Nursing Care of the Community

CHAPTER 2: THEORETICAL FOUNDATIONS OF

COMMUNITY HEALTH NURSING PRACTICE
Instructional slides
 Objectives

Upon completion of this chapter, the students will

be able to:
1. Describe different theories and their
application to community/public health
nursing.
2. Critique a theory in regard to its relevance to
population health issues.
3. Explain how theory-based practice achieves
the goals of community/public health nursing
by protecting and promoting the public's
health.
 Introduction

• Disease management in the community is

challenging as illnesses are interwoven with
social, economic, genetic and
environmental risks in ways that are difficult
to understand and more difficult to change.
• In the face of these challenges, how can
nurses succeed in their goal to improve
public health?
 Nursing Theories

• Theories or parts of theoretical frameworks

to guide practice best achieves the goal of
improving nursing practice- including that of
public health.
• A theory is like a map of a territory as
opposed to an aerial photograph. The map
does not give the full terrain (i.e., the full
picture); instead it picks out those parts that
are important for its given purpose
-Barnum, 1998
Historical Perspectives on Nursing Theory

• Era of Florence Nightingale

– First nurse to formulate a conceptual foundation for
nursing practice
– Believed that clean water, clean linens, access to
adequate sanitation, and quiet   would improve
health outcomes, and she put these beliefs into
practice during the Crimean War
• 1980 onwards
– Several nursing theorists, Dorothy Johnson, Sister
Callista Roy, Imogene King, Betty Neuman, and Jean
Watson among them, have included community
perspectives in their definition of health.
 General Systems Theory

• Viewed as an “open system,” the client is

considered as a set of interacting elements that
exchange energy, matter, or information with
the external environment to exist.

• This concept is particularly useful when

analyzing interrelationships of the elements
within the client, as well as those of the client
and the environment.
 Open Systems

The basic structures of a family that is found in

all open systems:
• Boundaries
• Environment
• Inputs
• Outputs
• Processing (throughput)
• Feedback
• Subsystems
 Health Belief Model

• Provides the basis for much of the practice of

health education and health promotion.

• Developed by a group of social psychologists to

explain why the public failed to participate in
screening for tuberculosis.

• “Behavior is based on current dynamics

confronting an individual rather than prior
experiences “ –Kurt Lewin
Constructs of the Health Belief Model

• Perceived severity/ seriousness

• Perceived susceptibility
• Perceived benefits
• Perceived barriers
• Cues to action
• Self-efficacy
 Health Belief Model

• Limitations of the model:

– It places the burden of action exclusively on the
client.
– It assumes that only those clients who have
distorted or negative perceptions of the specified
disease or recommended health action will fail to
act.
– It focuses the nurse's energies on interventions
designed to modify the client's distorted
perceptions, without acknowledging the health
professional's responsibility to reduce or alter health
care barriers other than patients’ perspectives
Milio’s Framework for Prevention

• Provides a complement to the Health Belief

Model
• Provides a mechanism for directing attention
“upstream.”
• Provides for the inclusion of economic, political,
and environmental health determinants;
therefore, the nurse is given broader range in
the diagnosis and interpretation of health
problems.
• Encourages the nurse to understand health
behaviors in the context of their societal milieu.
 Milio’s Propositions

• Population health results from deprivation

and/or excess of critical health resources.
• Behaviors of populations result from selection
from limited choices; these arise from actual
and perceived options available as well as
beliefs and expectations resulting from
socialization, education and experience.
• Organizational decisions and policies (both
governmental and non-governmental) dictate
many of the options available to individuals
and populations and influence choices.
 Milio’s Propositions

• Individual choices related to health promotion or

health damaging behaviors is influenced by
efforts to maximize valued resources.
• Alteration in patterns of behavior resulting from
decision making of a significant number of
people in a population can result in social
change.
• Without concurrent availability of alternative
health-promoting options for investment of
personal resources, health education will be
largely ineffective in changing behavior patterns.
Pender’s Health Promotion Model

• Explores the many biopsychosocial factors that

influence individuals to pursue health
promotion activities.

• Contains seven variables related to health

behaviors, as well as individual characteristics
that may influence a behavioral outcome.

• Does not include threat as a motivator, as

threat may not be a motivating factor for
clients in all age groups.
 Seven Variables of
Pender’s Health Promotion Model
• Prior related behaviors
• Personal factors
• Behavior specific cognition and affect
– Perceived benefits of action
– Perceived barriers to action
– Perceived self-efficacy
• Activity-related affect
– Interpersonal influences
– Situational influences
• Commitment to a plan of action
• Immediate competing demands and preferences
• Health-promoting behavior
 Transtheoretical Model

• Combines several theories of intervention,

thus the name “transtheoretical”.

• Based on the assumption that behavior

change takes place over time, progressing
through a sequence of stages.

• Assumes that each of the stages is both

stable and open to change.
Constructs of the Transtheoretical Model

• Stages of Change
– Precontemplation
– Contemplation
– Preparation
– Action
– Maintenance

• Decisional Balance
– Pros
– Cons
 Precede-Proceed Model

• Developed by Dr. Lawrence W. Green and

colleagues.

• Provides a model for community assessment,

health education planning and evaluation.
 Precede-Proceed Model

• PRECEDE: stands for Predisposing, Reinforcing,

and Enabling Constructs in Educational
Diagnosis and Evaluation.
– A model for community diagnosis

• PROCEED: stands for Policy, Regulatory, and

Organizational Constructs in Educational and
Environmental Development
– a model for implementing and evaluating health
programs based on PRECEDE
 Precede-Proceed Model

• Predisposing factors refer to people’s

characteristics that motivate them towards
health-related behavior.

• Enabling factors refer to conditions in people

and the environment that facilitate or impede
health-related behavior.

• Reinforcing factors refer to feedback given by

support persons or groups resulting from the
performance of the health-related behavior.   
END OF CHAPTER