Contributor – Jessica K. Cochran, BSN RN

At the age of 29, three weeks deep into the haze of being freshly postpartum, I found myself on the couch seemingly continuously nursing my new baby and glued to the coverage of the aftermath of Hurricane Katrina. I was particularly riveted by the story of a young pregnant woman trapped by flood waters on a bridge, tragically ironic as she did not have safe water to drink and was suffering from dehydration. That moment and the upwelling of empathy I felt, fueled by my post-partum hormones, set me on a path to becoming a bachelor’s prepared maternal/child nurse. I was ripe for the rush of life purpose her story provided.

As I moved from a novice to a competent nurse, the very natural albeit naive feelings of wanting to “save and fix” also matured into an understanding that nursing service means supporting, educating, and informing, but not fixing. My motivation for being a nurse, my “Why,” grew from wanting to fix a problem into a belief that if patients have more understanding, then they will be more motivated to fix their own problems. The estimable Maya Angelou once said, “Do the best you can until you know better. Then, when you know better, do better.” I believe this with my whole heart. In the nursing environment, the reward of teaching patients the why behind their course of treatment or their plan of care is often immediate. Clear communication empowers patients to actively participate in their care, builds rapport and it always decreases conflict, all of which make a nurse’s job easier. This is very important in obstetrical nursing where the risk of litigation is high, and the statute of limitations is the longest in the industry. I became more interested in promoting clear communication with patients, fellow nurses, and obstetrical providers. Rather than saying, “do you have any questions?” I started saying “What questions do you have?” On many occasions, I pulled up the rolling stool that was in every labor room and indicated that a newly minted medical resident should sit down when talking with a patient who was lying in bed rather than stand over her. When a patient came in for an induction, I would state clearly what I knew to be the plan of care and ask them if it matched what they knew about their situation.

Sometime during my nursing school journey, I saw a news story about Nurse-Family Partnership (NFP). I recognized my future in that story and said out loud to myself, “I am going to do that job someday.”
Fast forward, seven years after my L & D internship began, I was offered a job at the local “Help Me Grow” partner agency which has one of the oldest and largest NFP programs in the country. NFP’s mission is to “transform the lives of vulnerable mothers, babies, and families.” We do this through an evidence-based nurse partnership model pioneered by Dr. Davids Olds, which has 40+ years of research behind it proving just how much difference it makes in generations of families in decreasing childhood trauma, addressing the impact of systemic poverty, and encouraging self-efficacy. The NFP model of nursing practice is a strengths-based model. At its base, it is supported by concepts from the Human Ecology, Attachment, and Self-efficacy theories.

Each bachelor’s prepared nurse carries a caseload of about 25 low-income, at-risk women who begin the program when pregnant. The model was designed for primiparous women but has now evolved to serve multiparous women as well. We keep these clients until the index child reaches age 2 allowing for a strong relationship to bloom between the client and her nurse. Through regular visits, the nurse builds rapport with each client offering education, support, encouragement, and connection to resources when needed. Sometimes this is as simple as educating a woman about her body, how to have a healthy full-term pregnancy, and basic gentle parenting strategies. Other times this looks more like crisis management when there is interpersonal violence, preterm labor, or food insecurity.

It’s deeply challenging work and with the challenges also come great rewards that we get to see almost weekly. NFP teaches us to recognize and set aside our biases so that we can see the strengths in each woman and family rather than only risks. This sets the tone for success. Our nursing interventions are based on NFP’s deeply held tenets that the client is the expert on her own life and that her heart’s desire (what goal or priority is most important to her) is what motivates her. We use motivational interviewing and scaling techniques to get to the roots of her desire. For example, we may consider smoking cessation to be a high priority, but the client may not, instead she is focused on securing safe housing or a college degree. This is where the nurse’s focus must be as well.

We like to say, “only a small change is necessary.” Looking through the lens of a client’s strengths helps the nurse see her as someone to support, not someone to fix. This guidance frees the nurse. We are not responsible for getting someone to make drastic changes in their lives, in fact, most often, what seems to mean the most to the client and that fuels her desire to make small positive changes in her life is because she has a nurse who shows up, is kind, non-judgmental and who listens to her. It is the relationship that does the heavy lifting.

Another hallmark of the NFP model is reflective supervision. This is a weekly meeting between the nurse and her supervisor that is in many ways, like the relationship between the nurse home visitor and her client. The supervisor provides support, encouragement, resources when needed, and a listening ear to a nurse that is often burdened with client drama. The knowledge and wisdom that come from experience are shared in these weekly sessions. My nurse supervisor, Becki Ravencraft, will often remind us of when we get too far out on the branches and need to come back to the trunk of the tree of the NFP model. In her analogy, the branches are crowded and overwhelmed with things that can make the client and the nurse feel powerless. These can include interpersonal violence, unsafe housing, substance use, pre-term delivery, poor decision making, cuts in government assistance and any myriad other threats to stability and security. Nurses can start to feel like we need to fix problems and carry burdens that are not ours. It is helpful to be reminded that the client is the expert on her own life, and that she was solving her own problems before she became a client and will be solving them long after she graduates from the program, which is why teaching, modeling, and supporting self-efficacy in so important. Becki reminds us that if we focus our efforts on teaching skills that address the basics, think Maslow’s Hierarchy of Needs, and on responsive parenting, many of the things that crowd the branches can be eliminated. These are life-long skills that a client can use time and again even after she has graduated from the NFP program.

An interesting side effect of this job is feeling the theories, tenets, and education sinking into our own lives. You will often hear new nurses say, “I wish I’d known this stuff when my kids were little.” As NFP nurses we are highly trained in the effects of trauma on physical and emotional well-being, indeed this is what we are trying to mitigate in the next generation. We know our clients’ Adverse Childhood Experiences (ACE) scores, and we understand the impact this has on their lives. This knowledge deepens our compassion and understanding of our clients.

Today, 11+ years after graduation, using my Why, I have cobbled together a “perfect” job for me and for my family life as a nurse educator and nurse home visitor. The threads of my Why, that when we know better, we do better, feel better and share better always run through everything I do for my fellow nurses, clients, family, and myself. As you reflect on my nursing journey, I would also ask you to reflect on your own journey by answering the following questions: 1) What is your nursing practice “why” and 2) How is your practice guided by Theory-based, empirically tested models? Please share your thoughts in the comments section below.

About Jessica K. Cochran

Jessica Cochran graduated in 2011 with her BSN. She is pictured here with her son who is the baby from the story. Jessica enjoys educating in several facets including teaching childbirth education classes, orienting new NFP nursing staff, and homeschooling her young daughter.