Home visits support first-time moms through pregnancy, early childhood
Nurses help disadvantaged women turn their lives around
Jane McKinley, RN, BSN, loves her job because she knows she's helping vulnerable first-time mothers have a healthy first pregnancy and learn to be a good parent.
"It's a rewarding experience when you watch someone blossom into her own person and become a responsive mother who enjoys her life and takes good care of her child. That's the wonderful part about this job," she says.
McKinley is a nurse with Boulder County Public Health (CO), which has collaborated with the nurse-family partnership to implement a community-based program that follows families from early pregnancy through the child's second birthday.
The nurse-family partnership model provides face-to-face case management in the homes of pregnant women who often face the challenge of multi-generational poverty and multiple psychosocial issues. The Denver-based nonprofit organization partners with community organizations to replicate the program in local settings.
"These families have lived in poverty for many generations, and that has a major impact on their ability to improve their lives. These young women don't have a lot of role models around them. We have clients who want to make a change, but the family group won't make a change," says Nancy Kehiayan, MS, RN, APRN-BC, associate nursing director at the NFP national service office.
Many times, the nurse from the nurse-family partnership is the first person who has been consistent in the client's life, she adds.
Randomized controlled trials of the program have shown increases in maternal health among participants, fewer pre-term deliveries, decreases in instances of child abuse and neglect, reductions in emergency department visits for accidents and poisonings, improved school readiness, and increased employment and reduction in the use of welfare and other assistance programs among mothers in the program.
Not all families stay in the program for the full two-and-a-half years, Kehiayan says. Some leave for practical reasons. Others decide they don't want to continue.
"In the research projects, we found positive changes even in the families who were in the program only a short period of time," she says.
The program receives referrals from people in the community; the women, infants, and children program; community health centers; health care clinics; and community agencies, McKinley says.
"More and more frequently, women are referring themselves as other women in the program encourage their friends to enroll," McKinley says.
Full-time nurses typically work with up to 25 families at a time, she says.
"Some are clients who are on the verge of graduating from the program and who do not need the constant attention that people who have just joined the program need," she says.
The nurse-family partnership typically connects with the clients before the 28th week of pregnancy.
The nurses visit the families in their homes once a week for the first six weeks they're in the program, then every other week until the baby is born. When mother and infant come home from the hospital, the nurses visit weekly for four weeks, and then every other week until the child is 21 months old. Then they see the family monthly until the child's second birthday.
When she gets a referral, McKinley sends a packet of materials to the woman who has been referred, describing the nurse-family partnership and including her phone number.
Then McKinley calls her clients and makes an appointment to come to the home.
"There are situations when I can't reach the client, and in that case, I go back to the referral source for help in contacting them, she says.
Sometimes, in the beginning, clients don't feel comfortable meeting at their home and the first face-to-face meeting takes place at a library, a recreation center, or the nurse-family partnership organization's headquarters, McKinley says.
Over the first few weeks a client is in the program, McKinley works to establish rapport and earn the trust of the young mothers she works with.
"It takes time to establish a relationship. It doesn't happen in one visit. We focus on determining what challenges this mom and her family face and helping her overcome them," McKinley says.
The main goal of the program is a healthy pregnancy and healthy development of a child, McKinley says.
"We want to empower the mothers to become increasingly self-reliant so they can get the community care they need and take care of themselves in the world," she says.
When the nurses first meet with the mothers, they assess their psychosocial situation to determine what community resources they need to have a healthy pregnancy and take care of their child once they're born.
They work with the women to develop healthy habits, such as eating healthy foods, stopping smoking and/or the use of illegal drugs, and keeping any chronic diseases, such as hypertension or gestational diabetes under control.
In the beginning, the nurses face the challenge of making sure the client's basic needs, such as food, housing, and utilities, are met. If they have a crisis situation, such as losing utilities or facing eviction, the nurses provide education and support and link the mothers with community resources and services, Kehiayan says.
The nurses do not perform physical assessments of the clients, although they do weigh the babies and make a cursory assessment of each baby's health during each visit.
"We don't let go of our nursing skills, but we don't want the client to think that we are the medical provider. Our job is to help them find the right kind of care and to use it appropriately," she says.
The nurses arrange for the women to receive prenatal care and make sure they have transportation to their appointments. They help the families get lined up with a primary care provider and help them make a list of questions to ask during their doctor's appointments.
"Our goal is to support our clients in using medical providers appropriately. Our area has a really good system of medical providers so if we walk into the house and the client or child looks sick, we stay with the client while she calls the clinic and arranges for someone to take them to the doctor's office," she says.
Because the Boulder area offers good prenatal care for indigent women, connecting women in the program with care providers isn't a big problem for the nurses in her area, McKinley says.
However, the majority of women face other psychosocial challenges that could affect their pregnancy and the child's well-being, she adds.
"As nurses, we are constantly assessing our client. When we work with clients in the home, we learn a lot of things about them that we wouldn't learn over the telephone or face-to-face in other locations. We can observe the home environment. Is it clean and neat or cluttered and crowded? We can see how they communicate with other people in the home," she says.
As they work with their clients, the nurses learn each woman's specific needs and empower her to access the community services that can help meet her needs, McKinley says.
"One of our biggest challenges is moving through some of the myths that are out there about pregnancy and child-rearing. The advantage of working with women who are pregnant for the first time is that they are eager to get as much information as possible. However, the program works because we have a close, personal relationship with clients. If we just gave them a manual to follow, it wouldn't be successful," she says.
McKinley anticipates problems the clients may have in staying healthy or providing for their child and works to overcome them. For instance, if she gives a client the number for a community service, she'll help the client make a list of questions to ask and offer to help her make the call.
"It's a matter of empowering them to act rather than doing it for them," she says.
After the baby is born, the nurses help the women transition to becoming parents and work hard to build a good and healthy attachment between parent and child, Kehiayan says.
As the child gets older, becomes more mobile, and starts to express his or her own will, the nurses work with the families to help them learn to encourage growth and development and to manage and work with the child effectively, she says.
"Our hope is that during this critical period, we can help the families learn skills that will carry them forward. There is a lot you can teach families during this phase about discipline and how to encourage growth and development of the child that will help as the child grows older. We work really hard to help the families understand the child as an individual and helping the moms and dads see things from the child's perspective," she says.
For instance, discipline is a challenge for young families with no role model, Kehiayan points out.
"We get the parents to talk about their own childhood and what they might like to have been different," she says.
On each visit, McKinley reviews with the mother what they discussed in the previous visit, what goals they set, and the mother's progress in reaching those goals.
"As a case manager working with these women, I often get two messages. One is that the client wants to make the change but the other is that she isn't following any of my advice or the plans we jointly developed," McKinley says.
In that case, she sits down with the client and reviews the plans they made over the last visit, answers any questions the client has, and develops a plan for the client to complete before the next visit.
"Usually, the client didn't act because something else came up. When we review, we work together to come up with another plan," she says.
McKinley and the other nurses have a respectful attitude when they meet with their clients.
"If there are shoes by the door, I ask if they want me to remove my shoes. I always ask if there is a special place they'd like me to sit," she says.
The nurses are skilled in making sure the situation in the home is conducive to having a productive visit with the mother and child.
"I have no difficulty asking someone not to smoke in their own home or to turn off the television so there won't be any distractions. Sometimes there are other people watching, and I invite them to become part of the visit," she says.
The young women in the nurse-family partnership program face tremendous odds as they experience pregnancy for the first time and take on the challenges of raising a child, McKinley points out.
"Every person I meet has incredible strengths. I support their resilience and their capacity to care for themselves as much as I can," she adds.
Jane McKinley, RN, BSN, loves her job because she knows she's helping vulnerable first-time mothers have a healthy first pregnancy and learn to be a good parent.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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