Theoretical Basis of

Community Health
Nursing
Berthy adiningsih, s.kep, ners, m.kep
Learning Objectives :

 3 characteristics of nursing service when community as a client : community

oriented, population- focused & relation-based care
 Brief description of 5 models in community nursing practice
 Brief explanation of benefits the 8 principles application in community
nursing practice.
 Identification of contemporer issues that influence community health nursing
 Perbedaan antara teori dan model
 Macam-macam teori dan model
 Kekuatan dan kelemahan teori dan model
Think about it !

 You guys get into a senior nursing home and decide to promote about
cardiovascular or diabetic issues, advocate exercise equipment that suits
them or suggest changes in the on site meal programs. How theories of
nursing contribute to your success ?
 You realize that there are a lot of stuff to do for local health centres
(puskesmas) but we run out of staff. You decide to approach the city council
about the need to increase staffing of public health services. Which model of
community health nursing that might support your argument ?
 Is there any difference between theory and model ?
Community Health Nursing
Characteristics
 First, nursing were and still exists to address people’s health care needs  we
works in various specialty areas.
 Speciality of nursing characterized by the unit of care  each needs
particular area of knowledge and set of skill in practice
 Community health nursing is a specialty that the unit of care is a specific
aggregate and the main responsibility of nurses is promote group health.
 Skill required are epidemiology, research, teaching, community organizing
and interpersonal relational care.
 As mention earlier, it is characterized by community-oriented, population-
focused care & is based on interpersonal relationships.
What is community ?

 A group of people who have some characteristic in common which bounded by

time, interaction, or a feel of connection one to another.
 They might share similar experiences, concerns, certain values and often
influence one another’s behaviours.
 People in a community might recommend food choices, complementary
therapy or the chosen exercise which all of these things may influence their
healthiness.
Community-Oriented

 This is a process that is actively shaped by unique experiences, knowledge,

concerns, values, beliefs and culture of a given community.
 Thus why, when there is an outbreak of a disease, community health nurses
does more than simply treat the individuals infection. Nurses uses disease-
investigation skills to locate possible sources or causes. Also, they determine
about the community knowledge,values, beliefs and prior experiences with
the infection that could influence their interpretation, understanding,
response to the outbreak and treatment preferences. After that nurses use
knowledge and suggestion gathered from the community to develop,
collaborate with other profesionals and plan community specific program to
prevent future outbreak.
What is population ?

 Any group of people who share at least one characteristic, such as age,
gender, race, particular risk factor and/or disease. The concept of population
may also include delineation of time (ex : all children that were born by year
2000)
 Smokers and cancer survivors are two different populations, although they
may share mutual characteristic.
 Nurses limit the population based on population they serve.
 Population focus implies nurses to use all skills required for being community
health nurses as the basis of interventions. Ex : If nurses found that there is a
repetitive cases of population refusing vaccination for the last 5 years, they
need to develop program for reducing cases and lobby all possible stake
holders to adopt the programs.
What is Relationship Based Care ?

 It is incorporate the value of establishing and maintaining a reciprocal, caring

relationship with the community.
 A necessary, important, feasible aspect and a foundational to caring
effectively for the community’s health.
 It is including : listening, participatory dialogue and critical reflection that
may also involve sociopolitical elements of practice (advocacy, community
empowerment and movement action).
 For example : we provide relationship based care when working with parents
of children with special needs, therapists, psychologist and the hospital to
determine the needs of each family and to facilitate the formation of self-
help group.
Theories & Models
Ready ? Set. Go !
What is Nursing Theory ?

 A creative and rigorous structuring of ideas that project a tentative,

purposeful, and systematic view of phenomena.
 Theory refers to a coherent group of general propotions uses as principles of
explanation.
 Nursing theories give a plan of reflection in which to examine a certain
direction in where the plan needs to head. It is also administer a structure for
communicating with other nurses and with other representatives and
members of health team.
 Nurses theories assist the development of nursing in formulating beliefs,
values and goals. They help to define different particular contribution of
nursing with the care of clients. They guide research and practice.
Types of Nursing Theories

 Metatheory : The theory of theory. Identifies specific phenomena thru

abstract concepts.
 Grand Nursing Theories : have the broadest scope and present general
concepts and propotions. At this level, they not designed for empirical testing
but reflect and provide insight useful for practice  directing, explaining and
predicting nursing in particular situations.
 Mid-Range Theories : narrower in scope than the grand ones and offer an
effective bridge between grand nursing theories and practice. They present
concepts and lower level of abstraction and guide theory-based research and
nursing practice strategies. They are more tangible and verifiable through
testing  describe, explain, predict phenomenon  simple, straightforward,
general and consider limited number of variables and limited aspect of
reality.
Continue..

 Nursing Practice Theories : most limited scope and developed for use within
specific range of nursing situations. They provide frameworks for nursing
interventions and predict outcomes and the impact of nursing practice. The
capacity of them are limited and analyze a narrow aspect of a phenomena.
Usually defined to an exact community or discipline.
 Theories’ characterisctics : interrelate concepts to create different way of
looking at a particular phenomenon, logical in nature, generalizable, bases of
hypotheses that can be tested, increase the general body of knowledge within
discipline thru research implemented to validate them, use by practitioners
to guide and improve their practice and are consistent with other validated
theories, laws and principles but will leave open unanswered questions that
need to be investigated.
What is Nursing Models ?

 Usually described as a representation of reality or more simple way of

organizing a complex phenomenon. It is a consolidation of both concepts and
the assumption that combine them into meaningful arrangement.
 A model is a way of presenting a situation in such a way that it shows the
logical terms in order to showcase the structure of the original idea.
 The term nursing model CANNOT be used interchangeably with nursing theory.
Their components

 There are 3 main key components to a nursing model :

1. Statement of goals that the nurses try to achieve
2. Set of believe and values
3. Awareness, skills and knowledge the nurse need to practice

☼ Common concepts of nursing modelling is metaparadigm ( consist of

person/patient, health, environment and nursing)
☼ Each theory is regularly defined and described by nursing theorist. The main
focal point of nursing out of the four various common concepts is the person
(patient).
Nursing Theories and Model in
Community Health Nursing

Conceptual Models Public Health Practice Model

 Nightingale’s Environtment Theory
 Minnesota Wheel – The Public
 Orem’s Self Care Deficit Nursing Theory
Health Intervention Model
 Neuman’s System Model
 Roger’s Theory of Unitary Human Beings  Omaha System
 King’s Theory of Goal Attainment
 Parse’s Human Becoming Theory
 Public Health Nursing Practice
 Pender’s Health Promotion Model
Model
 Roy’s Adaptation Model of Nursing
 Orlando’s Nursing Process Dicipline Theory
 Kocklaba’s Theory of Comfort
 Watson’s Philosophy and Science of Nursing
 Roper-Logan-Tierney’s Model for Nursing Based on Model
of Living
 Salmon’s Construct for Public Health Nursing
 Mencer’s Maternal Role Attainment Theory
Their objectives in nursing practice

 Aid nurses to understanding the rationale behind community-oriented care.

 Florence Nightingale’s environmental theory emphasizes the importance of
improving environmental conditions to promote health
 Orem’s self care model provides framework within which the publich health
nurse can promote a community’s collective independence and self-care
ability
 Neuman’s health care system model describes the nurses’ role as one of
assisting clients to remain stable within their environment
 Roger’s model of science of unitary man focuses on client-environment
interaction and holistic health
Continue…

 King’s theory of Goal Attainment reminds nurses to work in partnership with

clients to achieve the best health outcomes
 Parse’s Human Becoming Theory posits qualily of life from each person’s own
perspective as the goal of nursing practice
 Pender’s model focuses on the promotion of health behaviour in people (the
goal of nursing is to enhance the likelihood that people will engage in health
promoting behaviours by assessing and influencing perceptual and modifying
factors.
 Roy’s adaptation model describes the nurse’s goal as one that promote
healthful coping mechanism and adaptive responses to stressors.
 Salmon’s construct for public health nursing prescribe education, engineering
and enforcement with individuals, families, communitied and nations.
Continue…

 Minnesota wheel intervention model, Los Angeles County-Public Health

Nursing Practice Model and The Omaha system model of Problem Solving
Process  provide a mechanism for public health nurses to assess, plan,
intervene and evaluate the care they provide in their communities.
Theory & Model that focused on
individuals of a family :

Nies & Mc.Evan.(2015) dan Standhope &

Lancaster (2016):
a. Self-Care (Orem)
b. Health Belief Model (HBM)
c. Adaptasi (Roy’s)
Orem Theory Framework

Self-care
+
Self-care demand Self-care agency
- Universal
- Developmental
- Deviasi Kes

Self-care defisit
Total
Parsial
Supportive-educative
Continue..

 3 Tipe Kebutuhan Self-Care :

 Universal : umum utk semua manusia, aktifitas Self-Care yg penting utk
memenuhi kebutuhan fisiologis dan psikologis
 Developmental : aktifitas penting utk membantu seseorang utk kemajuan
perkembangan
 Deviasi kesehatan : aktifitas yg dibutuhkan utk membantu seseorang
mengatasi kemunduran tingkat sehat (wellness)
Continue…

 Berbuat sesuatu (direct care)

 Mengajarkan
 Membimbing
 Mengarahkan
 Menciptakan lingkungan yang menunjang kesehatan & tumbuh kembang
SELF CARE DEFISIT (OREM)
Society mandates
existence & condition

Person - environment Nursing

- Human services
self care requisite
- Deliberate action
- Pract. disiplin
Universal
Developmental
Health defisit Researcher
Educator
Practitioner
SC demand SC defisit

Self Care agency Nursing agency

Nursing system
Self Care defisit Supportive educative
Partially compensatory
Wholly compensatory
Therapeutic Self Care
APLIKASI SC OREM
Pengaruh Lingkungan
- Budaya
- Industri
-Sosek
- Pendidikan

Kebutuhan
- Universal
- Developmental
- Deviasi kesehatan
Keb SC Kemampuan SC

Kemampuan individu, keluarga, komunitas

Kebutuhan Selfcare rendah

Kemampuan Selfcare kurang

Bantuan SC
Example

 The increase of street juvenile/punkers may lead to habits of tattoo, free sex,
drugs or eat from the same plates.
 Community Health Nurses have skills to recognize dangers or risk related of those
behaviours that not only endanger themselves but also the environment.
 What nurses need to do :
1. Membantu Anak jalan menyadari risiko dan identifikasi masalah yang risiko dan
aktual dialami anak jalanan
2. Mengidentifikasi kebutuhan untuk perubahan perilaku anak jalanan
3. Melakukan skrining kesehatan (HIV/AIDS, NAPZA, penyakit kelamin) dan melakukan
bila perlu melakukan rujukan ke pusat pelayanan kesehatan untuk anak jalanan yang
aktual mengalami masalah.
4.Memberikan asuhan keperawatan individu sesuai masalah yg ditemukan dengan
melibatkan keluarga
Description of Practicing Orem Theory
 Faktor-faktor Kemungkinan
Persepsi Modifikasi
Individu Aksi
-Variabel Demografi: usia,
jenis kelamin, suku, ras, dll Persepsi thd keuntungan
Health -Variabel Psikososial: Kegiatan prevensi
Belief kepribadian, tk sosial, peer
dan pressure group, dll
-
Persepsi hambatan
Model -Variable Struktural: penge- Kegiatan prevensi
tahuan ttg penyakit, saat
terakhir kontak dgn peny, dll
- Persepsi
Kelemahan
akibat penyakit X Kemungkinan melakukan
-Persepsi Persepsi ancaman thd upaya prevensi
serius/parah- penyakit Kesehatan yg
nya suatu Direkomendasikan.
Isyarat thd ancaman:
penyakit
-Kampanye mass media,
-Saran orang lain, kartuperingatan
dokter/drg
-Peny. Anggota klg/ teman
-Artikel surat kabar/majalah
27
Continue..

 Persepsi individu thd kelemahan penyakit dan seriusnya penyakit  persepsi

thd ancaman penyakit
 Faktor pemodifikasi dan Isyarat thd ancaman  persepsi thd ancaman
penyakit
 Selisih persepsi thd keuntungan
 kegiatan prevensi dan persepsi hambatan
 Kegiatan prevensi  Kemungkinan melakukan upaya prevensi kesehatan yg
 direkomendasikan dan persepsi thd ancaman penyakit
Kerangka Konsep Teori Roy

Stimulus: Koping proses Hasil

Focal Regulator Adaptif
Kontekstual

Residual Kognator Maladaptif

Model Adaptasi:
1. Fisiologis
2. Konsep diri
3. Fungsi peran
4. Interdependensi
29
ROY’S …

 Dua proses respons thd stresor : regulator & kognator  Proses

regulator menerima stimulus dari lingkungan internal dan eksternal,
proses merupakan kombinasi informasi utk menghasilkan respons.

 Contoh: Keinginan masyarakat (komunitas) adalah melindungi remaja

dari merokok (stimulus Focal) dan kebijakan kota melarang menjual
produksi tembakau thd generasi muda (stimulus kontektual) serta
riwayat penyakit kanker paru pada perokok (stimulus residual).

30
Roy’s ...

☼ Timbul larangan generasi muda membeli rokok (mekanisme koping), melalui

model:
- konsep diri (harga diri, gambaran diri)
- fungsi peran (melibatkan remaja dengan kegiatan produktif, misalnya Karang
taruna, PKPR).
☼ Hasilnya rendahnya persentase merokok pada populasi tersebut (hasil-
adaptif koping).

Proses kognator meliputi persepsi, belajar, keputusan dan emosi

apabila memformulasikan respons thd stimulus
Theory & Model that focused on
population/community :

a. Community as Partner (turunan dari teori Betty Neuman)

b. The Intervention Wheel Model
c. Integrative model for holistic community health nursing
d. Betty Newman
e. Transcultural nursing

32
Community as Partner

 Ada 2 komponen utama yaitu roda pengkajian komunitas dan proses keperawatan
 Roda pengkajian komunitas terdiri dari : inti komunitas (community core),
subsistem komunitas (the community subsystems), dan persepsi.
 Model ini berfokus pada community health care yang berupa praktek, keilmuan
dan metodenya melibatkan masyarakat untuk berpartisipasi penuh dalam upaya
peningkatan kesehatannya.
 Core : demografi, statistic vital (sekunder ttg morbidity & mortality rate),
karakteristik penduduk (fisik, psikologis, sosial dan perilaku)
 Sub system : physical environment, health system, economy, safety &
transportation, policy & governance, communication, education, recreation
 Perception : bagaimana persepsi masyarakat dan keluarga terhadap suatu
penyakit/kondisi kesehatan dilingkungannya dan yang melatarbelakanginya
Continue…

 Core : demografi, statistic vital (sekunder ttg morbidity & mortality

rate), karakteristik penduduk (fisik, psikologis, sosial dan perilaku)
 Sub system : physical environment, health system, economy, safety &
transportation, policy & governance, communication, education,
recreation
 Perception : bagaimana persepsi masyarakat dan keluarga terhadap
suatu penyakit/kondisi kesehatan dilingkungannya dan yang
melatarbelakanginya
Continue…
Lingkungan: Bio-Psiko-
Sosio-Kul-Spiritual
1 s.d 8  elemen-elemen
yg mem-pengaruhi kom
8 5
Core : kumpulan agregat
2 3 (individu,keluarga,
1
klp/kom) di suatu
Core: 4 wilayah :
Kom
6 Entry point : Individu,
7
Keluarga, kelompok /masyarakat

Teori DIAGNOSIS Kenyataan

Prevensi Prevensi
PERENCANAAN
primer tersier
Prevensi
sekunder

IMPLEMENTASI

j.Sahar
EVALUASI 35
Wheel Intervention Model
Integrative Model
Betty Neuman – Health Care System Model
Continue..

 Keperawatan bersifat kompleks dan komprehensif  perlu struktur

yang luas dan fleksibel
 Sistem Neuman memungkinkan perawat untuk berfokus pada kluen
dan lingkungan sekitarnya dengan kreatif dan interaktif
 Klien sebagai system terdiri dari 5 sub system : biopsikososiokultural
 system klen mencakup individu, keluarga, kelompok dan
masyarakat (komunitas)
Continue…

 Sistem klien adalah suatu concentric rings yang terdiri dari 3 garis
pertahanan :
1. Fleksibel  pertukaran energy dengan lingkungan
2. Normal  level sehat dari system klien
3. Resisten  factor-factor yang mendukung garis-garis pertahanan dan
proteksi struktur dasar system klien.
 Tujuan utama keperawatan disini : mempertahankan system klien
dalam keadaan stabil melalui pengkajian yang actual, potensial
stressor, dilanjutkan dengan melakukan intervensi yang tepat
  Prevensi Primer : memperkuat
garis pertahanan dengan menekan
factor resiko dan mencegah stres
 Prevensi Sekunder : dimulai
setelah timbul tanda dan gejala,
agar dapat memperkuat garis
Intervensi yang Tepat pertahanan normal melalui tujuan
dan intervensi relevan

Lingkungan :  Prevensi Tersier : dilakukan

- Internal : Emosi, perasaan,
setelah terapi, memobilisasi klien
persepsi untuk mencegah penyulit lebih
- Eksternal : keadaan alam,
lanjut
lingkungan

Kesehatan :
- Keseimbangan dan kestabilan
ke-5 factor tersebut
- Parameter : normal line defense
Transcultural Model
ASUMSI DASAR
 MANUSIA
- Memiliki kemampuan untuk memenuhi
 Keperawatan dengan fokus
pada analisis kultural pada kebutuhan, kesehatan & kelangsungan
pelaksanaan asuhan
hidup
keperawatan.
- Mampu memberikan asuhan dengan
 Keyakinan, kepercayaan,
nilai-nilai budaya yang berbagai budaya, kebutuhan & keadaan
berkenaan dengan sehat
 SEHAT
sakit menjadi dasar dalam
proses asuhan - Keadaan sehat secara budaya (mampu
keperawatan
melakukan peran & aktivitas sesuai budaya)
 LINGKUNGAN
- Budaya yang dianut
- Fokus: pola tindakan, pikiran & keputusan sesuai keyakinan, nilai-
nilai dan norma yang dianut
 KEPERAWATAN
- Profesi yang melibatkan kultur dalam
proses asuhan keperawatan
 Culture Care World view

Cultural & Social Structure Dimensions

Sunrise Model Cultural Political
Kinship & value & & Legal
sosial factor Lifeways factor
Religion & Environmental context
Philosophical Language & Ethnohistory Economic
factor factor
Influence
Care expression
Technological Pattern & practice
Educatinal
factor factor
Holistic Health (Well being)

Individual,, Family, Group, Community

in Diverse Health System

Generic
or folk Nursing Profesional
system care system

Nursing Care Decisions & Action

Culture care preservation/Maintenance
Culture care accommodation/negotiation
Culture care re-patterning/restructuring

Culture Congruent Nursing care

Konsep dalam Transkultural Model
 Care
Fenomena yang berhubungan dengan bantuan, dukungan atau kemampuan untuk mencapai kebutuhan,
mengembangkan potensi.
 Caring
Tindakan yang bertujuan untuk membantu, mendukung pemenuhan kebutuhan dan pencapaian potensi
 World view
Bagaimana manusia memandang dunia atau kehidupannya.
 Sosial structure
Melibatkan faktor-faktor struktur dan organisasional yang dinamis pada budaya masyarakat & bagaimana
faktor-faktor ini berfungsi dalam memberikan arti terhadap struktur sosial (agama, kekeluargaan, politik,
ekonomi, pendidikan, teknologi, nilai & gaya hidup)
 Culture
Cara belajar, berbagai, pertukaran nilai, keyakinan, norma, cara hidup yang mengarahkan cara berfikir,
mengambil keputusan, bertindak, cara berbicara.
 Culture care
Pengetahuan kognitif tentang nilai, kepercayaan dan pola ekspresi yang membantu, mendukung kemampuan
untuk mempertahankan keadaan/ mengembangkan potensi.
Continue…
 Cultural value
Tujuan atau cara yang digunakan untuk berperilaku sesuai budaya
 Culture care diversity
Keragaman pola, nilai atau simbol budaya yang dapat mempengaruhi kesehatan
 Culture care universality
Keseragaman pola, nilai atau simbol budaya yang mempengaruhi kesehatan
 Ethnocentric
Kepercayaan bahwa ide, keyakinan dan tindakan seseorang lebih baik dari budaya lain.
 Culture care preservation
Bantuan atau fasilitas yang didasarkan pada budaya untuk membantu mempertahankan kesehatan
dan cara hidupnya.
 Culture care acomodation
Bantuan atau fasilitas yang didasarkan pada budaya untuk beradaptasi atau negosiasi
 Culture Care Re-patterning
Rekonstruksi atau pola untuk membantu klien mengubah kesehatan atau pola hidupnya.
8 Principles of Public Health Nursing

☼ Principles may defined variably as a rule of conduct or an underlying aptitude

or ability (Meriam-Webster, 2012). ANA (2007) identified 8 principles for public
health nursing practice :
 Focus on community
 Give priority to community needs
 Work in partnership with the people
 Focus on primary prevention
 Promote a Healthful Environment
 Target All Who Might Benefit
 Promote Optimum Allocation of Resources
 Collaborate with Others in The Community
Why some of theories are
unpracticable ?
 Theories, in any diciplines, not only in nursing are set naturally in their ideal
level  practicable in a perfect situation (no specific limits, lacks of
resources and/or practical problem)
 Unevitable to seem unrealistic or unpracticable to fit the reality
 Theories are important to remain ideal and challenge the practitioners and
profesionals to recognize where the barriers lie and how they overcome.
 This will vary depending on the type of theory (grand theory, systems level or
interpersonal)
 AND theories mostly created by professor nurses not nurses that work at the
fields.
Societal Influences on Community-
Oriented, Population-Focused Nursing
 Nurses must anticipate and adapt to societal changes in order to fulfill their
mission of promoting the health of all people. Contemporary societal
influences on public health nursing include :
1. Communication technology
2. Genetic, Genomic & genetic engineering
3. The global economy
4. Migration
5. Terrorism and bioterrorism
6. Climate change
Activities to Promote Critical Thinking

 Interview a public health nursing director in Pontianak City to determine what population-
focused programs are offered. Explore nursing’s role assessment, development,
implementation and evaluation of these programs. Discuss with the director how public
health nurses might expand their population-focused interventions.
 Select one of cases from the interview results and determine theory or models that suitable
for the case.
 This is an individual task and would be considered as part of final test.
 You may interview the same public health centre, but everyone should differ one to another
by : the chosen case OR the chosen theory/model
 You may select the same case, but everyone should differ one to another by : the chosen area
OR the chosen theory/model
 You may select the sampe theory/model, but everyone should differ one to another by : the
chosen case OR the chosen area
 Please send your work A DAY before the final test schedule (3 pm)