Early childhood home-visiting programs have proliferated in the last decade in an effort to promote healthy child development and prevent child abuse and neglect in at-risk families. Although public health nurses are the most common professionals delivering home-visiting programs, other professionals, such as midwives and social workers, are sometimes employed. More recently, programs have been developed that employ lay home visitors (paraprofessionals) under the supervision of professionals, usually public health nurses (e.g., Hawaii Healthy Start Program; Earle, 1995). Although there is a growing literature evaluating home-visiting programs that use lay home visitors (Barnes-Boyd, Fordham, & Nacion, 2001; Norr et al., 2003), there is little discussion of the issues in programs that primarily use lay home visitors for the day-to-day work with families. The purpose of this article, therefore, is to describe issues related to delivering a home-visiting program, BabyFirst, using lay home visitors from the perspective of public health nurses and lay home visitors.
The BabyFirst program is a universal home-visiting program established in the Canadian province of Manitoba in 1998. The program focuses on children (prenatal to 3 years of age) assessed as living in conditions of risk. Risk factors include substance abuse by parents, parents' own experience of abuse and/or neglect as a child, social isolation, parents' lack of education and basic literacy, unstable housing, and other conditions. The program was modeled after the Healthy Start Program (Duggan et al., 1999; Earle, 1995) and modified for local needs. Eligibility for enrollment in the program is based on the scoring from a detailed family assessment and consent of the parent carried out by public health nurse. The BabyFirst program emphasizes positive parenting, enhanced parent-child interaction, improved child health and development, and optimal use of community resources (Children and Youth Secretariat, 1998). Consenting parents are assigned a trained lay home visitor supervised by a public health nurse. Public health nurses also provide some direct service to families. Visits reflect the program goals and a strength-based philosophy and are structured using a specifically developed curriculum entitled "Growing Great Kids."
Paraprofessionals in Home-Visiting Programs
There is a growing trend in home-visiting programs toward using paraprofessionals (nonprofessional workers) to deliver services to families with infants and young children. In this article, the terms lay home visitors and home visitors refer to these paraprofessionals. Home visitors usually receive specific training in working with families from their employing agencies. In some cases, they are recruited from the geographic or cultural communities they serve under the premise that life experiences similar to prospective clients ("walking the walk") will enable them to work more effectively with parents. In a review of home-visiting programs for young pregnant women, Persily (2003) maintained that home visiting by nonprofessional workers may be more acceptable to pregnant women, particularly women from similar cultural groups.
Several studies have examined the effectiveness of lay home visitors on several child and family health variables. Compared to controls, mothers and infants receiving home visiting services have demonstrated improved outcomes on several measures (Barnes-Boyd et al., 2001; Norr et al., 2003). Other studies report few or mixed results (Duggan et al., 2004; Logsdon & Davis, 2004; Olds, Robinson, & Pettitt, et al., 2004). In a systematic review of the effectiveness of home-visiting programs that included studies of home visitors and professional home visitors, usually nurses (Kendrick et al., 2000), the outcomes for children and families visited by lay visitors seemed to be similar to those of professional visitors. However, the authors conclude that there were few studies in the review (n = 8) in which lay visitors were used; most programs used professional visitors. Other research reviews have produced inconsistent conclusions as to the effectiveness of home visitors compared with professional visitors (Persily, 2003; Sweet & Appelbaum, 2004).
One of the most longstanding and rigorous evaluations of home-visiting programs is Olds and colleagues' (2004) 20-year longitudinal research of home-visiting services delivered from the prenatal period to age 2 using professional nurses and lay home visitors. In the follow-up evaluation at age 4, the benefits to mothers and children were significantly greater in the families visited by nurses compared to home visitors. This is a particularly noteworthy study given the large sample size, rigorous design, and long-term follow-up.
In addition to assessing the effectiveness of programs using home visitors, several issues related to the hiring of home visitors have been noted in the literature. Because programs using home visitors lack standardized credentials, home visitors are often hired based on personal attributes (e.g., maturity, warmth, empathy), which are thought to be effective in developing relationships with clients (McGuigan, Katzev, & Pratt, 2003). However, there has been little systematic evaluation of home visitor attributes to determine whether there is benefit to families when these characteristics are present.
There is some empirical support that the retention of families in home-visiting programs is associated with factors related to the visitors. The home visitor's age (younger) was found to be predictive of longer duration of parents in a home-visiting program and a greater number of home visits (Daro, McCurdy, Falconnier, & Stojanovic, 2003). Also, families were more likely to remain in a home-visiting program when the visitor received more hours of direct supervision (McGuigan et al., 2003).
Little literature reports on the issues related to using lay home visitors in child health home-visiting programs from the perspectives of the service providers (public health nurses and home visitors). The aim of this overall study was to uncover perceptions of the program from the perspective of the providers and recipients (parents). Providers' perspectives of the issues related to delivering the BabyFirst program was a major theme that emerged from the study and is the focus of this article.
Study Design and Methods
A descriptive, qualitative, interpretive design was used to document the perceptions of individuals involved in the BabyFirst program. The qualitative, descriptive design is supported by Sandelowski (2000) as useful for obtaining "straight" answers (i.e., minimally theorized or otherwise transformed) to questions of special interest to practitioners and policy makers.
Setting and Sample
The study was conducted in one regional health authority where approximately 65% of the provincial population resides. The sample consisted of 24 public health nurses and 14 home visitors. Purposive sampling facilitated variation in the data, including type of participants (public health nurse and home visitor) and location of employment (inner city and suburban districts) (Field & Morse, 1995). Inclusion criteria were set to ensure that the nurses and home visitors were familiar with the program (minimum of 2 years for nurses and 12 months for home visitors). All participants had to be English speaking.
Data Collection and Analysis
One in-depth, semistructured, tape-recorded interview that lasted between 45 min and 1.5 hr was conducted with each participant. All interviews were carried out by one experienced research coordinator, which ensured standardization of the interviewing process. Participants also completed a demographic form. Data collection took place over a 5-month period from October 2003 to February 2004. Data analysis was carried out concurrently with data collection. All transcripts were fully transcribed using the Microsoft Word word processing program, checked for accuracy of transcription, and printed with wide margins. Transcribed data were analyzed using content analysis techniques (Field & Morse, 1995), including open coding in the margins of the transcripts and developing and refining themes (Strauss & Corbin, 1990). Data were coded by all three researchers and reviewed for congruence of coding. Where any discrepancies were found, the data were re-examined until consensus was attained. The researchers undertook standard measures to enhance the rigor of the research process, including careful line-by-line analysis of the transcripts, regular debriefing of the data collector, and detailed memo writing (Lincoln & Guba, 1985).
Ethical Issues
Ethical approval for the project was received from the researchers' university ethics board. Verbal and written consent was secured from each person who agreed to participate.
Results
Public health nurses and home visitors reported many benefits and strengths in delivering the BabyFirst program, and participating parents expressed very positive views of their home visitors (reported in detail elsewhere). However, public health nurses and home visitors also identified several issues associated specifically with the use of lay home visitors and more broadly with the delivery of the BabyFirst program. These issues are discussed in the following categories: issues related to (a) the home visitors, (b) the BabyFirst families, and (c) the general administration of the program (Box 1).
Issues Related to Home Visitors
Five main issues related to home visitors were identified that affected the day-to-day activities of nurses and home visitors. The first issue, a high turnover rate, was identified because it resulted in a lack of available home visitors for eligible families:
"Probably not enough home visitors. You know because there are families that are missed. There is just that three month window of opportunity (to enroll families) and if all of a sudden in your area there are five moms that qualify and everybody is full." (home visitor)
The second issue identified was a lack of qualifications and performance of home visitors. Nurses and home visitors expressed concern that some of the home visitors were lacking appropriate educational preparation and work experience. There was also concern that some home visitors had problems of their own that qualified them as potential BabyFirst families:
"She [home visitor] had too many things to resolve herself[horizontal ellipsis] And not only that, she probably needed some counselling maybe, to deal with issues, and she ended up leaving the program because she wasn't being effective anywhere. The families would leave her and she would have conflict dealing with some families" (nurse).
"I don't know who hires some of these people but some of the home visitors don't seem like they should be home visitors. They seem like they should be BabyFirst families themselves" (home visitor).
The third issue directly related to home visitors was the difficulty home visitors had with maintaining boundaries when working with families. There was a potential for home visitors to become too close to families. Nurses and home visitors viewed this as an issue not only because they felt that becoming too close could be emotionally draining for home visitors but also because it could prevent home visitors from doing their job properly:
"If they start getting into that counselling mode or get sucked into the vortex that doesn't work because then it becomes a boundary issue[horizontal ellipsis]Even if they feel that this is the right thing to do, it will sometimes backfire on them" (nurse).
The last two issues, salary and safety issues, focused more on the agency policies in relation to home visitors. A high turnover rate by home visitors was often attributed to the low salary paid to them:
"They [home visitors] didn't last because it is twelve dollars an hour. It is a lot of responsibility for them. They are dealing with a lot of families in crisis which is extremely stressful[horizontal ellipsis]" (nurse). "Our pay is not the greatest; it does not reflect our abilities and capabilities. It just doesn't reflect what we do" (home visitor).
Safety issues for the home visitors were related to home visitors not only being placed in difficult and potentially unsafe family situations but also not having the appropriate resources that would help them deal with such situations:
"Safety is a big one. You don't see police walking too much. There have been situations where I am in a home and family will burst in and they are drunk[horizontal ellipsis] They are blocking the door and the kids are there and they are fighting and I am thinking I need a phone, there is no phone here. I can't remove myself from the situation and that is expected what we are supposed to do" (home visitor).
Issues Related to the BabyFirst Families
Public health nurses and home visitors felt that certain families really would not benefit from the BabyFirst program because they had such complex needs and required more intensive services (e.g., family therapy). Some families were viewed as having too many issues or being in crisis situations or too transient for the program to be beneficial in meeting their needs.
"It doesn't work if the family is very transient and has multiple problems and is all over the map as far as being there. It obviously doesn't work if the parents are not or do not feel positive about the program. It doesn't work if the families have had a lot of intervention. If in the past where the Child Protection Agency has come in frequently and there is a lot of anger issues still. It doesn't work if people are addicted to things. Like alcohol or prostitution, those people who don't do well with all of their lives usually don't do well with BabyFirst either. And that is the people without supports, without anybody. It doesn't work for a lot of people who are very stressed in life and who are under supported; who are very young; who have no knowledge of coping skills; who have had very little success in life" (nurse).
Issues Related to the General Administrationof the Program
Public health nurses and home visitors discussed six main issues when using home visitors to deliver the home-visiting program. The first was the heavy workload and conflicting priorities of public health nurses. Several public health nurses noted that the BabyFirst program was very labor intensive and had substantially increased their workload. They also commented that the BabyFirst program was only one component of their workload. They stated that they had "too many hats to wear," that they were spread out in too many directions, and that it was difficult to prioritize all the different public health programs they had to implement (e.g., immunizations, communicable disease, BabyFirst, postpartum referrals). Home visitors also commented on the heavy workload of the nurses, which sometimes created difficulties in contacting a nurse about a family:
"Some of nurses are so busy with whatever else they've got going on, like, immunizations or this or that, that you don't want to bother the nurse" (home visitor).
The second issue with the administration of the program was that it was perceived as not valued at all levels of the organization and, because of that, it often took a back seat to other programs perceived to be of higher priority:
"BabyFirst takes a backseat when priority programs the mandated program, particularly communicable disease or if you just get plain busy with an inundation of post-partum referrals and it can spiral" (nurse).
The third administration-related issue raised by public health nurses and home visitors was a lack of central orientation process and time required for orientation:
"We had a new home visitor a few months back and there was no orientation manual and I was like, How am I supposed to orientate her?'" (nurse).
"Well for me with my years of experience working with families it was well there a long orientation process which was too long for someone like me; I was ready to start immediately because I had ten years experience working with families. So for me it was a little slow the process. It took several months before I was seeing families. I had to wait for my training with Growing Great Kids (the curriculum) and the core training which didn't come up for several weeks um and then I sat at my desk and I went crazy" (home visitor).
The fourth administration-related issue was related to the supervisory role of the public health nurses. In addition to carrying out their usual nursing duties in the general public health program, nurses were also responsible for guiding and supervising home visitors. Several expressed frustration with their lack of preparation for the supervisor role:
"Then on day five [of orientation] you have sort of this half day of discussing what are some of the supervisor's role. So when I went away quite frankly I didn't feel anymore prepared for the role than I had when I was put into it without training. I found that a little odd because normally you would feel that I have come out of this and I have a stronger sense of what my role is. But to be honest I didn't feel that way at all. There were a lot of components that were very confusing. So I fumbled along" (nurse).
The fifth issue identified dealt with policies on transitioning between home visitors. Home visitors, in particular, expressed concerns when they had to "give up" their families when they moved to a location outside their district:
"I feel that is the failure of the program is that every time our families move they get a new home visitor. I don't feel it is appropriate because we are not teaching these families about consistency. And I think it is also about building a bond. Trust doesn't come over night and to keep that trust is important and that is to continue working with them wherever they move to" (home visitor).
The last administration-related issue was related to the "Growing Great Kids" curriculum. Although both public health nurses and home visitors found the curriculum useful for families and a means of structuring visits, the home visitors identified issues related to the appropriateness of the content for some families or for all visits:
"I think for a lot of families this Growing Great Kids hasn't worked. Because they have been programmed to death. The families that we go into, they have had many programs before us. Parenting programs and things stuffed down their throats that everybody thinks that they need to know" (home visitor).
Clinical Implications
Public health nurses and home visitors reported many issues related to delivering the BabyFirst home-visiting program that have the potential to affect the success of the program. Attention to the issues discussed in this article has implications for improving the BabyFirst home-visiting program and other similar early childhood programs. The concerns identified by nurses and home visitors suggest the need to target the following three areas: (a) training and retention of nurses and home visitors, (b) program delivery, and (c) enrollment of families.
Training and Retention of Nurses and Home Visitors
The findings suggest that in addition to careful selection of prospective applicants, considerable resources should be provided in preparing public health nurses and home visitors for their respective roles. A central orientation should be provided for public health nurses and home visitors and repeated with sufficient frequency to ensure that all nurses and home visitors receive the orientation shortly after being hired. The lead role nurses should receive initial and ongoing training regarding their role in supervising the home visitors. Administrators also need to give careful consideration to retention strategies to ensure a stable workforce. Opportunities for staff development and continuing education for nurses and home visitors should be supported. Issues identified as important to the home visitors should be addressed, such as safety, transportation, and salary.
Program Delivery
Changes specific to the delivery of the program are also needed to ensure the success of the program. Both nurses and home visitors in the BabyFirst program were sensitive to the impact of large or frequently changing case loads. Limiting the size of the home visitor's caseload has been suggested as important to allow for the establishment of more intense relationships (Daro et al., 2003). Programs should be set up so that nurses are able to provide quality supervision and evaluative feedback to home visitors. Although attention to these issues is time consuming, there is some evidence that better outcomes to families may be a benefit. For example, the amount and quality of supervision of the home visitor has been found to be related to the retention of parents (McGuigan et al., 2003).
Nurses and home visitors also discussed many issues concerning the "Growing Great Kids" curriculum. The suitability of the curriculum for all families and for all visits was an issue raised by home visitors, which suggested the need for a more flexible curriculum and in response to the family's immediate needs.
Finally, the findings suggest that administrators of home-visiting programs should demonstrate to nurses and home visitors their belief and support of such programs.
Enrollment of Families
Many families seemed to have very complex needs, and it seems that not all families are likely appropriate for this type of program. Linkages should be developed with other programs to ensure timely referral and access to the most appropriate services for the family. Some families might benefit from other agencies or programs. Continued nursing research is needed to determine the best "mix" of quality and cost-effective services.
Limitations and Strengths
One limitation of this study is that the perspectives of public health nurses and home visitors who participated may have differed from those individuals who chose not to participate. Another limitation is that non-English-speaking parents were not recruited. Strengths of the study relate to the qualitative design, which provides rich descriptive data of the perspectives of persons most involved with the program.
Conclusions
Findings from this study provide information about the issues related to providing home visiting services delivered by lay home visitors. Attention to these issues has implications for improving the BabyFirst home-visiting program and other similar early childhood programs. Nurses who are key decision makers for the management of early childhood home-visiting program should identify what services (if any) are to be delivered to which clients by which workers.
Acknowledgments
We would like to thank Claire Betker, MN, RN, for her contributions to this project.
ONLINE
Healthy Child Manitoba
http://www.manitoba.ca/healthychild
Healthy Families America
http://www.healthyfamiliesamerica.org
Suggested Clinical Implications
Orientation and Training
* Require central orientation for all nurses and home visitors
* Provide initial and ongoing supervisory role training for lead role nurses
* Maintain ongoing continuing education opportunities
Program Delivery
* Limit the size of the home visitor's caseload
* Provide quality supervision and evaluative feedback to home visitors
* Provide a curriculum that is flexible to the changing needs of families
* Have administrator support in place
Enrollment of Families
* Promote thorough screening processes and in-depth family assessments
* Consider alternative or additional service for families with complex needs
References