The purpose of this concept analysis is to uncover the processes involved in conceptualizing home visiting in the setting of contemporary community health nursing practice. From this concept analysis, the concept of home visiting is defined as
an interactive process between the health-visitor and the client/family unit, occurring within the home setting, in which the health-visitor gains entry into the home and develops an understanding of the client's health need as he/she sees it. Consequences of this process include the potential for improved health status for the client, with improved knowledge of community resources and selfcare capability.
Walker and Avant's framework for concept analysis is used as the organizing framework. Several case studies are presented to highlight the identification of critical attributes, antecedents, and consequences of home visiting. A brief review of the research literature regarding home visiting is also presented. This process can be used to generate many research questions for examining the meaning of home visiting in today's community nursing practice.
The aim of this concept analysis is to uncover the essential elements involved in home visiting in the context of contemporary community health home care practice. Concept analysis is a strategy that allows us to examine the attributes or characteristics of a concept (Walker & Avant, 1995). Increasingly, new service home care delivery models are emerging, and some of these involve dramatic changes in the provider-client interaction. For example, home telehealth involves remote healthcare delivery or monitoring between a healthcare provider and a patient who are not physically in the same place at the same time (Chetney, 2003). What does home visiting mean in this context? It is essential to define the boundaries of the concept of home visiting so that newer practice models can remain true to its essential elements. Pertinent home visiting research literature is presented here, as well as possible research direction for advancing home health care knowledge about this concept.
To conduct this concept analysis, a review of the professional research literature was first conducted using Medline and Cinahl, using the search terms "home visiting," "home visitor," "community health," and "concept analysis." Only Englishlanguage entries were investigated, but an effort was made to find literature that spanned many cultural and geographic boundaries. Fifty-seven entries were searched, and the references for each publication were also hand-searched for more data.
Next, the framework of Walker and Avant (1995) was used to discover critical events or incidents that must occur before the occurrence of a concept (called "antecedents"); the cluster of attributes most frequently associated with the concept and that allow the analyst the broadest insight into the concept (called "critical attributes"); the events or incidents that occur as a result of the occurrence of the concept (called "consequences"); and the classes or categories of actual phenomena that, by their existence or presence, demonstrate the occurrence of the concept itself (called "empirical referents"). Table 1 provides a summary of these antecedents, critical attributes, consequences, and empirical referents for home visiting.
Research Literature Supporting the Concept Analysis of Home Visiting
Brainard (1922) identified three movements of the 18th and 19th centuries that were historical forces that influenced the nature of home visiting: (1) the growing social awareness of the situation of the poor, (2) the growing knowledge that poor hygiene and living conditions caused many diseases that were preventable, and (3) the development of nursing into a respectable profession, based on scientific principles. The founding of settlement houses was a major movement that affected the character of visiting nurses in this country.
Nehls and Vandermause (2004) examined community-based nursing and found a strong ideological commitment to working with, not simply in, the community. This intimate knowledge of the community in which home care was practiced differentiated this practice environment. Elkan et al. (2001) examined the role of the home visitor and the interventions that made a difference to health outcomes of the treated population. They determined that the role of "home visitor" is the most fundamental of all community health visitor roles, focusing on family centeredness of the nursing care. This literature focused on the essential inputs of an identified health need, a visited individual or family ("the visited" or client), a health visitor, a home environment where the client lived, and a neighborhood assessment.
The process of home visiting involves forming a relationship with the client. Byrd (1995) conceptualized the home visitor's gaining entry as the first step in beginning the home visiting process. Gaining entry was viewed as both the physical process of entering the home and the acceptance of the home visitor as essential to the client's health need. Ross and Johansen (2002) identified the home visitor as a guest who enters into a contract with the client and family (if present) to achieve a mutually determined goal. Of particular interest in their work is the client who may be unable to identify or agree to a mutually determined goal, such as a client with dementia or one with limited cognitive or interpersonal function. In this case, the nurse enters into the agreement with the family or spokesperson, who agrees to have that client visited. Ross and Johansen's qualitative study of health visiting practice in Denmark found that the significance of the "joining" of family health goals with the health visitor was unique to this practice setting. A critical part of the health visitor's role is to assist the client to identify perceived needs using an organized structured interaction. The establishment of the plan of care continues the home visiting work. The change of setting from hospital to patient's home shifts the balance of power, making the contact more equal, as compared with the contact in an inpatient setting (Ross & Johansen).
Ramsdell et al. (2004) compared clinic-based home assessment to a home visit in demented elderly patients. Eight-four percent of the serious problems identified by clinicians were found only at the home visit, and not at the clinic visit. They concluded that a clinic-based home assessment is not comparable to a home visit for assessing the home environment and safety of demented elderly patients. Byrd (1995) referred to this as the "seeing" phase of the home visit. Ramsdell et al. found that important first-hand observation and assessments of the client's natural environment, social isolation, caregiver stress, and fall risk could not be duplicated in a clinic setting. Additional research could investigate whether this outcome is valid for all patients, not just those with dementia.
In 1915, Wald's groundbreaking work in the community identified neighbors' occasional view that home visiting was a sign of the family's failure to give adequate care to a sick member could be a possible negative consequence of home visiting. These concerns have translated today into concerns for patient privacy and confidentiality, but one could wonder if a family could still feel inadequate in the presence of the nurse visitor? This may be another promising area for future nursing research. Dolan et al. (1990) stated that an essential activity after the visit was the "telling" phase, alluded to by other authors, comprised of reporting and referring, documenting, and using community resources in an ethical manner to strengthen continuity of care and maintain the client at home after the nurse has exited.
In a three-armed randomized clinical trail conducted to examine the effectiveness of home visiting by paraprofessionals and nurses, Olds et al. (2002) found that nurse-visitors produced significant positive effects on a wide range of maternal and child outcomes. In a large randomized psychosocial intervention study on the effect of home visits to Danish patients with colorectal cancer, Ross and Johansen (2002) first performed a qualitative interview study to investigate how home visits should be done. Improved understanding of the physiological and psychological aspects of one's disease, improved coping, enhanced social supports and contacts, improved knowledge of community resources, and a broader understanding of the patient on the part of the health professional were observed as outcomes in this study.
Outward signs that signal the existence of a home visit are the empirical referents. "If we are to measure this concept to determine its existence in the real world, how do we do so?" (Walker & Avant, 1995, p. 46). Empirical referents are extremely useful in instrument development because they are clearly linked to the theoretical base of the concept, thus contributing to both the content and construct validity of any new instrument.
Kendrick et al. (2000) performed a systematic review of the literature of randomized controlled trials and quasi-experimental studies evaluating home visiting programs in the United Kingdom, on a range of maternal and child health outcomes. This review suggests that home visiting indicated a significant improvement in a variety of measures of parenting and an increase in the quality of the home environment.
In a meta-analysis that investigated the effectiveness of home-based support for older people, Elkan et al. (2001) found that older people remained in their own homes for longer time periods, which was an objective of government policy in the United Kingdom for several decades. Investigators also noted that the identification of previously unmet medical and social needs occurred with home visiting. One may infer that the home visit allows the clinician the opportunity to more accurately assess the client's health needs, home environment, safety issues, and social supports because a firsthand observation in the natural setting occurs.
Case Studies
Several home visiting case studies are presented to apply the components of this concept analysis.
A model case (Walker & Avant, 1995) is a pure case of the concept, a paradigmatic example, one that we are absolutely sure is an instance of the concept.
CARLA is a 39-year-old white woman, referred to the visiting nurse agency by calling there herself, requesting assistance with her ileostomy at home. She lives in a middle-class neighborhood outside a large city in New England with her spouse and 9-year-old son. The visiting nurse knew this area well because her agency was organized so that each nurse delivered care within her own district (geographic region). Carla was recently having increasing difficulty managing her ostomy care since becoming pregnant unexpectedly 8 months ago. Apparently, she had a long history of ulcerative colitis and had undergone a small bowel resection resulting in an ileostomy at the age of 19 years. She immediately shared with the visiting nurse that she was a recovering alcoholic who was employed part time in the evenings as a bartender. Thinking she had secondary infertility, she was shocked to find out only recently from her obstetrician that she was again pregnant. She had initially feared that she has some kind of an intestinal tumor.
The nurse's first priorities were to reduce this client's anxiety, build trust, and see this situation from the client's perspective. Because Carla was unable to visualize her ostomy underneath her enlarging abdomen, the surrounding skin was raw and excoriated. While bathing the area and attempting to provide ostomy care, the nurse made conversation and completed her assessment. This client's stressors were many: a surprise pregnancy, a son to care for, a distant husband, a troubled marriage, limited income, no family nearby, disruption of her bowel regimen and independence, and fear and anxiety.
The nurse began to plan care with Carla and identify mutual priorities. We included the patient's son because she asked that he be taught her care to assist her, and he was able and interested in doing so. We discussed community services that may be useful to her (babysitting coop, outpatient wound care specialists, home delivery services for groceries, home delivery of ostomy supplies). During the coming weeks, we altered our skin care and bowel management plans, made dietary modifications, and made a referral to the nutritionist on staff, until the patient had beautiful skin integrity and a reduction in anxiety. Newer products in ostomy care management were introduced and tried with this patient until she was comfortable with assessing the newer products and how they could be useful to the management of her ostomy.
Carla's normal lines of defense had been altered, and the nurse's interventions were aimed at attempting to assist the client toward restoration. The last days of Carla's pregnancy were stressors for all of us, when she came down with chickenpox the day before her planned cesarean section. The surgery was performed 1 week later, with special operative precautions and isolation of mother and healthy baby boy. The nurse planned to make several postoperative visits to complete the plan of care and assist Carla to return to her previous good state of health and independence.
One sees that evidence of the critical attributes, antecedents, and consequences of home visiting are evident in this model case. The antecedents included identifying the health need, the client/family unit, the home setting, and the nurse's knowledge of the neighborhood. Critical attributes included gaining entry into the home and the client's family life, setting mutual goals, shared responsibility, the client in control, and education for self care. The nurse formed a cooperative partnership in establishing the plan of home care. The use of the word "we" is indicative of this joint approach. Consequences were evidenced in the improved health status of this client, increased client satisfaction with her health and self-care management, and a broad understanding of this family's functioning and needs. Empirical referents, which demonstrate the existence of the concept in this example, include referrals to other providers, measurable improvements in self-care activities, and improved health outcomes.
The borderline case is that example or instance that contains some of the elements of the concept being examined, but not all of them. These cases are inconsistent in some way, and as such they help us to see why the model case is not (Walker & Avant, 1995):
JACKSON is an 85- year-old white man living alone in a suburb of New York. He is referred to the visiting nurse service for care of his multiple medical needs, including end-stage renal disease, Parkinson's, hypertension, cerebral vascular accident, deep vein thrombosis, and indwelling central line Tesio catheter for hemodialysis access. Jackson has a live-in nurse who assists him with most of his health care and personal care needs. During a home visit, the visiting nurse attempts to teach Jackson about his medical regimen. However, he refuses to learn about his medications, diet, or physical therapy exercises, stating, "My livein nurse takes care of that for me. Teach her everything." Although he is friendly and chatty, mutual goal setting and care planning is not possible because this client does not wish to become involved in his care, and his family wonders if this is partly because of increasing cognitive decline. The family hires a consultant to begin planning for possible skilled nursing facility placement for Jackson.
In this borderline case, the nurse is welcomed into the patient's home and the patient acknowledges her expertise and interest in his care. However, the patient does not join into a mutual relationship with the nurse, preferring to give responsibility for his care to his private home care provider. No sharing of responsibility for care is evident between the visitor and the patient. Self-care is limited by the patient's lack of interest in education or responsibility.
A contrary case is clearly an example of "not the concept." This gives us information about what the concept should have as defining attributes if the ones from the contrary case are clearly excluded (Walker & Avant, 1995):
EVELYN was an elderly white woman with a primary diagnosis of breast cancer, living in suburban New England. This was her first serious illness, and she was not happy about the limits her chemotherapy treatment put on her lifestyle. Independent by nature, she reluctantly agreed to have the visiting nurse come to her house, on the doctor's recommendation. At each visit, Evelyn would try to rush the nurse out and hoped she would not return. Although the nurse attempted to ask questions to make a health assessment, Evelyn repeatedly answered with one-word answers and did not want to discuss her illness with the nurse. During the third visit, she stated, "I don't really need you. I am fine." After a few visits, the nurse phoned the physician to discuss this situation, and the doctor agreed that the visiting nurse services should be discontinued. Evelyn was discharged from agency services the next week but was encouraged to phone for services if she should require them.
In this contrary case, there is no evidence of home visiting. The patient refuses the intervention of the nurse and does not share her health concerns or even see the need for the nurse's presence. She seeks to avoid the interaction and prefers not to have the nurse in her home.
Implications for Home Visiting Team Members
Concept analysis can be useful in suggesting hypotheses regarding concepts and in stimulating research in other ways (Walker & Avant, 1995). Identified attributes, antecedents, and consequences of home visiting can be used to generate research questions to be examined regarding home visiting in today's community nursing practice. Empirical research is needed to refine conceptualization and develop measurement tools to address outcomes in the specific setting of home care. Application of these concepts to the changing nature of the home care arena provides a rich source of future research. Comparison of different service delivery methods in home care can identify whether differences in the relationships between home visitors and clients occur, or under which structural conditions the health outcomes of the home care clients can be maximized.
What appears to be limited in the literature searched for this concept analysis is research data that ask the home care client directly to describe his/her concept of home visiting. The clients are the users of home care services. Porter's (2005) recent publication of older widows' experience of home care is such a research study, an empirical study of the essence of the experience. Tying the home visiting process to important patient and health system outcomes is essential to advance nursing science.
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