Abstract
Purpose:
Home visiting (HV) work represents an expanding, extremely promising, and commonly practiced approach that can be seen in various areas of social work as well as health care. This report presents the results of the research study “‘home treatment’ (HT)—transdisciplinary research in HV work.”
Method:
It is the first German study that has used qualitative and quantitative methods to collect data from different professions in respect to this topic. From the point of view of the professionals, the study underlines that HV work principally seems to be a good base for establishing a professional and confidential relationship. They attribute more sustainability and participation from the clients to home-based interventions than other forms of help. After a short introduction about the current situation of HV work, the research project will be explained and the qualitative and quantitative methods described.
Results:
The results of the “HT Questionnaire” will be presented in 10 sections and the qualitative results in a model for reflection based on three points of view and five main topics.
Discussion:
Finally, some ethical and safety aspects will be discussed.
We outline home visiting (HV) work/home treatment (HT) as an expanding method that can be seen in the field of social work as well as health care (Bauer et al., 2016; Cornelis et al., 2018; Howard & Brooks-Gunn, 2009), which is practiced in several countries. In the context of our article, we use both terms—home visiting work and home treatment—as synonymous; in general, the term “home visiting” is used in the field of social work, whereas the term “home treatment” is more common in the health-care sector. The reasons why we are so engaged in this topic are caused by the fact that it is a well-proved and commonly practiced method in the field of social work as well as health care. Additionally, there is a certain lack of research—especially in Europe in HV research (Frindt, 2013; Gerull, 2013; Howard & Brooks-Gunn, 2009). For instance, research about the similarities and differences of the various professions, which are working in the HT and HV field (social worker, midwives, nurses, general practitioners, and therapists) in Germany, barely exists. Home visitors who are involved in this special setting are faced with tremendous challenges because of high complexity of case scenarios and because of “the unique, unpredictable nature of social work” (Ruch, 2005, p. 112). The work in the home of the clients enables all people to participate in social assistance systems, due to its flexibility eligibility and access rules. At the same time, home-based interventions offer a big chance to get a picture of the family and to adapt the interventions to the daily life situation of the family. Furthermore, HV work promotes some advantages regarding to the daily-life transfer and to the better consideration of the environment of the clients (Pantucek, 2009). The underlying idea behind the HT research project is to determine these setting-related properties more precisely. Additionally, it tries to describe the assessments of the professionals about their work in a differentiated way. A number of studies have been published in recent years on HV and HT programs (i.e., Brand & Jungmann, 2013; Cervello et al., 2019; Conen, 2002; Daro & Harding, 1999; Duggan et al., 2000; Helming et al., 2004; Howard & Brooks-Gunn, 2009; Morant et al., 2017; Olds et al., 1999). According to the U.S. Department of Health and Human Services up to date, there exist 14 high-evaluated research-supported HV programs in the United States. The present-day research in Germany regarding to this topic is not as well developed.
This study demonstrates the characteristics of home-based and family-related work. The aim of the research project funded by the federal state of Mecklenburg-Western Pomerania is, at first, to collect data on forms of assistance, caregivers, and methods of providing assistance in an outpatient, family-related setting. Thereafter, the results are to be compared internationally—predominantly to standard work practices in the United States—and then analyzed. The subsequent results should serve as recommendations for action to be taken for the further development of concepts for outreach work in Germany. Our data focus on the perspectives and attitudes of different kind of professionals in relation to what they do. To our knowledge, this work is the first in Germany, which comprehensively considers perspectives and attitudes of different kind of professionals in this field. The goal of the research project is to develop an interdisciplinary concept (social work, early education, psychology, medicine), which specifies the special opportunities and challenges of assistance in a domestic setting. From this, quality standards should be generated, and with them the situation for clients/patients and professional caregivers should be improved. Moreover, theme-related offers for further training should be developed for the HT sector.
Method
We used a mixed method design to examine the attitudes of different professional groups to their HV work. A quantitative survey made it possible to interview a large number of professionals nationwide. Therefore, we used the quantitative “HT Questionnaire” (HTQ) to garner wide impressions and significant data on the attitudes and perceptions of home visitors. The HTQ is an adaptation of the “home-based therapy survey” by Worth (2004). One main methodological problem, which we mention also later with the limitations, was the unknown population of our target group. To explore the views of the professionals in more depth, we used some qualitative methods also. We conducted group interviews with very heterogeneous teams and used a method mix of group discussion and dialogical introspection. Consequently, we aimed to get knowledge about those implied topics not discussed openly. This “method-triangulation” (Flick, 2011, p. 75) was used to get a two-way review of the hypothesis. Using both methods, it was possible to get on the one hand a focused view of the theoretically chosen topics and, on the other hand, the possibility to be open to new impacts.
In conclusion, the quantitative part with the HTQ gave the possibility to answer questions on 10 main topics and described some main perspectives and attitudes of the professionals in the home visiting setting. The qualitative part with the group interviews remained open for new developments and lead to a model of reflection, which could be a frame to supervise HV work.
Quantitative Method: HTQ
In the context of establishing an international review, we looked into the questionnaire developed by Worth (2004) for home-based family therapy. We modified the self-completion questionnaire for use in different professions in the social field and adapted it to the German cultural context and carried out a national survey. We conducted several pretests to minimize the effects of the adaption on validity of the instrument. The questionnaire, which we called the HTQ, is a self-assessment of the professionals and hopes to reveal the attitudes and perspectives of different professionals in the field of HV family-related work. It is divided into 10 different sections (demographic information, relationship, safety, boundaries, training, ethical concerns, indication and access to services, disturbances in the treatment process, treatment acceptance, and home-based client profile).
The results of each section rely, like all the project-collected data, on the impressions and attitudes of the home visitors, which means that they show their reported point of view.
The questionnaire mainly employs Likert-type scales and offers scant opportunities for individual answers. Our intention in using this instrument was to gain a wide overview of how different professionals work in this setting. The HTQ refers to the experience which the professionals have in their practice and how they evaluate their said experience. The study targeted social workers, midwives, therapists, and general practitioners. The data collection occurred online, and the participants got informed by e-mail or by word of mouth. For this purpose, we informed the youth welfare offices and different children’s services authorities and the various relevant medical organizations. The response to the survey was quite positive: The link was clicked 1,697 times; we got 937 predominantly completed questionnaires, but for the sake of precision, we have included only the results of the 888 completely filled questionnaires.
We analyzed the data with the statistic program SPSS. We worked mainly with frequency distributions but also with cross tabulation and statistical testing of significance. In this article, we present primarily descriptive results relating to the frequency of the statements made.
Qualitative Method: Group Interviews
In the context of the qualitative data collection, we conducted group interviews with mixed professional teams (social workers, psychologists, midwives). Six interviews were undertaken in Germany in different parts of the country and three in the United States in the states of Kansas and Missouri. We included American teams to contrast our data interculturally because we expected—based on the review of the relevant literature—a bigger heterogeneity relating to the perspectives, for instance, respecting safety issues. In this article, however, we will primarily refer to the data collected in Germany.
The group interview was divided into two parts: The first part, termed dialogical introspection, describes a special form of data collection in a group. This method offers a good opportunity for the participants to gain a thematic access. It focuses on their feelings and spontaneous associations. Concretely this means a “stimulus” is given to the group, and the group discusses its impressions and feelings in relation to the stimulus. In our case, we showed as a stimulus a clip of the movie “Elling,” where a social worker visits two clients in their flat—and tries to motivate them to overcome their social phobia. The second part is what Bohnsack et al. (2010, p. 7) term “group discussion.” It reflects the group dynamic processes and deals with the “possibility of reconstruction of commune orientations.” It aimed to figure out the perspectives and attitudes of the group members and the opinions of the whole group, which could be analyzed by means of interactive characteristics like special and group-related behavior.
The analysis proceeded in several steps; we used the heuristic methodology of searching and finding according to Kleining (2010, p. 52) and the qualitative content analysis according to Mayring (2002). These steps essentially include paraphrasing central text passages, encoding these passages to a higher level of abstraction, and then creating categories that are checked against the source material. The use of different methods of analyses in the group interviews should show the various accesses to the perspectives and attitudes of the professionals. Besides that, we aimed to connect the quantitative and the qualitative research approaches. Using different methods gave the possibility to verify the topics from the quantitative research and the reviewed literature as well as to be open to new topics and a deeper understanding of the views of home visitors.
Results
Results Quantitative Data: HTQ
The descriptive results of the 10 sections are presented in a short overview.
Demographic information
This section includes questions about the gender of the home visitors, the educational and work biography, the opportunities for professional reflection in their current job, and the location of their present workplace (state/region). In all, 72.3% of the participants identify themselves as women and 27.7% as men. In all, 62.5% described themselves as social workers. Most of them had one (62.7%) or more (21.6%) additional therapeutic or counseling qualifications. Two thirds (65.3%) are equipped with longer professional experience (more than 10 years), and 66.3% have experience in residential care or in an office setting.
Additionally, the section gives a first overview of typical tasks and duties of home visitors asked by a rating of key words, that is, transporting clients, procuring state, or federal aid for clients, being on call 24 hr per day.
We also asked about the situation of supervision and the possibility to enter into professional exchanges with colleagues. In all, 79.1% told us they have continuous supervision, 55.5% monthly, and the others have reported about infrequent supervision. In all, 94.9% claim to have constant professional exchange with their colleagues (see Table 1).
Demographic Information.
Relationship
This section is based on the hypothesis that the professional relationship forms faster, more empathetically, and more cooperatively in a home-based setting than in an office setting. Ninety percentage of the participants confirmed this presumption. They confirmed too that they had a better perception of the client’s situation and that the clients are more capable of having confidence in their work. The results of three statements are: (1) HV allows the home visitor to generate more empathy and understanding toward the client’s condition, (2) home visitors willing to go into the home are perceived as more cooperative by their clients, and (3) HV accelerates the process of rapport building with clients can be seen in Table 2.
Relationship Between Home Visiting Work and Client.
Safety
The perception of the several risks regarding safety is influenced by the imagination, the experience, and the actions of the professionals (see Lüngen et al., 2014). Only 50.4% of the participants confirmed the hypothesis that professionals experience a higher safety hazard in a home-based setting than in an office setting. Most answers of the participants were in the middle field, which makes the result more neutral and unclear.
Table 3 presents the results of the three statements about safety: (1) In my work, as a home visitor, there was a situation where I felt unsafe; (2) before or during a home visit, I take safety precautions; and (3) home visitors are at greater risk of injury than office-based helpers.
Safety.
Boundaries
In the frame of home-based work, the professionals are confronted with several physical, psychological, and social boundaries. Physical boundaries are related to physical needs and physical integrity, psychological boundaries refer to their inward differentiation and the affective regulation, and social boundaries describe the involvement with the construction of interactions and relationships.
Regarding the physical boundaries, the professionals mostly refuse to accept snacks offered, but they mostly accept drinks offered. The exact results of the responses to the statements (1) When I’m invited, I’m willing to have a refreshment with my client and (2) When I’m invited, I’m willing to have a meal with my client, are given at the end of the section. We hypothesized, that these reactions are due to personal reasons, that is, the sensation of disgust—or to institutional reasons—the organization forbids the acceptance of meals, that is, in order for the professional not to lose their neutrality.
The participants confirm the hypothesis that a professional has to be very attentive to keep his inward differentiation in a home-based setting because it is harder to do so there than in other settings. The statements which underline this conclusion were (3) It is more difficult for home visitors to set boundaries in their work than for office-based practitioners and (4) home visitors have to reflect their role more than practitioners in other settings.
Related to the social boundaries, the professionals mostly refused to be reachable 24 hr and voted for clear agreements with the clients. (5) Home visitors should be available to their clients, 24 hr per day on every day of the week. Especially, this result might be interesting because the widely established crisis HT resolution teams in Great Britain were signed with the understanding of being available 24 hr a day (Jones & Jordan, 2010; Williamson & Marshall, 2011). (6) Home visitors should work with their clients to have well-established guidelines for dealing with distraction in the home (i.e., phone calls, visitors, etc.) during home visits (see Table 4).
Boundaries.
Training
In Germany, professionals are not especially trained for home-based work. Compared to Germany, in the United States, paraprofessionals more often do the home-based work, but usually they get special training and frequent (weekly or fortnightly) supervision. We were very interested in how professionals judge the necessity for special training regarding home-based and family-related work. The participants confirmed the hypothesis that special training is necessary but rejected the idea of a degree course specialized in this kind of work. The following four statements were used in this section: (1) At the training school/university I attended, there was a course that specifically addressed the process of HV. (2) The training of my qualifying degree(s) prepared me specifically to work in this setting. (3) Practitioners who work in the home of clients should have completed graduate work specific to the task of conducting home visits. (4) HV is a specialized practice; practitioners should be explicitly trained for this work (see Table 5).
Training.
Ethical concerns
The ethical concerns regarding the home-based and family-related work are related to data protection, the reflection about norms and values, and the comprehension of cultural aspects. In all, 91.4% of the participants confirm the statement that professionals have to adjust their own convictions of tidiness and cleanliness for example. The participants confirmed the necessity for special attention regarding cultural diversity. The following three statements were used to collect the data in this section: (1) Home visitors are more frequently exposed to situations that require a breach of confidentiality (e.g., danger to self or others, inadequate living conditions of minor), (2) home visitors have reset their own moral concept (e.g., tidiness, cleanliness) compared to the ideals of their clients, and (3) home visitors need a fine grasp of cultural diversity (e.g., habits, rituals; see Table 6).
Ethical Concerns.
Indication and access to services
In all, 99.2% of the participants agree that they get more information about the family’s context in a home-based setting than in an office setting. (1) Going to the home provides the possibility to gain access to information that might not be obtained if the client was to come to an office-based setting. In all, 98.6% agree that they develop a better understanding of the daily life problems of the family. (2) HV allows the practitioner a better understanding of clients’ daily problems. This also includes a higher opportunity to perceive some risks of child abuse or child neglect in the frame of this setting. (3) Home visits give a higher opportunity to recognize emotional and/or physical abuse/neglect (see Table 7).
Indication and Access to Services.
Disturbances in the treatment process
This section includes considerations related to possible disturbances of the helping process in the home-based setting. These might be external interruptions caused by spontaneous visits from neighbors or the noise of TV, breakups of the help, or the nonadherence to meetings. The participants agree that home-based work is prone to more external interruptions but reject the statement that breakups or nonadherence to meetings are more frequent in this setting. (1) Home visits are more prone to distractions (phone calls, visitors, etc.). (2) Practitioners in home visits are more often faced with client cancellations than practitioners in office-based settings. (3) As compared to office-based practitioners, home visitors are faced with more client no-shows (see Table 8).
Disturbances in the Treatment Process.
Treatment acceptance
We had the hypothesis that home-based work facilitates a clearer understanding of the aims, a better comprehension of the sustainability of the interventions, and a better participation for the clients. The study results allow the conclusion that, in the view of the practitioners, home visits have more potential to produce a sustainable development for the clients, especially, because they are more involved in defining goals and have more influence in creating the process. Table 9 shows the results of the three following statements: (1) Home visits allow the practitioner and the client to arrive at a clearer understanding of the goals of the aid than in office settings, (2) change that takes place in the clients’ home has greater longevity than in other settings, and (3) during home visits, clients have a higher chance of influencing the process.
Treatment Acceptance.
Home-based client profile
We had the idea of a typical client profile as regards background, means of subsistence, family connections, and access to services. We are unable to substantiate such a profile based on the statements of the professionals. We only found that the professionals mostly perceive their clients as German people who collect social welfare, are single parents or live in patchwork families.
Results Qualitative Data: Group Interview
The group interviews were analyzed by different qualitative methods. In the context of this article, we only describe some main results, which we deduced from the qualitative material and which completes our results from the quantitative material.
We extracted three points from the material, which could be useful and relevant when reflecting on home-based work. These points of view can be called the “helpers’ view,” the “clients’ vew,” and the “setting view.” Depending on the particular point of view, the different main topics appear in a different light. As the main topics, we found out boundaries, disturbances, ethical concerns, intimacy, and safety.
In more concrete terms, that means the following: safety issues, for example, reflected from the helpers’ view are related to their individual and biographical experience with dangerous and/or uncontrolled situations, to their personality, or to their specific personal traits. Safety issues from the clients’ view depend, for example, on previous experience with helpers and their decent or maybe intrusive behavior and safety issues; from the setting view are some objective conditions like a snapping dog or the client’s possession of a gun. It is also possible to reflect several relevant topics from one point of view—in a special training for home-based work, it would be useful to focus on the setting view; in a personal coaching situation, it makes sense to concentrate on the helpers’ view; and in a casual supervision, it might be useful to focus more on the clients’ view. At the center of the different perspectives is the helper–client relationship, which has to be continuously reflected upon. To visualize these results, we use Figure 1.
Model of results.
This model focuses on relevant aspects of reflection due to HV work and offers a chance for professionals to unfold a reflexive practice as Schön (1983) already described it in his book The Reflective Practitioner. It describes how the helping processes have to be considered and how this thinking should affect the actions in the helping process. This would have to lead to a new perspective and be reflected upon again, and these considerations would also have to have an impact on the further course of action. From our point of view, this continuous reflection seems necessary for developing a client-centered helping process. Furthermore, it could support the home visitor to pay more attention on self-care.
In Figure 1, the middle shows the relationship between the helpers and clients (HBZ: abbreviation of “Hilfebeziehung,” which is the German for “Professional Relationship”). The three white ellipses represent the three views: the helpers’ view, the clients’ view, and the setting view. The five different circles demonstrate the five topics: boundaries, disturbances, ethical concerns, intimacy, and safety. The mirror represents the reflection of the views, topics, and relationship.
Discussion
Despite numerous described limitations, this study shows some interesting results regarding relevant components of home-based and family-related work from the point of view of the professionals. We used quantitative and qualitative methods to gain some knowledge about the perspectives and attitudes of professionals who work in this setting. Although we have collected more data from the social worker profession than from the other professions, it is the only transdisciplinary study known to us to date in the field of HV. Most of the professionals have long professional experience and a further qualification in counseling or therapy, but almost none of them are specially trained in HV methods. The asked professionals show interest relating to specialized training, which focus on home-based work but not regarding a further study degree. They think that the work at home is a good base for establishing a professional and confidential relationship. The professionals questioned attribute more sustainability and more participation of the clients to home-based interventions compared with other forms of help. The practitioners have the impression that the home-based work supports gaining more information about risk situations like child abuse or child neglect. That seems to be a clear advantage of home-based work. Safety issues seem to be a more unconscious and suppressed topic for the German home visitors. This is in contrast to several American studies (Lyter & Abbott, 2007) where safety is a huge topic, and the risk for the helpers in a home-based setting is much higher compared to other forms of work.
For us, however, the most interesting and important point of our study is the need for continuous reflection under the different perspectives. Home visitors are forced to reflect consistently the setting and context their clients live in. With focus on the private boundaries of the clients, the social workers have to be extra sensitive but still have to keep their mission or mandated case with the goals in mind. The paradox of help and control could be faced constructive with different strategies, which deal with the reflection of the described three views called the helpers’ view, the clients’ view, and the setting view. In addition to this, social workers should continuously reflect their moral ethics and standards and focus on the professional relationship (Ruch, 2016) to achieve a positive help outcome. The essential of the developmental model of reflection due to the three levels is the professional relationship. Reflection about how to get related with clients and how to positive confuse them to expand their perceptions and open them for new or unused potentials is an important duty.
Limitations
This study has several limitations which almost all refer to the quantitative part of the study. First, we do not know the number of the professionals who figured in our target group. Hence, we cannot judge how high the level of participation of the professionals really was. Another difficulty is the different participation of the professional groups in answering the questionnaire. In all, 62.1% social workers participated, but only 9.7% were general practitioners, 8.2% pedagogues, 5.7% educators, 3.5% midwives, 2.4% psychologists, and 8.2% none specified professionals. The distribution of the professional groups is not proportional to the actual representation of the professionals but rather reflects the heterogeneous accessibility to the questionnaire. Probably, there was a different motivation to complete the questionnaire too. Second relating to our qualitative research, we were able to collect data from different professional groups (psychologists, social worker, midwives), but we could not collect data from a mixed professional group, and the perceptions of general practitioners are completely missing. In terms of a transdisciplinary concept, especially the interpretation of our quantitative results is little limited too; we collected more data from the social workers than from the other professional groups. In addition, we had open access to the questionnaire and no way of controlling who completed the questionnaire or if anybody completed it twice.
Conclusion
The results of our study are mainly congruent with recent research (Gerull, 2014; Ness et al., 2012), but further future research may explore the view of the clients more systematically. HV work is a promising concept but implicits also the risk of harming the intimacy of clients. That means a high challenge for the professionals. On the one hand, they have to establish a steady relationship to their clients; on the other hand, they have to pay attention on their potentially intrusive role. Therefore, the HV setting needs further research for identifying reasons if home-based interventions are indicated or not. From the point of view of the professionals, HV work seems to be a good chance to gain a better inside view in the daily life of their clients. We suppose that from the point of view of clients, home-based interventions must reveal a strong supportive effect to justify such intrusion into their homes. Furthermore, it would be very interesting and promising to gain a deeper insight in matching factors regarding the relationship between helper and client. Especially, in Germany, a deeper discourse about safety and self-care issues for this type of professionals is urgently necessary because the danger of burnout in this professional field is rather high (Cortes, 2004, p. 186). Finally, we would like to highlight the significance of the necessary development of professionalization. Due to HV work, it makes a lot of sense to reflect the own impressions of the family, the memory of the scene, and the interactions between the clients and the professional by supervision. In the context of family’s home, psychosocial support usually is much more confusing and complicated, than in an office setting because of the variety of possible disturbances, for example, running TV, ringing by neighbors, and so on (Lüngen et al., 2016; Lüngen et al., 2014). Respecting to these aspects, home visitors should continuously reflect their moral ethics and standards (Müller, 2010) and focus the professional relationship (Ruch, 2016) because the understanding of hidden topics and dynamics is very challenging and so a strong reflection on one’s own action is required.
The development of specialized training for professionals who are working in this area will need further investigation. Maybe our extracted different points of view and the collected main topics could be a useful base for such special training.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research and/or authorship of this article: Forschungsfond Mecklenburg-Vorpommern.
