Margaret Comerford Freda, Ed.D., RN, FAAN, saw it happen frequently: A pediatric nurse, while tending to a patient, would ask the child’s pregnant mother if she was receiving prenatal care and, if not, would offer to set up an appointment for her. Or a nurse who saw a woman for a respiratory infection would confirm that the patient was up-to-date on her Pap tests.

Nurses intervene every day across the country. It’s part of the job. But it is usually off the record and without recognition.

"Nursing is always involved with the family and always concerned about how the family reacts, how it interacts, what it is all about," Freda said. "We are trained from day one in nursing school to take into account the family and the context. But it is not often that we keep track of that and are able to see the impact. I have no doubt nurses in ambulatory centers all over the U.S. are doing this, but they just aren’t getting credit for it."

Linda Daum, RN, chief nurse executive at McAllen Medical Center in McAllen, Texas, agrees that nurses intervene for patients’ family members all the time.

She has even seen a nurse, who picked up on a family member’s chest pains, rush the individual to the cath lab in time for treatment.

Keeping track
Freda, an associate professor of obstetrics and gynecology at the Albert Einstein College of Medicine at Montefiore Medical Center in Bronx, N.Y., decided to formalize the intervention practice at her facility.

Nurses conducted in-depth interviews with patients, in which they asked about family members, what kind of health care they were receiving, and encouraged appointments for those who needed them. The numbers were surprising, even to Freda.

"I had hoped we would perhaps get one visit for each patient that we interviewed. We interviewed 50 patients and had 158 appointments." That number includes only appointments made and kept, not emergency department visits.

Maude Joseph, MPS, RN, administrative nursing manager in primary care medicine at Montefiore’s family care center, helped Freda confirm the numbers. "We knew there were family members at home getting no care," she said. "This was making sure they got into the system to get adequate care, and continue that care." Thirty-one percent of family members interviewed had no health care provider.

The interviews and follow-up process weren’t easy, Joseph said. She provided her nurses with direction on interviewing skills and encouraged them throughout the study. "It is really preventive health maintenance––when we see someone in for inoculations, we automatically ask about siblings. But we made an extra concerted effort to document something that we do naturally, and to try and get more families to come in. I really wanted to see a lot of men coming in for checkups."

Trusted caregivers
Some nurses initially thought it intrusive to ask the questions, but changed their minds when they saw how helpful it was and how receptive people were, Joseph said. "You have to think about it from a community health perspective and see people from a holistic point of view."

That approach is standard procedure at the Primary Care Division, City of Austin, Texas, where Connie Hockema, RN, is charge nurse and facilities manager. Mothers who bring in newborns for checkups often reveal their own medical problems. Or a husband accompanies his wife to an appointment, and the woman asks if the nurse can look at a problem he is having.

"More often than not, we’ll address the concern on some level," Hockema said. "Because particularly in the public health environment there are transportation issues and work issues––they don’t get paid if they aren’t at work. We deal with the situation while they are [here]."

"I think every nurse has intervened, but probably not every day," Daum said. "A lot of it [depends on] the individual and the circumstances."

Nurses need to be made aware of the benefits of intervention and be given permission, support and direction from someone who has seen it work, Joseph said. "They have to buy into it, test it. People get used to their routine, they have to branch out a little bit. But teaching is our role. Nurses teach all the time."

She understands that for today’s busy nurse, the thought of adding intervention on top of the day’s work might seem overwhelming. But she asks nurses to set modest goals—maybe just one patient a day.

"The payoff is astronomical. There isn’t a shortage of patients at all, if every community center and hospital started an intervention project and encouraged patients to bring in family members."

It also pays off for the nurses.

"One of the important things about this study was that it really helped the nurses increase their job satisfaction," Freda said. "They know in a very concrete way that they are making a difference."

The study’s results also made the hospital’s administration sit up and take notice. "People came in and some were admitted. That generated revenue," Joseph said. "Everyone benefited." Joseph and Freda are convinced that the intervention approach can be used in many different nursing settings.

"Nurses have an important role in the ambulatory care of patients," Freda said.
"It is not just walking someone back to the room and telling them the doctor will be there."

And she has the numbers to prove it.