  Clarify family’s plan of care related to potential health emergency appropriate to health problems. 20.  Discuss plan for next home visit and discuss activities to be accomplished in the interim by the community/public health nurse, individual client, and family members. 21.  Leave written identification of yourself and agency, with telephone numbers. Characteristics of Relationships with Families Some differences are worth discussing in nurses’ relationships with families compared with those with individual clients in hospitals. The difference that usually seems most significant to the nurse who is learning to make home visits is the fact that the nurse has less control over the family’s environment and health-related behavior ( McNaughton, 2000 ). The relationship usually extends for a longer period. A more interdependent relationship develops between the community/public health nurse and the family throughout all steps of the nursing process. Families Retain Much Control The family can control the nurse’s entry into the home by explicitly refusing assistance, establishing the time of the visit, or deciding whether to answer the door. Unlike hospitalized clients, family members can just walk away and not be home for the visit. One study of home visits to high-risk pregnant women revealed that younger and more financially distressed women tended to miss more appointments for home visits ( Josten et al., 1995 ). Being rejected by the family is often a concern of nurses who are learning to conduct home visits. As with any relationship, anxiety can exist in relation to meeting new, unknown families. Families may actually have similar feelings about meeting the nurse and may wonder what the nurse will think of them, their lifestyle, and their health care behavior. A helpful practice is to keep your perspective; if the clients are home for your visit, they are at least ambivalent about the meeting! If they are at home to answer the door, they are willing to consider what you have to offer. Most families involved with home care of the ill have requested assistance. Because only a few circumstances exist (as previously discussed) in which nursing care can be forced on families, the nurse can view the home visit as an opportunity to explore voluntarily the possibility of engaging in relationships ( Byrd, 1995 ). The nurse is there to offer services and engage the family in a dialogue about health concerns, barriers, and goals. As with all nurse–client relationships, the nurse’s commitment, authenticity, and caring constitute the art of nursing practice that can make a difference in the lives of families. Just as not all individuals in the hospital are ready or able to use all of the suggestions made to them, families have varying degrees of openness to change. If after discussing the possibilities the family declines either overtly or through its actions, the nurse has provided an opportunity for informed decision making and has no further obligation. Goals of Nursing Care Are Long Term A second major difference in nurse relationships with families is that the goals are usually more long term than are those with individual clients in hospitals. Clients may be in hospice programs for 6 months. A family with a member who has a recent diagnosis of hypertension may take 6 weeks to adjust to medications, diet, and other lifestyle changes. A school-aged child with a diagnosis of attention deficit disorder may take as long as half the school year to show improvement in behavior and learning; sometimes, a year may be required for appropriate classroom placement. For some nurses, this time frame is judged to be slow and tedious. For others, the time frame is seen as an opportunity to know a family in more depth, share life experiences over time, and see results of modifications in nursing care. For nurses who like to know about a broad range of health and nursing issues, relationships with families stimulate this interest. Having had some experience in home visiting is helpful for nurses who work in inpatient settings; it allows them to appreciate the scope and depth of practice of community/public health nurses who make home visits as a part of their regular practice. These experiences can sensitize hospital nurses to the home environments of their clients and can result in better hospital discharge plans and referrals. Because ultimate goals may take a long time to achieve, short-term objectives must be developed to achieve long-term goals. For example, a family needs to be able to plan lower-calorie menus with sufficient nutrients before weight loss is possible; a parent may need to spend time with a child daily before unruly behavior improves. Nursing interventions in a hospital setting become short-term objectives for client learning and mastery in the home setting. In an inpatient setting, giving medications as prescribed is a nursing action. In the home, the spouse giving medications as prescribed becomes a behavioral objective for the family; the related nursing action is teaching. Human progress toward any goal does not usually occur at a steady pace. For example, you may start out bicycling faithfully three times a week and give up abruptly. Similarly, clients may skip an insulin dose or an oral contraceptive. A family may assertively call appropriate community agencies, keep appointments, and stop abruptly. Families can be committed to their own health and well-being and yet not act on their commitment consistently. Recognizing that setbacks and discouragement are a part of life allows the community/public health nurse to be more accepting of reality and have the objectivity to renegotiate goals and plans with families. Box 11-4 includes evidence-based ways to foster goal accomplishment. Box 11-4 Best Practices in Fostering Goal Accomplishment With Families 1.  Share goals explicitly with family. 2.  Divide goals into manageable steps. 3.  Teach the family members to care for themselves. 4.  Do not expect the family to do something all of the time or perfectly. 5.  Be satisfied with small, subtle changes. 6.  Be flexible. Changes are sometimes subtle or small. Success breeds success, at least motivationally. The short-term goals on which everyone has agreed are important to make clear so that the nurse and the family members have a common basis for evaluation. Goals can be set in a logical sequence, in small steps, to increase the chance of success. In an inpatient setting, the skilled nurse notices the subtle changes in client behavior and health status that can warn of further disequilibrium or can signal improvement. Similarly, during a series of home visits, the skilled nurse is aware of slight variations in home management, personal care, and memory that may presage a deteriorating biological or social condition. Nursing Care Is More Interdependent with Families Because families have more control over their health in their own homes and because change is usually gradual, greater emphasis must be placed on mutual goals if the nurse and family are to achieve long-term success. Except in emergency situations, the client determines the priority of issues. A parent may be adamant that obtaining food is more important than obtaining their child’s immunization. A child’s school performance may be of greater concern to a mother than is her own abnormal Papanicolaou (Pap) smear results. Failure of the nurse to address the family’s primary priority may result in the family perceiving that the nurse does not genuinely care. At times, the priority problem is not directly health related, or the solution to a health problem can be handled better by another agency or discipline. In these instances, the empathic nurse can address the family’s stress level, problem-solving ability, and support systems and make appropriate referrals. When the nurse takes time to validate and discuss the primary concern, the relationship is enhanced. Families are sometimes unaware of what they do not know. The nurse must suggest health-related topics that are appropriate for the family situation. For example, a young mother with a healthy newborn may not have thought about how to determine when her baby is ill. A spouse caring for his wife with Alzheimer disease may not know what safety precautions are necessary. Community/public health nurses seek to enhance family competence by sharing their professional knowledge with families and building on the family’s experience ( Reutter & Ford, 1997 ; SmithBattle, 2009 ). Flexibility is a key. Because visits occur over several days to months, other events (e.g., episodic illnesses, a neighbor’s death, community unemployment) can impinge on the original plan. Family members may be rehospitalized and receive totally new medical orders once they are discharged to home. The nurse’s clarity of purpose is essential in identifying and negotiating other health-related priorities after the first concerns have been addressed ( Monsen, Radosevich, Kerr, & Fulkerson, 2011 ). Increasing nurse–family relatedness What promotes a successful home visit? What aspects of the nurse’s presence promote relatedness? What structures provide direction and flexibility? The nursing process provides a general structure, and communication is a primary vehicle through which the nursing process is manifested. The foundation for both the nursing process and communication is relatedness and caring ( ANA, 2003 ; McNaughton, 2005 ; Roach, 1997 ; SmithBattle, 2009 ; Watson, 2002 ; Watson, 2005 ). Fostering a Caring Presence Nursing efforts are not always successful. However, by being concerned about the impact of home visits on the family and by asking questions regarding her or his own motivations, the nurse automatically increases the likelihood that home visits will be of benefit to the family. The nurse is acknowledging that the intention is for the relationship to be meaningful to both the nurse and the family. Building and preserving relationships is a central focus of home visiting and requires significant effort ( Heaman et al., 2007 ; McNaughton, 2000 , 2005 ). The relatedness of nurses in community health with clients is important ( Goldsborough, 1969 ; SmithBattle, 2009 ; Zerwekh, 1992 ). Involvement, essentially, is caring deeply about what is happening and what might happen to a person, then doing something with and for that person. It is reaching out and touching and hearing the inner being of another…. For a nurse–client relationship to become a moving force toward action, the nurse must go beyond obvious nursing needs and try to know the client as a person and include him in planning his nursing care. This means sharing feelings, ideas, beliefs and values with the client…. Without responsibility and commitment to oneself and others…[a person] only exists. It is through interaction and meaningful involvement with others that we move into being human ( Goldsborough, 1969 , pp. 66-68). Mayers (1973, p. 331) observed 16 randomly selected nurses during home visits to 37 families and reported that “regardless of the specific interaction style [of each nurse], the clients of nurses who were client-focused consistently tended to respond with interest, involvement and mutuality.” A client-focused nurse was observed as one who followed client cues, attempted to understand the client’s view of the situation, and included the client in generating solutions. Being related is a contribution that the nurse can make to the family, independent of specific information and technical skills, a contribution that students often underestimate. Although being related is necessary, it is inadequate in itself for high-quality nursing. A community/public health nurse must also be competent. Community/public health nursing also depends on assessment skills, judgment, teaching skills, safe technical skills, and the ability to provide accurate information. As a community/public health nurse’s practice evolves, tension always exists between being related and doing the tasks. In each situation, an opportunity exists to ask, “How can I express my caring and do (perform direct care, teach, refer) what is needed?” Barrett (1982) and Katzman and colleagues (1987) reported on the differences that students actually make in the lives of families. Barrett (1982) demonstrated that postpartum home visits by nursing students reduced costly postpartum emergency department and hospital visits. Katzman and co-workers (1987) considered hundreds of visits per semester made by 80 students in a southwestern state to families with newborns, well children, pregnant women, and members with chronic illnesses. Case examples describe how student enthusiasm and involvement contributed to specific health results. Everything a nurse has learned about relationships is important to recall and transfer to the experience of home visiting. Carl Rogers (1969) identified three characteristics of a helping relationship: positive regard, empathy, and genuineness. These characteristics are relevant in all nurse–client relationships, and they are especially important when relationships are initiated and developed in the less-structured home setting. Presence means being related interpersonally in ways that reveal positive regard, empathy, genuineness, and caring concern. How is it possible to accept a client who keeps a disorderly house or who keeps such a clean house that you feel as if you are contaminating it by being there? How is it possible to have positive feelings about an unmarried mother of three when you and your partner have successfully avoided pregnancy? Having positive regard for a family does not mean giving up your own values and behavior (see Chapter 10 ). Having positive regard for a family that lives differently from the way you do does not mean you need to ignore your past experiences. The latter is impossible. Rather, having positive regard means having the ability to distinguish between the person and her or his behavior. Saying to yourself, “This is a person who keeps a messy house” is different from saying, “This person is a mess!” Positive regard involves recognizing the value of persons because they are human beings. Accept the family, not necessarily the family’s behavior. All behavior is purposeful; and without further information, you cannot determine the meaning of a particular family behavior. Positive regard involves looking for the common human experiences. For example, it is likely that both you and client family members experience awe in the behavior of a newborn and sadness in the face of loss. Empathy is the ability to put yourself in someone else’s shoes and to be able to walk in her or his footsteps so as to understand her or his journey. “Empathy requires sensitivity to another’s experience…including sensing, understanding, and sharing the feelings and needs of the other person, seeing things from the other’s perspective” according to Rogers (cited in Gary & Kavanagh, 1991 , p. 89). Empathy goes beyond self and identity to acknowledge the essence of all persons. It links a characteristic of a helping relationship with spirituality or “a sense of connection to life itself” ( Haber et al., 1987 , p. 78). Empathy is a necessary pathway for our relatedness. However, what does understanding another person’s experience mean? More than emotions are involved. A person’s experience includes the sense that she or he makes of aspects of human existence ( SmithBattle, 2009 ; van Manen, 1990 ). Being understood means that a person is no longer alone ( Arnold, 1996 ). Being understood provides support in the face of stress, illness, disability, pain, grief, and suffering. When a client feels understood in a nurse–client partnership (side-by-side relationship), the client’s experience of being cared for is enhanced ( Beck, 1992 ). To understand another person’s experience, you must be able to imagine being in her or his place, recognize commonalities among persons, and have a secure sense of yourself ( Davis, 1990 ). Being aware of your own values and boundaries is helpful in retaining your identity in your interactions with others. To understand another individual’s experience, you must also be willing to engage in conversation to negotiate mutual definitions of the situation. For example, if you are excited that an older person is recovering function after a stroke, but the person’s spouse sees only the loss of an active travel companion, a mutual definition of the situation does not exist. Empathy will not occur unless you can also understand the spouse’s perspective. As human beings, we all like to perceive that we have some control in our environment, that we have some choice. We avoid being dominated and conned. The nurse’s genuineness facilitates honesty and disclosure, reduces the likelihood that the family will feel betrayed or coerced, and enhances the relationship. Genuineness does not mean that you speak everything that you think. Genuineness means that what you say and do is consistent with your understanding of the situation. The nurse can promote genuine self-expression in others by creating an atmosphere of trust, accepting that each person has a right to self-expression, “actively seeking to understand” others, and assisting them to become aware of and understand themselves ( Goldsborough, 1969 , p. 66). When family members do not believe that being genuine with the nurse is safe, they may tell only what they think the nurse would like to hear. This action makes developing a mutual plan of care much more difficult. The reciprocal side of genuineness is being willing to undertake a journey of self-expression, self-understanding, and growth. Tamara, a recent nursing graduate, wrote about her growing self-responsibility: “Although I felt out of control, I felt very responsible. I took pride in knowing that these families were my families, and I was responsible for their care. I was responsible for their health teaching. This was the first semester where there was no a faculty member around all day long. I feel that this will help me so much as I begin my nursing career. I have truly felt independent and completely responsible for my actions in this clinical experience.” This student, who preferred predictable environments, was able to confront her anxiety and anger in environments in which much was beyond her control. A mother was not interested in the student’s priorities. A family abruptly moved out of the state in the middle of the semester. Nonetheless, the student was able to respond in such circumstances. She became more responsible, and she was able to temper her judgment and work with the mother’s concern. When the family moved, the student experienced frustration and anger that she would not see the “fruits of her labor” and that she would “have to start over” with another family. However, her ability to respond increased because of her commitment to her own growth, relatedness with families, and desire to contribute to the health and well-being of others. In a context of relating with and advocating for the family, the relationship becomes an opportunity for growth in both the nurse’s and the family’s lives ( Glugover, 1987 ). Imagine standing side-by-side with the family, being concerned for their well-being and growth. Now imagine talking to a family face-to-face, attempting to have them do things your way. The first image is a more caring and empathic one. Creating Agreements for Relatedness How can communications be structured to increase the participation of family members? Without the family’s engagement, the community/public health nurse will have few positive effects on the health behavior and health status of the family and its members. Nurses are expert in caring for the ill; in knowing about ways to cope with illness, to promote health, and to protect against specific diseases; and in teaching and supporting family members. Family members are experts in their own health. They know the family health history, they experience their health states, and they are aware of their health-related concerns. Through the nurse–family relationship, a fluid process takes place of matching the family’s perceived needs with the nurse’s perceptions and professional judgments about the family’s needs. Paradoxically, the more skilled the nurse is in forgetting her or his own anxiety about being the good nurse, the more likely the nurse is to listen to the family members, validate their reality, and negotiate an adequate, effective plan of care. One study of home visits revealed that more than half of the goals stated by public health nurses to the researcher could not be detected, even implicitly, during observations of the home visits. Therefore, half the goals were known only to the nurse and were, therefore, not mutual. The more specifically and concretely the goals were stated by the nurse to the researcher, the greater would be the likelihood that the clients understood the nurse’s purposes ( Mayers, 1973 ). To negotiate mutual goals, the client needs to understand the nurse’s purposes. The initial letter, telephone call, or home visit is the time to share your ideas with the family about why you are contacting them. During the first interpersonal encounter by telephone or home visit, explore the family members’ ideas about the purpose of your visits. This phase is essential in establishing a mutually agreed on basis for a series of encounters. As a result of her qualitative research study of maternal-child home visiting, Byrd (2006, p. 271) stated that “people enter…relationships with the expectation of receiving a benefit” that may be information, status, service, or goods. Byrd asserted that it is important for nurses to create client expectations through previsit publicity about (marketing) home-visiting programs. Also it is essential to understand the expectations of the specific persons being visited. Family members may have had previous relationships with community/public health nurses and students. Family members may be able to share such information as what they found to be most helpful, why they are willing to work with a nurse or student again, and what goals they have in mind. Other families who have had no prior experience with community/public health nurses may not have specific expectations. Asking is important. A contract is a specific, structured agreement regarding the process and conditions by which a health-related goal will be sought. In the beginning of most student learning experiences, the agreement usually entails one or more family members continuing to meet with the nursing student for a specific number of visits or weeks. Initially, specific goals and the nurse’s role regarding health promotion and illness prevention may be unclear. (If this role was already clear, undergoing a period of study and orientation would be unnecessary.) Initially, the agreement may be as simple as, “We will meet here at your house next Tuesday at 11:00  AM until around noon to continue to discuss what I can offer related to your family’s health and what you’d like. We can get to know each other better. We can talk more about how the week has gone for you and your family with your new baby.” These statements are the nurse’s oral offer to meet under specific conditions of time and place. The process of mutual discussion is mentioned. The goals remain general and implicit: fostering the family’s developmental task of incorporating an infant and fostering family–nurse relatedness. For the next week’s contract to be complete, the family member or members would have to agree. The most important element initially is whether agreement about being present at a specific time and place can be reached. If 11:00  AM is not workable for the family, would another time during the day when you both are available be mutually agreeable? For families who do not focus as much on the future, a community/public health nurse needs to be more flexible in scheduling the time of each visit. The word contract often implies legally binding agreements. This is not true of nurse–client contracts. Nurses are legally and ethically bound to keep their word in relation to nursing care; clients are not legally bound to keep their agreements. However, establishing a mutual agreement for relating increases the clarity of who will do what, when, where, for what purposes, and under what conditions. Because of some people’s negative response to the word contract, agreement or discussion of responsibilities may be better. An agreement may be oral or written. For some families, written agreements, especially early in the relationship, may be perceived as a threat. For example, a family that has been conned by a household repair scheme may be very suspicious of written agreements. Family members who are not legal citizens may not want to sign an agreement for fear that if it is not kept they will be punished. Do not push for a written agreement if the family is uncomfortable. If you do notice such discomfort, this may be a good opportunity to explore their fears. Written agreements are required when insurance is paying for the care provided by nurses working with home health agencies and to comply with the Health Insurance Portability and Accountability Act (HIPAA). Helgeson and Berg (1985) describe factors affecting the contracting process by studying a small convenience sample of 15 community/public health nursing students and 12 client responses. Of the 11 students who introduced the idea of a contract to clients, all did so between the second and the fourth visits of a 16-week series of visits; 9 students did so orally rather than in writing. No specific time was the best. Eight clients were very receptive to the idea because they liked the idea of establishing goals to work toward and felt the contract would serve as a reminder of their responsibility. The very process of developing a draft agreement to present to families provides the novice practitioner with an increased focus of care, clarity of nurse and family responsibilities and activities, and a basis from which to negotiate modifications in client behaviors ( Helgeson & Berg, 1985 ; Sheridan & Smith, 1975 ). The Home Visiting Evaluation Tool in Figure 11-3 lists nurse behaviors that are appropriate for home visits, especially initial home visits and those early in a series of home visits. Nurses can use this list as a preplanning tool to identify their readiness to conduct a specific home visit. Additionally, students and community/public health nurses have used the tool to evaluate initial home visits and identify their behaviors that were omitted and needed to be included on the second home visits. The tool also has been used jointly as an evaluation tool by nurses and supervisors and students and faculty. Figure 11-3 Home Visiting Evaluation Tool. (From Chichester, M., & Smith, C. [1980]. Home visiting evaluation tool [Unpublished manuscript]. Baltimore, MD: University of Maryland School of Nursing.)

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• Home Health Care
• Health Promotion and Risk Reduction in the Community
• Disaster Management: Caring for Communities in an Emergency
• Financing of Health Care: Context for Community/Public Health Nursing

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Come visit the largest selection of annuals and perennials on the Palouse. Find everything you need for a beautiful garden or in Moscow & Pullman Building Supply’s garden centers. Whether you’re completely overhauling your landscape, or in need of some flower bed additions, we have a huge selection to choose from. Come see our garden centers in person today, you won’t be disappointed!

Create the outdoor living space you’ve always dreamed of with the help of our garden center pros! Did you know we’re a Proven Winners Certified Garden Center. What does this mean? Well, our nursery employees are all trained and certified by Proven Winners. And if you can’t find what you’re looking for, ask our staff to see if we can order it in. Don’t forget to check out our latest blog, all about Pollinators !

See below for a few examples of typical plant varieties that what we carry. Our stock many more varieties than those listed, see us in person to check out our selection. While supplies last.

ANNUALS Petunias, Pansies, Geraniums, Primrose, Ranunculus

SHRUBS/EVERGREENS Roses, Barberries, Dogwoods, Arborvitaes, Boxwoods, Rhododendrons

SUN-LOVING Dianthus, Echinaceas, Iris, Phlox, Poppies, Lilies

SHADE-LOVING Ferns, Hostas, Hellebores, Heucheras

TREES Fruit, Nut, Flowering, Shade, Espalier, Conifers, Deciduous

EDIBLE PLANTS Herbs, Fruits, Veggies, Berries, Root Veggies, Ornamentals

BASKETS/PLANTERS Annuals, Fruits, Herbs, Basket Fillers

INDOOR PLANTS Cacti, Succulents, Pothos, Monsteras, Ficus, Marantas, Dracaenas

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Don’t know where to start? Check out the Gardener’s Idea Book by Proven Winners for inspiration, ideas, color combinations, planting recipes, and more! And if that’s not enough… check out our lawn & garden blog – In Bloom on the Palouse.

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35 Nursery Ideas to Welcome Your Bundle of Joy in Style

Tiny details, big dreams.

But where to begin? For starters, choosing a soothing color palette is key to creating a calming environment, according to Homegirl founder and designer Erin Lichy. “Shades like soft grays, blush pinks, and light blues are perfect for a soothing nursery,” she explains. Once colors are chosen, think about furniture. Lichy advises parents-to-be to choose pieces that will be functional after the child leaves the nursery . For example, dressers can double as changing tables, or reading chairs can later work as accent chairs. Having this mentality when picking and choosing furniture ensures maximum utility and longevity of the pieces. Lighting, then, comes into play. Lichy is a fan of layered lighting, which means a mix of ambient, task, and accent lighting and a dimmable overhead light, a floor lamp, and a soft night-light to create the perfect atmosphere.

Once the foundation of the nursery is complete, it’s time to bring in accessories and add that personal touch. Decorating with artwork, photos, or personalized decor items is a great and easy way to add a unique element. Additionally, soft textures like plush rugs, comfortable bedding, throw blankets, and smaller accent rugs will give your nursery that lived-in feel. Finally, it wouldn’t be a nursery without toys. Mobiles, colorful wall decals, and tactile toys can be both aesthetically pleasing and stimulate the baby’s senses.

Ready to give your precious bundle of love the entrance he or she deserves? (If we’re being honest, this is as much for the parents as it is for the baby.) Below, we included our 35 favorite nurseries with a wide range of decor styles, color palettes, and aesthetics that will be a sanctuary no matter how sleep-deprived you are.

Pretty Pink Nursery

Are we seeing double? This twin nursery in Diablo, California, designed by Marea Clark, is a fresh take on the traditional pink aesthetic. The desaturated hues of the scalloped valances and taupe curtains over the gold oak cribs pair fetchingly with the bold yellow and white ceiling wallpaper that your little ones will inevitably stare up at before catching some zzz’s.

Safari-Themed Nursery

Decorating a nursery means you've been given liberty to push the boundaries of colors and patterns. Take, for instance, this fun nursery corner designed by Powell & Glenn in Toorak, Australia. A pair of rattan animals sit perched on a graphic wallpaper, overseen by an impertinent ape-turned-side table. If parenthood isn't its own expedition, your tiny human will be right at home waking up in the wild each morning.

Storybook Nursery

In the wise words of Beatrix Potter, “there is something delicious about writing the first words of a story. You never quite know where they’ll take you.” The same can be said of a nursery, and this chic space is straight out of a children’s book. A whimsical floral chandelier is overseen by a larger-than-life bunny portrait that simply can't be anything but the legendary Peter Rabbit. How could you say no to just one more story in this space?

Chic Nursery

For a less obvious take on the Beatrix Potter aesthetic, this London nursery is giving us all the storybook illustration vibes. Decorated in white curtains and a monochrome palette, its contemporary aesthetic is chic yet soft. Here, core memories are waiting to be made!

Colorful Nursery

Decorating a nursery can be a task, but more often than not, a fun one, so why not let loose a little with color? ELLE DECOR A-List designers Ashe + Leandro created this nursery with bold tones in mind. The custom color-blocked cabinets, Moroso rocking chair, and Cassina side table are giving us all the baby loving vibes.

Nursery Wall Art

Svetlana Tryaskina of the Toronto-based design firm Estee Design wanted to bring life and playfulness into this neutral-colored nursery. Installing pretty wall art and shelves is an easy and beautiful way to do that. In this case, Tryaskina opted for a tree-inspired wall installation and shelves with stuffed animals to decorate for a playful touch.

Pastel-Hued Nursery

The nursery of this Santa Monica home , designed by Natasha Baradaran, embraced pink with unabashed ease. The colorful mosaic-style rug by the Rug Company complements the rosy-toned furniture and paint throughout the room. If pink is not just a color, but a state of mind as Jessica Lynn once surmised, this nursery is brimming with attitude.

Looking to latch onto current maximalist trends ? In this Hamptons home , designer Alec Holland brought together Farrow & Ball’s dazzling Bumble Bee wallpaper in Stone Blue and a bold yellow paint. To tie it all together, he then added a thin line of red on the walls to match the kinetic sculpture by Jim Hunter and the chair by Knoll. In a room like this, baby is sure to know his primary colors well ahead of his peers.

Statement Nursery Piece

Decorating a nursery in neutral tones is a safe choice if you want it to feel timeless and enduring. However, if you're not afraid to take the road less traveled, a patterned rug—like this chic polka dot rug—can add an unexpected element of interest, making it more fun and lively.

Nursery Wallpaper Moment

Lauren Buxbaum Gordon created this vibrant nursery by mixing traditional wallpaper with colors that wouldn’t usually go together—but make total sense in hindsight. The room ties together beautifully, a combination of botanical prints, salmon-colored furnishins, and metallic accent mirrors and lamps. Slumber safe and sound, little one.

High-Contrast Nursery

The nursery of this airy Parisian flat is proof that a modern aesthetic can be cozy. To achieve this welcoming look, the owners incorporated warm wood finishes throughout the room, flanked by black and grey accent pieces.

Blue Nursery

A nursery needn’t be only kid-centric. In this very blue nursery, an adult-size couch offers seating to all who might want to join the little one in an imaginary adventure. Varying textures and patterns create added layering to this sweet boy’s room.

Neon Nursery

And you thought primary colors were bold. This cool cat nursery takes the color mantra one step further, packed with neon-colored decorative elements and trinkets against a midnight black wall. Designed by Michelle Gerson for her son in her New York City apartment , the yellow dresser, emerald green poufs, and skateboard wall decor up the energy in this stylish nursery.

Nautical Nursery

Opting for white and blue stripes is a great way to make your nursery feel on-theme. To complete the room, the owners added a skirt for the crib and a zigzag patterned rug.

Striped Nursery

For a more bombastic take on the stripe aesthetic, this orange and pink-striped nursery is giving us all the circus tent vibes. The room's colorful kid-sized furniture is further anchored by a thick stripe of fuchsia on the wall.

Dark-Toned Nursery

If you’ve given your soul to the dark side, this moody dark-green nursery, designed by Pappas Miron , is all the inspiration you need to commit to buying three cans of paint (if you really love this particular hue, it’s Benjamin Moore’s Dragon’s Breath). A fleet of pretty blue ceramic plates and a quizzical looking hedgehog add a sophisticated-yet-playful energy to the space.

Cloud Nursery

Are you the kind of parent who will support a little daydreaming? L’Objet founder and creative director Elad Yifrach’s home in Lisbon features a nursery that encapsulates the feeling of dreaming. The Fornasetti wallpaper of floating clouds complements the custom high-pile white rug and the white bouclé armchair. Proof that having your head in the clouds isn’t always a bad idea, no matter how old you are.

Contemporary Nursery

Many parents want their nursery to mirror the aesthetics of the rest of the home, which is why we had to share the nursery in this New York City loft designed by Ghislaine Viñas. Chic furniture (is that a black egg chair ?) and fixtures make for a room that is seamless and contemporary. “A kid’s room can be just as modern and creative while still being fun,” says Viñas.

Imaginative Nursery

Chicer than a pillow fort, baby tepees are a great way to add color to an otherwise neutral nursery. This happy yellow tepee is the perfect place for afternoon play and story time.

Whimsical Nursery

Nurseries feel magical when they look like they were taken out of a children's book. Joyann King kept her nursery in Millbrook, New York , charming and light, covering the walls with a whimsical forest mural by Rebecca Rebouche, a crib by Restoration Hardware Baby, and a rug by Serena & Lily.

Sofia Quintero is the Editorial Assistant for ELLE DECOR. She helps out with all aspects of print production and is a frequent contributor to elledecor.com. She graduated from university in Paris, and is originally from Costa Rica.

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Hamas official in Russia, talks hostages, seeks Moscow mediation in cease-fire

Senior Hamas official Mousa Abu Marzouk called on Russia to be a guarantor of a future cease-fire agreement with Israel, and after a meeting in Moscow on Monday night, he vowed to free the remaining Russian hostages from Gaza.

Marzouk, who heads Hamas’ foreign relations, met Russia’s Deputy Foreign Minister Mikhail Bogdanov in the Russian capital. The two discussed the war in Gaza as well as efforts to achieve Palestinian unity, Hamas said in a statement.

In an interview with the Russian state media outlet Sputnik on Tuesday, Marzouk said that Russia should be a “guarantor” of any future cease-fire agreement with Israel because the Eurasian country has a more balanced view on the conflict than the United States.

“We still insist that Russia be the guarantor of such a cease-fire agreement, because obviously the United States is on the side of Israel,” said Marzouk. “Russia’s position is fairer, more acceptable to all sides, and it is ready to act in this direction. We want to put an end to the hegemony of the United States and its one-sided influence on the Palestinian issue.”

The United States has been making a push for a cease-fire in recent weeks, though an agreement has not been reached.

Marzouk told Russian government news agency RIA Novosti on Tuesday that the two Russian citizens being held captive in Gaza will be the first released in any cease-fire agreement with Israel.

“We said that as soon as there is a decision on this (a cease-fire), the two Russians will be the first released,” Marzouk told the outlet.

Israel believes more than 130 hostages remain in Gaza, and recent cease-fire negotiations have focused on securing the release of the captives as part of the deal. Lebanon-based Hamas official Osama Hamdan told CNN earlier this month that "no one has any idea" how many hostages are still alive. 

Alexander Lobanov and Alexander Trufanov are the two Russian-Israeli hostages still in Gaza. Trufanov is being held by Islamic Jihad, another armed group in Gaza and an ally of Hamas, according to Israeli media.

Hamas released three Russian citizen hostages from Gaza in November as part of an agreement with the Kremlin.

Why it matters: Russia has been pushing for the release of the Russian hostages and a greater role in mediating between the Palestinian factions. Earlier this month, Russian Ambassador to Israel Anatoly Viktorov said that Russia is calling for all hostages to be released from Gaza, including the two Russian citizens.

Russia hosted Palestinian factions, including Hamas and Palestinian President Mahmoud Abbas’ Fatah group, for reconciliation talks in March.

The March meeting followed a Hamas delegation led by Marzouk visiting Moscow in January, during which Russia called on the group to release the Israeli and foreign hostages, including Kozlov, Lobanov and Trufanov.

Marzouk and other Hamas officials also visited Moscow in October shortly after the start of the war, leading to a rebuke from Israel.

What’s next: Marzouk told Sputnik that Russia is “trying” to organize a new meeting of Palestinian factions in Moscow. He said the date for the meeting could be discussed during Abbas’ upcoming visit to Russia.

Russian presidential aide Yury Ushakov told reporters on Tuesday that a date for Abbas’ visit has been agreed upon, though he did not say what the date is, according to Tass. Abbas last visited Russia in 2021.

Hamas and Fatah said on Monday that the Palestinian reconciliation meeting that was scheduled to take place in China this month has been postponed.

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The Israel-Hamas War: Live Q&A with Amb. David Satterfield (Part 2)

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