CHAPTER-6

NURSING PROCESS IN THE

CARE OF THE COMMUNITY
• Community and Public Health Nurse
• Aims to improve the health status of the community in general.
• Undertaken utilizing the nursing process in cyclical scheme.
• Community
• Not only setting or the context but it is the focus of nursing care (Nies and McEwen,
2011)
• “groups of people that may or may not be spatially connected, but who share
common interests, concerns or identities”. (WHO)
• Has common interest or characteristics
• Interacts with one another
• Has sense of unity and belonging
• How about according to Clark (2008)
• Dimensions:
• aggregate of people,
• Location in space, time
• social system
• Community
• Dimensions:
• aggregate of people,
• Location in space, time
• social system
 PRINCIPLES OF COMMUNITY AND PUBLIC
HEALTH NURSING (ANA, 2007)
1. Focus on the community as the unit of care
2. Give priority to community needs
3. Work with the community as an equal partner of the health team
4. In selecting appropriate activities, focus on primary prevention
5. Promote a healthful physical and psychosocial environment
6. Reach out to all who may benefit from a specific service
7. Promote optimum use of resources
8. Collaborate with others working in the community
 CONDITIONS IN THE COMMUNITY
AFFECTING HEALTH
• People
• Size
• Density
• Composition
• Rate of growth/decline
• Cultural characterisitics
• Mobility
• Social class
• Educational level
 CONDITIONS IN THE COMMUNITY
AFFECTING HEALTH
• Location
• Natural and man-made variables
• Rural or urban
• Geographic features
• Climate
• Flora and fauna
• Presence of open spaces
• Location of facilities
• Quality of soil, air and water
 CONDITIONS IN THE COMMUNITY
AFFECTING HEALTH
• Social System
• Family
• Economic
• Educational
• Communication
• Political
• Legal
• Religious
• Recreational
• Health systems
 CHARACTERISTICS OF A HEALTHY
COMMUNITY
• All its body parts contributes to its well-being as to carry out their specific functions
• All system of a community need to function effectively and work together to maintain
the health of the community
• All citizens has a descent way of life in all aspects
• Characteristics of a health community(6)
• Shares sense of being a community
• Empowerment and control
• Participate in decision making
• Coping ability
• Communication
• Equitable and efficient use of community resources
CHARACTERISTICS OF A HEALTHY
COMMUNITY
 ASSESSING COMMUNITY HEALTH

• Essential process for understanding the community, identifying its needs or

weakness, and assets or strengths that is useful to achieve healthy communities.
• Other definitions?
 ASSESSING COMMUNITY HEALTH

• The data that need to be collected

depend on the objectives of the
community assessment. In general,
the nurse needs to collect data on
the three features of a community:
• People
• Place
• Social System
 PLANNED APPROACH TO COMMUNITY
HEALTH(PATCH)
• It was designed to provide a model to assist state and local public
health agencies, in their partnership with local communities, to plan,
conduct, and evaluate health promotion and disease prevention
programs.
• 5 Elements Critical to PATCH
• Community member participation
• Data-based program development
• Collaborative development of a comprehensive health promotion strategy
• Evaluation for feedback and improvement
• Enhancement of community capacity for health promotion
 PLANNED APPROACH TO COMMUNITY
HEALTH(PATCH)
• It was designed to provide a model to assist state and local public
health agencies, in their partnership with local communities, to plan,
conduct, and evaluate health promotion and disease prevention
programs.
• 5 phases
• Mobilizing the community
• Collecting and organizing data
• Choosing health priorities
• Developing a comprehensive intervention plan
• Evaluation
 PLANNED APPROACH TO COMMUNITY
HEALTH(PATCH)
• Successful implementation depends upon actively engaging
community members in the process, having adequate time and
resources to gather and interpret data to guide program
development, and developing cohesion among stakeholder
organization.
• It has been applied in a wide variety of settings, including
hospitals, managed care organization, universities, and other
agencies.
 PLANNED APPROACH TO COMMUNITY
HEALTH(PATCH)
• Box 6.1: Data Collected for the PATCH Process for Health
Planning
• Community profile: demographic, educational, and economic data
• Morbidity and mortality data, including unique health events
• Behavioral data focusing on behavioral risk factors
• Opinion data from community leaders
APPROACHES IN COMMUNITY ASSESSMENT
• COMPREHENSIVE NEEDS ASSESSMENT
• Gathers information about the entire community using a systematic process, all aspect of
the community to identify actual and potential health problems.
• Useful health assessment of a community (First Time)
• Periodic assessment and evaluation of health may also require

• PROBLEM-ORIENTED ASSESSMENT
• Focused on a particular aspect of health
• Collects information with a certain community problem in mind, and then proceeds to
gather information
• Workable when the nurse is familiar with the community and comprehensive assessment
has been done previously.
 TOOLS FOR COMMUNITY ASSESSMENT

• Primary • Secondary (Taken from

• Observation existing data sources)
• Survey • Vital registries

• Informant interview • Health records and reports

• Community forum • Disease registries

• Census data
• Focus group discussion
METHODS TO PRESENT COMMUNITY DATA
8 STEPS TO COMMUNITY HEALTH NEEDS
ASSESSMENT
1. Identify and engage
stakeholders
2. Define the community
3. Collect and analyze data
4. Select priority community
health issues
5. Document and communicate
6. Plan improvement strategies
7. Implement improvement plans
8. Evaluate progress
Social Systems

Health Care

Religion
Social Welfare

FAMILIES/
PEOPLE/
Education
Commerce Communication

Government
Transportation

Recreation
10 sub systems
• COMPARE County-State-National Statistics

Demographics?
Education level?
Income?
Health Statistics? PEOPLE/FAMILIES
Occupations?
Marital status?
Risk factors?
 • Percentages in age categories—establish
these logically for priority setting
purposes
• Percentage in gender categories—priority
PEOPLE OF setting
THE • Education (College, HS, Elementary
COMMUNITY School—literacy?)
• Socioeconomic Status (SES)
• Race/ethnicity
• Occupations
• Changes since last census = stability of the
community
 COMMUNITY
PARTNERSHIPS
Include a mix of community stakeholders
and professional disciplines
 • Birth rates
• Death rates
• Leading causes of
HEALTH morbidity/mortality
STATUS • Abortion rates
INDICATORS • Risk Profiles
• National Center for Health
Statistics www.cdc.gov
• Compare several years for trend
analysis
COMMUNITY OPINION SURVEY
• Ask the people in your
community what they think
their health problems
are—choose key
informants
• Who would you talk to in
your community?
 Health Care Resources
Hospitals
HEALTH CARE Clinics
SUBSYSTEM
Pharmacies
Emergency
Home Health
Other
Public (any tax supported agency),
Private for profit, not for profit
 • State Legislators
• Federal Legislators

GOVERNMENT • County Government

• Responsibility of county
government

• Local Government
• Responsibility of local government
 • History of Community helps to explain
where they are now
• Museums, Ballet, Symphony, Theaters
• Public Libraries
• Clubs/Organizations
SOCIAL WELFARE • Sanitation
• Safety……Fire ……Police……Judicial
• EMS, Food Programs, Protective services
• Relationship of agencies
 • Child Care
• Kindergartens-pre K-Head Start
• After school programs
• Elementary Schools
EDUCATION • Middle Schools
• High Schools
• Junior Colleges
• Colleges/Universities
• Quality of Schools—Outcomes
• Problems?
 RECREATION
• Parks/Recreation Centers/Walking
• trails
• Entertainment
• Clubs ( i.e. Boys and Girls)
• Sports
• Annual community events (parades,
picnics, fairs, festivals
TRANSPORTATION
• Are there major highways/interstates which
make the community accessible?
• How do people travel within the community?
• Does the cost of transportation affect the
community?
• Public Transportation?
• Walking/Biking trails
• Safety Concerns?
 COMMUNICATION

Newspapers
Radio and Television
Post Office
Telephones/Cell
Computer access
High Speed internet?
 RELIGION
• Number of Churches/Houses
of Faith
• Types/Denominations
• Outreach activities
• Are there health-related, faith-
sponsored programs?
• Are there support groups?
 COMMERCE
• Stores/Shops
• Grocery Stores
• Restaurants
• Department Stores
• Banks
• Gas Stations
• Manufacturing
• Other Business
 COMMUNITY DIAGNOSIS

• Is the process of determining the health status of the community and

the factors responsible to it.
• Allows identification of problems and areas of improvement, thereby
stimulating action (WHO, 1994).
• In this phase, health worker makes a judgement about the community’s
health status, resources, and health action potential or the likelihood
that the community will act to meet health needs or resolve health
problems.
 COMMUNITY DIAGNOSIS
• NANDA
• Focused more on individual health conditions
• Shuster and Geoppinger (2004)
• Focus on population groups
• Consist for 3 statements
1. Health risk
2. Specific community
3. Related factors (Box 6.3)
• Omaha System
• Designed for clients in a community setting
• Framework for the care of individuals, families, communities
 COMMUNITY DIAGNOSIS
• Omaha System
• Developed by the VNA of Ohama, Nebraska
• Community focused documentation system
• 3 components to use
1. Problem classification scheme (4 levels)
2. Intervention scheme
3. Problem rating scale for outcomes
 COMMUNITY DIAGNOSIS
• Omaha System
• 3 components to use
1. Problem classification scheme (4 levels)
a. General level of classification
➢environmental
➢Psychosocial
➢Physiological
➢Health related behaviors
b. Problems or area of concern
c. Classified into qualifiers
d. Cluster of signs and symptoms
 COMMUNITY DIAGNOSIS
• SOCIAL DIAGNOSIS
• Represents the impact of the health problem in terms of the
overall quality of life of the people in the community.
• Examples of indicators of the extent of social problems
present in the community or a population.
• It is described as:
• Prevalence of the problem
• Population affected by the problem
• Prognosis of the problem
• Implications
 PLANNING COMMUNITY HEALTH
INTERVENTION
• Community health interventions is based on findings during assessment and
formulated nursing diagnoses.
• Logical process-making decision-determine-identified health concerns
require more immediate consideration and actions to achieve goals and
objectives.
• Priority setting, formulating G&O, and identifying community interventions.
• Require active participation of people and involvement in all stages of
planning and intervention.
 PLANNING COMMUNITY HEALTH
INTERVENTION
• Priority Setting
• WHO suggested criteria to decide on a community health concern for
intervention.
1. Significance of the problem
2. Community awareness
3. Ability to reduce risk
4. Cost of reducing risk
5. Ability to identify target population
6. Availability of resources
• Joint effort is required for a realistic and useful outcome.
 PLANNING COMMUNITY HEALTH
INTERVENTION
• Priority Setting
• The group makes a list of the identified community health problems
or a conditions.
• Shuster and Geoppinger (2004) suggested the following steps
a. Scale of 1 to 10 (degree of importance in solving problem)
b. Scale of 1 to 10 (likelihood of the group being able to influence or change
the situation
c. Collate the weights (table 6.1 and 6.2)
d. Priority score of the problem is calculated by adding the products obtained
(table 6.3)
 PLANNING COMMUNITY HEALTH
INTERVENTION

•Formulating goals and objectives

• What’s the purpose?
• SMART
• Box 6.5
DECIDING ON COMMUNITY INTERVENTIONS
• “what may work for one community may not be effective in
another.”

• The group analyses the reasons for people’s health behavior and
directs for strategies to respond to the underlying causes.

In the process of developing the plan, the group takes into

consideration the demographic, psychological, social, cultural and
economic characteristics of the target population.
 PLANNING MODELS IN THE COMMUNITY

• PRECEDE-PROCEED
 PLANNING MODELS IN THE COMMUNITY
• Planning Approach to Community Health (PATCH)
• Essential element-Community Participation
 PLANNING MODELS IN THE COMMUNITY
• Assessment Protocol for Excellence in Public Health
(APEX-PH)
• provides local communities with a means of increasing
their organizational capacity and strengthening their
leadership role in their communities. Through a three-part
process, local health departments (LHD) assess internal
capacity, identify priority community health issues, and
develop action plans.
 PLANNING MODELS IN THE COMMUNITY
• Assessment Protocol for Excellence in Public Health
(APEX-PH)
• The benefits of APEXPH include increased understanding
of the community’s actual and perceived health problems;
strengthened relationships with government and
community partners; and community recognition of the
LHD as having a major role in ensuring the public’s health.
 PLANNING MODELS IN THE COMMUNITY
• MAPP Model
 PLANNING MODELS IN THE COMMUNITY
• MAPP Model
• is a community-wide strategic planning process for
improving community health and strengthening local
public health systems.
• Facilitated by public health leadership, MAPP provides a
framework that helps communities prioritize public health
issues; identify resources for addressing them; and
develop and implement community health improvement
plans.
 PLANNING MODELS IN THE COMMUNITY
• MAPP Model
• The result of MAPP is not a strategic plan for the LHD,
rather MAPP results in a strategic plan for the entire
community whereby local public health system partners,
collectively, address priority areas.
 PLANNING MODELS IN THE COMMUNITY
• MAPP Model
• The benefits of MAPP include increased visibility of
public health within communities; more public health
advocacy and prioritization in local governments; better
ability to anticipate and manage change; stronger public
health infrastructure; stronger public health partnerships;
more engaged communities, and stronger leadership
roles for LHDs within communities.
 PLANNING STRATEGIES FOR COMMUNITY
HEALTH INTERVENTIONS

• Overall goal?
• 5 steps strategy to planning
• Determine where you are
• Identify what is important
• Define what you must achieve
• Determine who is accountable
• Review
IMPLEMENTING COMMUNITY HEALTH
INTERVENTIONS
 EVALUATION
• Structure Evaluation
• Process Evaluation
• Outcome Evaluation

• Ongoing evaluation or monitoring is done during implementation to

provide feedback on compliance to the plan as well as on need for
changes in the plan to improve the process and outcomes of
interventions.
 STANDARDS OF EVALUATION
• Good evaluation is based on:
• Utility
• Feasibility
• Propriety
• Accuracy