Making home visits and delivering home-based nursing gives the nurse an excellent opportunity to observe and interact with families in an environment that is familiar to them. Further, by visiting the home, the nurse is able to assess safety, hygiene, support systems, and play stimulation within the environment that is closest and most familiar to the family.
Making Home Visits
In making home visits, it is essential that the nurse recognize his or her status as a visitor in the home with services that the family can accept or reject. The relationship is a negotiated one, and the nurse must recognize that successful negotiation entails gaining support and acceptance from the family.
To gain and maintain access to the home, the nurse needs to demonstrate flexibility, an understanding of the diversity present in homes, and an awareness of social rules that will affect the relationship between the family and nurse. In establishing initial contact with a family, some guidelines assist in ensuring that the contact is successful:
▪ With the first telephone call, identify affiliation, source of referral, purpose of referral, knowledge of situation, and how families can further contact the nurse.
▪ Demonstrate willingness to negotiate times for the visit.
▪ Ask for clear directions to the home. If the area is unfamiliar, check with a supervisor for more detailed directions and ensure that safety equipment, including a telephone, is included.
▪ Alert the family about when the visit will occur.
▪ Establish where to park and how to access the home.
When making the initial visit, family-centered actions will facilitate development of trust and rapport. The nurse must also be aware of variables that will affect assessment and the safety of the nurse:
▪ Maintain a respectful distance. Do not enter the family’s space prematurely. Enter the home and less public areas within the home when verbally and nonverbally invited to do so.
▪ Respect customs. Place shoes and coat in areas comfortable to the family. Observe for and avoid special areas that certain family members claim for sitting.
▪ Suspend values. What works for a family might differ from the nurse’s perception of what is acceptable.
▪ Be prepared to accept hospitality; professional boundaries are less secure in home settings, and the relationship might be less formal.
▪ Be prepared for the unpredictable. Homes can be more distracting than clinical settings; they have no common baseline, and variables are less controlled. Distractions and variations provide useful information for ongoing care and the relationship.
▪ Priorities need to remain fluid to accommodate differences between the family’s perceptions and that of the nurse. Preset nurse agendas are often only a starting point. On the first visit, it is important to remember that it can take several visits to make a complete assessment and to avoid being excessively intrusive with questions and assessments. A family’s perception of overenthusiasm by the nurse in meeting assessment needs can destroy rapport and trust in a developing relationship with the family.
▪ Attend to personal safety. Keep car doors locked and park in a well-lighted area. Check surroundings before getting out of the car and for the presence of unfriendly animals or individuals; do not get out of the car if suspicious or aggressive behavior is occurring. Assess the safety of the interior environment of the home before entering.
▪ At the conclusion of the visit, establish dates and times for the next visit.
Assessment of the Home Environment
Hygiene
Observe for cleanliness, including storage and handling of perishable foodstuffs (especially meat), handling of pacifiers and bottles, unwashed cooking equipment or clothes, accumulations of dirt, disorderly surroundings, hand washing practices, odors, condition of water supply, type and adequacy of waste disposal, pests, pets, type and condition of clothing worn by family members, and hygiene of family members.
Availability of Transportation and Facilities
Observe for presence of vehicles; bus stops; condition of roads; driveways; distance to nearest neighbor; presence of telephone; and proximity to schools, shopping, recreation, and health care services.
Nutritional Practices
Observe for available snack foods, cooking odors, accessibility of food for children, availability of choice in menu, and ethnic or religious food observances.
Observe for family pictures and pictures of friends, presence of a telephone and type of calls received, and proximity to neighbors and other family members.
Family Interactions
Observe for spontaneous vocalization between parents and children, verbal responses of parents to vocalizations of children, use of praise with children, demonstrations of affection, use of scolding or shouting, attempts to explain or teach about objects or situations, attempts to look at children, teaching of culturally appropriate rules of behavior, display of children’s art/crafts, introduction of children to nurse, and encouragement of age-appropriate independence.
Provision of Stimulation and Opportunities for Rest
Observe for presence of age-appropriate toys and toys with variety, recreational and exercise aids, books, pets, and television. Observe if children are playing with matches, candles, sharp-edged toys, or cigarettes. Observe for amount of time that children spend watching television and interaction of parents in relation to television, programs and games in which children are engaged, areas and space available in the home for privacy, amount of space or crowding evident in home, and adequacy of sleeping facilities (e.g., number, type, and safety of beds and cribs; presence of bed linens).
Religious and Cultural Influences
Observe for presence of religious icons, bibles, art, and cultural artifacts; ethnic cooking utensils; and type of clothing worn by family members.
Related Nursing Diagnoses
Impaired home maintenance: related to lack of knowledge, insufficient family planning or organization, inadequate support systems, insufficient finances, impaired cognitive or emotional functioning, family disease or injury, unfamiliarity with community resources.
Ineffective family coping: related to lack of knowledge of resources, isolation, family disorganization or role changes.
Knowledge deficit: home safety and hygiene, community and social supports: related to cognitive or emotional limitations, lack of interest in learning, lack of exposure or role modeling, unfamiliarity with resources.
Hopelessness: related to lack of social support, socioeconomic conditions.
Risk for injury: related to home environment, lack of knowledge of provider, pollutants.
Risk for suffocation: related to fuel-burning heaters, abandoned equipment and vehicles, cribs, clotheslines, inadequate supervision.
Risk for poisoning: related to unprotected medications or poisonous chemicals; flaking, peeling paint or plaster; contamination of food or water; atmospheric pollutants; lack of safety or drug education; cognitive or emotional difficulties.
Risk for trauma: related to neighborhood crime, high beds, unsecured weapons, inadequate home safety measures with infants and young children, defective or abandoned appliances, highly flammable toys and clothing, inadequately stored combustibles and corrosives.
