Table 3.
Description of Case 3: Ladonna
| NHC process flow | Client response |
|---|---|
| Background | Ladonna is separated from her spouse, disabled with mobility problems, and walker dependent. She reported an income <$1,000 a month and has not worked for more than a decade. She is on Medicare/Medicaid for disability and receives SNAP support. She is dependent on public transportation because she was forced to give up her car owing to her inability to keep up with the loan payments. She lives with a family member and their children in a 2-story house. There is interpersonal family conflict, but she is overwhelmed with the challenges of trying to live independently. |
| Initial goals | Ladonna's goals were to become more independent and move to a less dangerous location into a living situation with less family conflict. In addition, she identified initial goals of eating more nutritious foods, learning meditation, starting chair exercises, and taking better overall care of herself. |
| Level of engagement | Ladonna was very engaged in the program from the start. She could readily identify the benefits of change; she recognized that improving her physical mobility, strength, balance, and stamina was key to accomplishing her goal of moving and living independently. She started making short walks in a safe environment without using her walker. Ladonna was ambivalent about exploring PT support to develop strength and balance. She had had a previous experience where she felt neglected by the physical therapist and attributed that to “getting poorer treatment when you're on Medicaid.” The NHC validated her concerns and supported her autonomy/choice in this decision but also actively worked with her on envisioning the benefits of getting PT from a therapist who was attentive and skilled. This strategy of softening sustain talk (barriers against change) and evoking change talk (motivation for change) to help a client work through ambivalence is an advanced Motivational Interviewing skill.9 Within a short period, Ladonna recognized that the benefits outweighed her concerns, and she worked with the NHC to get a PT referral to a facility known to be accommodating to Medicaid recipients. |
| Deeper meaning and later goals | Ladonna soon revealed that she wanted to move to the same location as another family member who lives in another state; one which was safe and would remove her from the conflict of her current situation. The NHC worked with her to get specific about the details of what it would take to prepare her for the move—financially, physically, and emotionally—essentially helping her to set a SMART goal.10 In addition, through deepening trust built through empathic reflection, Ladonna revealed that she had chronic issues controlling her charitable giving to others in her community, even though she had so little herself. She also recognized that being overweight added to her disability and functional decline. |
| Concluding outcomes | Ladonna became empowered to actively pursue her goals that she knew would improve the quality of her life. She opened a savings account to save money and applied for a job that would allow her to save $600/month. The NHC supported her in starting psychotherapy through a subsidized, virtual program to better understand her continued impulse to give money to charity when she had so little to meet her own needs. Not only had she recognized that she was having trouble controlling this chronic behavior, but she also committed to addressing the issue head-on by getting help. She started eating more fruits and vegetables and started eating more fish rather than beef. She preferred not to focus on weight but did notice that her clothes were fitting more loosely and her nails and hair were healthier. She started dedicating more time to her favorite hobby because it assisted her in stress management. She used that time as quiet, alone time to think, setting boundaries with her family and neighbors to protect this valuable activity. |
NHC, nurse health coach; PT, physical therapy; SMART, Specific, Measurable, Achievable, Relevant, and Time-bound; SNAP, Supplemental Nutrition Assistance Program.