Home visit

A home visit is a purposeful interaction in a home directed at promoting

and maintaining the health of individuals and the family.

A major distinction of a home visit is that health professional goes to the

client rather than the client coming to the health professional

Home visiting involves a process of initiating relationships with family

members, negotiating and implementing a family-focused plan of care, and
evaluating health outcomes and family satisfaction

Comprehensive Community- and Home-based Health Care Model

Systematic strategy was developed to retrieve cases, and give a simple and
obvious objective to purposeful home visits. It involves identifying, in a
small and well-defined group, the cultural and environmental determinants
of human behaviors and the means of influencing them positively.
Purposes
Home visits are carried out for several purposes such as, Case-finding for
public health and protection in cases such as abuse, neglect communicable
diseases and school-related health conditions, Promoting health and
preventing illnesses by providing services such as antenatal, newborn and
well-baby care; child development and care of the elderly; and Providing
care for the sick and terminally ill such as home health, and palliative and
hospice care
Advantages & Disadvantages of Home Visiting
Advantages:
Home visits provide an opportunity for health personnel to see
a complete picture of clients living experiences, in which illness is
only one aspect of their lives. This will enable them to better provide
holistic care that meets the physical, psychological, social and
spiritual needs of their clients.
In the home, health personnel see environmental factors that affect
health, and social and psychological influences; relationships between

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 and among family members; and interaction of clients with families
and social networks.
In addition, health workers can see first-hand how well the clients can
perform self-care at home and make a more accurate evaluation of the
health care interventions required.
A home visit is effective when clients are able to exercise more
control over their care and are part of the health care team, rather than
dependent, passive recipients of care.
Health personnel should promote a sense of empowerment in the
clients and families for self-care and healthy living as well as proper
health-seeking behaviors.

Disadvantages:
1. Travel time is costly
2. Less efficient for nurse than working with groups or seeing many clients
in an ambulatory site
3. Distraction such as TV and noisy children may be more difficult to
control
4. Clients may be resistance or fearful of the intimacy of home visits
5. Nurses safety can be an issue

Criteria for Home Visits

It is not cost-effective to provide care at home for every client. For optimal
utilization of resources for the health of the community, eligibility criteria
for home visits and home care will need to be decided and agreed upon with
the community. This will vary from place to place, depending on the health
needs identified during community assessment
In general, priority should be given to make health care more accessible to
vulnerable, disadvantaged and high-risk groups. These include the
following:
Handicapped people;
Elderly people; Those who are confined to their homes and are
unable to seek care at health facilities, such as mothers who have
delivered recently and newborns, and post cardiovascular accident
cases;
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 Pregnant women and children under 5 years of age who miss
appointments;
Chronic patients whose condition is not under control
Clients requiring long-term, home-based care such as those with HIV/
AIDS; and
Clients requiring follow-up care at home post-hospital/operation

Conducting a Successful Home Visit

Phases and Activities of a Home Visit

Actions that health personnel should carry out for a successful home visit
are provided below

I. Initiation phase Clarify source of referral for visit

Clarify purpose for home visit
Share information on reason and purpose of home visit with family

II. Pre-visit phase Initiate contact with family/ planning stage

Determine which clients need to be seen according to the agreed

criteria.
Prioritize the scheduled visits based on clients health needs and in
coordination with other health team members.
Review family folders, clients records, goals of care and reasons for
the home visit.
Validate the scheduled visit with clients and/or family members, and
assess the specific needs of clients and non-formal caregivers (such as
supplies).
Conduct inventories of the home visit bag, equipment needed, and
supplies and educational materials for clients.
Review safety considerations, such as the timing of the visit and
assessment of the environment

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III. In-home phase Introduction of self and professional identity
Implementing the visit(applying nursing process)
Initiate the visit by the introduction and identification of health
personnel to the client, and a brief social dialogue to establish
rapport(Social interaction to establish relationship)
Practice appropriate hygienic practices before assessing the client
such as hand-washing.
Review plans for the visit with the client.
Determine the expectation of the client regarding home visits.
Conduct an assessment of the environment, client, medication,
nutrition, functional abilities and limitations, psychosocial spiritual
issues, and evaluate the effectiveness of previous visit interventions.
Modify the plan of care based on clients needs and situation.
Carry out health interventions.
Deal with distractions environmental and behavioral

Evaluating the visit

Evaluate the effectiveness of the interventions based on established
short-term (response during the visit) as well as long-term outcome
criteria (effects of the intervention at subsequent visits).
Evaluate the conduct of the visit: availability of appropriate supplies
and preparation of health personnel for a visit.

Documentation
Document in the family folder and other record(s) according to
standard procedures.
Validate diagnoses and additional health needs based on visit.
Record actions taken, response of client and outcomes of intervention
(short-term and long-term).
Record both objective data (health worker-based) as well as subjective
data (client-based).

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IV. Termination phase
Review visit with family
Plan for future visits
Termination begins with the first visit as the health worker prepares
the client for the time-limited nature of home visits.
Review goal attainment with the client/family, and make
recommendations and referrals as appropriate for continued health
care issues.
Develop strategies for appropriate closure with clients who die, refuse
visits, or are terminated as care is no longer required due to various
reasons such as complete recovery or moving out from the area.
V. Post-visit phase
Plan for next visit

Principles of Nurse- Client Relationship with Family

Regardless of whether the CHN 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 decisions

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.

A helpful practice is to keep your perspective of you remember the clients

are home for your visit, they are at least ambivalent about the meeting. Most
families involved with home care of the ill have requested assistance.
The nurse if there to offer services and engage the family in a dialogue about
health concerns, barriers 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

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Characteristics of care provided at Home visit
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 in hospitals
Because ultimate goals may take a long time to achieve, short-term
objectives must be developed to achieve long-term goals.

Fostering Goal Accomplishment with Families

1. Share goals explicitly with family
2. Divide goals into manageable steps
3. teach family to do for themselves
4. do not expect family to do something all of the time ore perfectly
5. Be satisfied with small, subtle changes
6. Be flexible

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
will give medications as prescribed becomes a behavioral objective for the
family; the related nursing action is teaching

Nursing Care Is More Interdependent with Families

Because families have more control over their health in their own homes, &
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
with which to be dealt

Families are sometimes unaware of what they do not know. The nurse must
suggest health related topics that are appropriate for the family situations

Increasing nurse- Family Relatedness- 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

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regarding her\his own motivations, the nurse automatically increases the
likelihood that home visits will be of benefit to the family.

Although being related is necessary, it is inadequate in itself for high quality

nursing. A CHN must also be competent. CHN also depends on assessment
skills, judgment, teacher skills, safe technical skills, and the ability to
provide accurate information.

Creating Agreements for Relatedness

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.
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 may be better.

Increasing Understanding through Communication Skills

The nurse's ability to be with family members determines the success of the
nurse-family relationship. A nurse can employ techniques of speaking and
listening appropriately and still not have a working relationship because
caring is not there.
The communication skills and their purposes and guidelines for use.
Listening, leading, reflecting, and summarizing are important
communication skills. Listening skills assist nurses in clarifying and
validating messages. Leading skills assist nurses in focusing and questioning
for the purposes of expanding the scope and depth of factual and emotional
messages and reducing confusion. Reflecting skills allow CHN to
understand the family's frame of reference and the meaning of its concerns.
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The three characteristics of a helping relationship "positive regard,
empathy, & genuineness"

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; & without further information, you can't determine
the meaning of a particular family behaviour.

Empathy is the ability to put you in someone else's shoes, to be able to walk
in her\his footsteps so as to understand his\her journey. Empathy requires
sensitivity to another's experience including sensing, understanding, and
sharing the feelings and needs of the other person, seems- things from the
other's perspective's
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 right to self-expression,
'actively seeking to understand'.

Reducing Potential Conflicts

Acknowledging that the nurse can feel uneasy because of reduced control
during home visits, how is mutually facilitated? Because coercion has little
place in public health and nursing, how can a nurse have influence over the
health of family members?
The truth is that the one person you can change is yourself. Changing
yourself is under your direct control. Through changes in yourself, you may
be able to affect your relationship with a client so that a shift in her or his
being and behaviour may take place.
Promoting Nurse Safety
Promote safety of CHN is critical. The purpose of the home visit is to offer
or provide nursing services that make contribution to the family's health and
to do so while maintaining the nurse's safety. The purpose of a home visit is
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to provide care at all costs. Assertiveness, not abandonment of one's own
needs, is required, which is especially true when you are learning to be a
CHN and the boundaries of your professional role.

Promoting Safe Travel

All CHN can benefit from basic crime prevention courses that local or state
police provide regarding safety on the street and in automobiles. Knowing
that she\he is incorporating basic self-protection behaviors is especially
helpful for a community health nurse.

Managing Time & Equipment

The community health nurse's effectiveness depends on the planning the day
for the efficient use of time and other resources. Physical resources are often
limited to equipment carried by the nurse, or provided by the family at the
home, or both. Consequently, making do with what is at hand and doing this
consistent with basic principles of safety and infection control are the
hallmarks of a skilled community health nurse, although more specialized
equipment is being used in the home to care for sicker individuals

Promoting Asepsis in the Home

The goals of infection control in the home are to prevent the spread of
communicable organisms from one family member to another and from one
household to another, to protect individual family members who are
especially susceptible to infection, and to protect the nurse from infection.
The CHN adapts these standards to the circumstances of each household and
to the specific needs of the family.

Airborne organisms can be transmitted to and from you and among

family members, even without direct contact.
Lice and scabies can be transmitted from clothing, bed- ding, and
upholstered furniture.
Direct physical contact and using equipment introduce the necessity
for medical asepsis or clean technique by the community health nurse.

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 Hand washing is as an essential component of infection control in
homes as it is in all other settings of practice
All sinks in homes are considered to be dirty. This determination is
not meant as a judgment of the family's house-cleaning skills; rather,
it is a basic principle of medical asepsis. Some homes will have sinks
planning water, liquid soap and separate hand towels for guests
Proper handling of equipment prevents the spread of communicable
organisms

Modifying Equipment & Procedures in the Home

From its inception, district nursing involved teaching families in the home
about the care of the ill and preventive hygiene practices. The nurses assisted
the family in using available equipment, in modifying household items for
health-related purposes and in making equipment. HOW can a family make
bed tables and bed rails?

Teaching family members to assess their own health status is often a

responsibility of commune health nurses. By using the family's equipment,
the procedures can be tailored to specific circumstances

When families give medications, especially liquids validating the type and
size of spoons and droppers used is important to ensure that the doses given
match the doses prescribed

Post-visit Activities
Post-visit activities provide a time for your evaluation and work on behalf of
the family collaboration, referral, and recording. This conclusion of one visit
becomes the beginning or preinitiation for the next encounter. A plan of care
is from the information you have assessed. This initial home visit, the first of
few or many visits in your nurse-family relationship, is complete

Consulting & Collaborating with the Team

Consultation is seeking the advice or opinion of an expert. CHN may
consult with a wide array of practitioners in other disciplines, such as
medicine, physical therapy and environmental hygiene

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Do and Donts for a Successful Community Home Visit

DONT be late for the home visit or make a surprise visit.

DO be on time! Make sure you have accurate directions and call in advance
to schedule the visit. If you find yourself behind schedule (and it can
happen!), call the client and give them your estimated time of arrival.
DONT wear fancy jewelry or your Sunday best.
DO wear clean, comfortable, machine washable clothes and minimal
jewelry. The idea is to look professional and blend into any neighborhood.

DO make sure your agency is aware of your schedule at all times! Call if
you have a change in plans.
DONT walk directly into a clients home.
DO knock and wait to be invited in. Remember, you are a guest in their
home.
DONT stay in the environment if you dont feel safe. Leave immediately
and call the client to reschedule your appointment. If problems arise during
the home visit, excuse yourself and leave as soon as possible.
DONT make judgments or negative comments about the appearance of the
clients home.
DO keep your facial expression friendly and non-judgmental. Ask the client
if they need help in anyway. Treat the client and family with respect.
DONT position yourself with your back to doors.
DO try to be aware of anyone entering or exiting the home. Position yourself
with a clear view of entrances and exits.
DONT tell the client what you want them to do.
DO ask the client how they are feeling and ask if they have any concerns or
questions.
DONT criticize the client or the caregiver for not following your
instructions or the health care plan.
DO discuss your observations. Compliment areas of care preformed
successfully and reinforce your teaching. Try to discover why procedures
were not preformed. Remember, everyone has their own way of doin

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things. As long as the principles are maintained, the procedures dont
matter.
DO listen to the client. They may have tips that will help you!
DONT use medical jargon when teaching or explaining procedures.
DO speak slowly and clearly. Make sure to reinforce your teaching with
handouts or pictures if the client is unable to read. Ask if the client has any
questions. Watch their facial expressions for signs of concern or confusion.
DONT rush your visit even if you are behind schedule.
DONT discuss sensitive topics, i.e., religion, politics, or discuss your
private life
DO ensure time for client concerns and some conversation. You can learn a
lot through small talk. Encourage them to tell you about themselves.
DO thank the client and family for the visit and confirm your next
appointment time.
DO follow through with your promises.
DO keep the client apprised of health care plan changes.
DO enjoy yourself! Community nursing is rewarding!

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Ethics Community Health Nursing Application Exercise
What do you believe?
1. How should health care resources be allocated among different groups?
2. Do you think health care funds should be used primarily for preventive health care or
curative care?
3. Should all taxpayers have access to health services funded by taxes? If so, why do you
think so? If not, who should be eligible for those services?
4. Should health care providers assist terminally ill clients to end their lives if they
request help?
5. Should the names of clients testing positive for HIV be reported to the state?
6. Why role should the state play in identifying and persecuting pregnant women testing
positive for narcotics
Ethical Decision Making
1. Identify the problem (Determination and acknowledgment of the conflict)
2. Identify the ethical issues (Clarification of the nature of the conflict (i.e., ethics
problem or ethics dilemma)
3. Define personal and professional moral positions and legal positions if applicable
4. Identify value conflicts
5. Identify all those involved in making the decision, and determine who should make the
decision
6. Identify each of the actions possible, and explore alternatives
7. Selection and implementation of a course of action
8. Evaluate results
Bioethics guides health care professionals. It uses principles for framing ethical issues in
any case. There are two approaches in bioethics. Deontology is concerned with duty and
the use of principles, especially beneficence, non-maleficence, and justice, to deal with
problems. Teleology or utilitarianism is concerned with consequences and uses
beneficence in seeking optimal outcomes.
Autonomy - (Advocacy) - respect for the person, individual dignity, self-determination,
and rights.
Inward autonomy: has the faculty and ability to make choices
Outward autonomy: choices are not limited or imposed by others
Will a particular course of action lead to anyone being used as a means to an end
without regard for his/her individual rights?
Based on the individual's right of self-determination.
Implies a partnership - but respects each person's ability and right to make decisions
even when those decisions seem to be not in the person's best interest

Nonmaleficence - do no harm or minimizing harm ("primum non nocere"). Health care

professionals must avoid causing harm and strive to protect clients from harm.

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It is an over-riding principle in health care - shared by both medicine and nursing
Nightingale pledge: "...I will abstain from whatever is deleterious and mischievous, and
will not take or knowingly administer any harmful drug...." (Craven & Hirnle, Chapt 16,
pg. 256)
Harm can be deliberate harm, risk of harm, and unintentional harm
Intentional harm is unacceptable in nursing, but what about risk of harm? There
may be risk of harm from an intervention that is intended to be helpful (e.g., pain
med to relieve suffering, but could hasten death). How much risk is morally
permissible?
Requires practice be up to standards - not following standards could be harmful
Veracity - truth telling; always tell the truth; never lie or deceive (formerly was common
not to tell people what their diagnosis or prognosis was).
Now, do we sometimes give too much information?
Deception can occur with beneficence and paternalism.
Deception can arise from the principle of nonmaleficence
What if the truth could cause harm? Would cause anxiety and fear? Is it better to
tell a lie in order to relieve anxiety?
The resultant loss of trust in the nurse generally outweighs benefits derived from
lying.
Informed consent arises from the principles of autonomy and veracity
Beneficence - do good. Client's well-being is sole importance; doing the greatest good
and balancing the risks and benefits. Health care professionals have an obligation to
implement actions beneficial to the clients. Doing good must be balanced with risk of
harm, especially with the advanced technology in today's health care.
A type of beneficence is paternalism
Do what you know is best - even if the client doesn't understand; Even if it means
restricting liberty or autonomy.
This is where there are some major ethical differences between medicine and
nursing.
Justice - Fairness, equitable use of resources and equal access to care. Individual need
justifies who gets what and how much. Individuals or groups are similarly treated. People
should have what they deserve or can legitimately claim.
What is fair?
Balance of resources:
o equal shares go to all recipients
o those in greatest need get what they need
Fidelity Faithfulness to the agreements and responsibilities undertaken; keeping your
promises; essence of trust
We have responsibilities to clients, employers, government, society, our profession,
ourselves.
Which contracts/agreements/responsibilities take precedence?
Contract with the employer?
Contract with the client?

Contract with the professional code of ethics?

May be affected by circumstances at any particular time

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The outpatient clinic

The clinic should be organized to provide health screening and simple treatment as active
and rational health activities and not as a passive response to an irrational demand while
considering the following:

The use of decision trees (strategies of diagnosis and treatment) drawn up with the
objective of detecting and dealing adequately with priority problems.

The use of essential drugs to reduce costs, improve use and promote the use of
effective drugs.

The systematic referral to hospital and an institution of a higher technical level when
needed.

2. Care and active follow-up in emergency situations

Health workers should be enabled to develop the necessary knowledge and skills to
provide relevant and appropriate advice, care, treatment and referral in emergency
situations.

3. Care and active follow-up of chronic patients

The follow-up process involves self-evaluation by analysis of data for case finding as
well as monitoring attendance of chronic patients at clinics.

4. Care and active follow-up of high-risk groups

In any community, it is necessary to identify high-risk groups. These may include groups
of people exposed to occupational health risks, e.g. industrial workers or agricultural
workers exposed to pesticides, or age groups such as the elderly or schoolchildren. The
identification of these high-risk groups calls for a certain amount of previous
epidemiological knowledge. Epidemiological data would be necessary to formulate
appropriate follow-up strategies for these groups.

However, young children and women of reproductive age are considered risk groups
found in every community. Family health care services for family planning, and antenatal
and postnatal care should be offered. Well child care with periodic weighing,
immunization and education for parents should be included.

5. Health promotion programmes

Promotion of healthy lifestyles in the home and community settings could include a
school health programme, an environmental health and occupational health programmes

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established by health workers. Healthy nutrition, exercising for health, accident
prevention, drug abuse prevention, HIV prevention, TB control, anti-smoking campaigns
are some examples of healthy lifestyle-promoting activities.

The above services are very basic, and necessary to start and expand primary health care
concepts. Other functions such as environmental sanitation, community health education,
etc. require a long-term relationship between the health service and community.

6. Community meetings

Community meetings are a part of the formal health centre activities. These should be
convened on a regular basis with a set agenda to facilitate and foster active involvement
of the community in the provision of health care as well as for addressing priority health
issues confronting the community.

Health personnel should facilitate the community meeting. However, it should be chaired
or led by a community leader or other prominent figure in the community. Overall
development of the community could also be achieved through these meetings.

Clinical Objectives:
1. Understand and utilize the correct reporting mechanisms and data interpretation for
communicable diseases.
2. Be able to appropriately access health statistics resources in the library and health
department to develop an accurate base for the assessment of an individual as well
as community.
3. Be able to use the concepts of epidemiology to provide appropriate interventions
in the community.
4. Implement interventions to control communicable disease in the community

Setting Primary prevention Home Health Health promotion

Secondary Tertiary prevention education Simple wound care
prevention treatments, e.g. Palliative care
Rehabilitation
Setting Primary Secondary Tertiary

prevention prevention prevention

Home Health education Simple treatments, e.g. Rehabilitation

Health promotion wound care Palliative care

Disease prevention Referral Management of chronic

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 Antenatal care Drug administration diseases, e.g. diabetes,

Immunization Safe delivery HIV/AIDS*+

HIV counselling Newborn care

Condom promotion

Community, e.g. Exercise programmes* Screening* Self-help groups such as

Health centres Elderly/health clubs Referral mental health support

Schools Environmental health Needs assessment groups and HIV/AIDS

Village halls campaign+ Care self-help groups

Places of Mosquito control Mass/group treatment Emergency care

worship campaign*+ (e.g. deworming of Community-based

Workplaces School health* schoolchildren) rehabilitation

Development of personal Community-based

skills *+ AIDS care

Parenting classes

Women/community

empowerment groups

Safe sex campaign*+

Information, education

and communication, e.g.

family planning

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