Strategies used by public health nurses to manage challenges encountered in serving vulnerable populations

There is relatively little research about the factors that affect the quality of implementation of public health nursing visits with vulnerable populations. Although staff competence is frequently identified as key to the effective delivery of services to vulnerable populations, how such competence is produced and sustained is poorly understood. This study examined how nurse home visitors involved in implementing the Nurse-Family Partnership (NFP), an evidence-based home visitation program for first-time mothers and their infants and toddlers, learned how to manage the challenges encountered in working with high risk families enrolled in the program. Focused ethnographic interviews were conducted with 72 nurses at 12 NFP programs in four large states. Sites were selected for the study in order to assure a mixture of urban and rural sites, programs operated by public health departments as well as those operated by other community-based organizations, and variations in characteristics of the families served by the program and their progress toward program goals. Stories about the challenges nurses experienced in working with the population served in their communities were elicited through the following question: “Think of a family in which you felt things were not going well, that is the family appeared disinterested in visits and you noted little change in behavior. You continued to visit and somehow things changed for the better. Please describe such a situation.” During the course of the articulation of the nurses' narratives, the interviewer used probes to clarify the changes that occurred over time, the strategies nurses tried to bring about change, their feelings, what they learned from the experience, and how their learning influenced their approach to new families that presented similar challenges. Interviews with the nurses were tape recorded and transcribed verbatim. Atlas Ti was used to analyze the qualitative data generated from the transcribed interviews. This paper will describe the challenges nurses encountered in working with families drawn from high risk maternal-child populations, the strategies used to manage the challenges and effect change, and how learning gained from the experience influenced subsequent interactions with similar family situations.