COMMUNITY HEALTH NURSING

According to American Nursing Association,

“Community health nursing is a synthesis of nursing practice and public health

practice applied in promoting and preserving the health of populations. the

nature of this practice is general and comprehensive. i t is not l imited to a

particular age or diagnostic group. It is continuous and not episodic. The

dominant responsibi l i ty i s to the population as a whole. Therefore Nursing

di rected to individuals, fami l ies or groups contr ibutes to the health of the total

population. Health promotion, health maintenance, health education,

coordination and continuity of care are uti l i zed in a hol i st ic approach to the

management of the individual, family group and community. The nurse’s

actions acknowledge the need for comprehensive health planning, recognize

the influences of social and ecological i ssues, give attention to populations at

r i sk and uti l i ze dynamic forces which influence change.”

Philosophy:

1) Philosophy of individual’s right of being healthy-

Health is believed to be one of the rights of all human beings nationally and

internationally according to the WHO charter.

Goal of health for all is based on the philosophy of individual’s right of being healthy.

This philosophy encompasses all the aspects of the society i.e sociocultural,economic

aspects, so that there is no hindrance of any kind to attain these rights.

2) Philosophy of working together under a competent leader for the common good

It is from the primitive ages of human ages, man has learnt to live together to meet

their needs.

The basis of modern community health nursing is to share responsibility of helping

each other.

When it comes to considering a organization, equal participation of the people

working through the community groups/people with the people,for the people for

their mutual benefit,change in behavior and health practices.

A democratic team functioning is essential for effective delivery of health care

services.

3)Philosophy that people in the community have the potential for continual development

and are capable of dealiong with their own problems if educated and helped

An individual with average intelligence can learn and deal with his/her own needs,

modify his/her lifestyles adjust to his or her changing enviournment i.e he can learn to

solve his or her problems.

On the basis of this philosophy ,emphasis is placed on health education projected

towards individuals in home,health centre, place of work, school, community places

or hospital.

This helps to modify their behaviours respective to health.

4)Philosophy of Socialism

Socialism as one of the social system in the community has control over production

and distribution eg:food, housing, material production of all kinds, education,

transportation,etc. should be shared with all people.

Aim:

The aim of community health nursing practice is to promote health and efficiency, prevent

and control diseases and disabilities and prolong life by providing need based, well

balanced comprehensive health care services to community at large through organized

community efforts.

Objectives:

1. To increase the capability of community to deal with their own health problems.

Provision of adequate information pertaining to their health problems,health issues

can increase the community’s capability to deal with the health problems in a

effective manner

People can be taught “how to care for themselves” through education,guidance

and supervision.

eg: Helping young mothers to give care to the children in meeting their physiological,

safety, love and security needs so as to have normal growth and development of

children.

Continuous need based health educationnot only improves health knowledge and

skills but also helps in developing positive attitude which brings change in health

behavior.

2.To strengthen community resources

Community resources include manpower,money material their development,

distribution their utilization.

Resources need to be strengthened,distributed and utilized properly.

For this purpose an intersectoral approach is regarded,wherein,there is need for a

strong political, legal and administrative support.

3.To control and counteract environment

It includes environment protection measures and changing reaction to environment

when some protection measures are not feasible.

Protection measures are as follows:

i. Safe drinking water

ii. Clean air and soil

iii. Safe disposal of refuse and excreta

iv. Good social security and safety

Changing reactions

i. Mass Immunizations

ii. Mass screening

iii. Mass prophylactic treatment

4. To prevent and control communicable and non-communicable diseases

This includes application all the three levels of preventive measures i.e:

1) Primary level

2) Secondary level

3) Tertiary level

5.To provide specialized services

It provides specialized services for mothers,children,workers,elderly, handicapped and

eligible couples,etc.

6.To conduct research

To conduct research to build up knowledge and contribute to further refinement and

improvement of community health practice.

7.To prepare Health personnel

To prepare health personnel in the community for community health care services.

Ultimate aim of community health care services is to reduce morbidity, mortality and

disability, improve nutritional status and increase life-expectancy at birth.

Principles of community Health Nursing

1) Community health nursing is an established based on recognized needs and

functioning within the total health programme.

2) The community health nursing agency has clearly defined objectives and purposes

for it’s services

3) An active organized citizens group of the community group is an integral part of the

community health programme.

4) Community health nursing services are available to the entire community regardless

of origin, culture or social and economic resources, and age, sex, creed, nationality,

political affiliation

5) Community health nursing recognized the family and community as units of service.

6) Health education and counseling for the individual, family and community are the

integral part of community health nursing.

7) Recipients of health care should participate in planning relating to goals for the

attainment of health

8) The community health nurse should qualify as a full-fledged nurse.

9) The community health nursing service should be based on the needs of the patient

and there should be proper continuity of services to patients.

10) Periodic and continuous appraisal and evaluation of health situation of the patients

are basic to community health nursing.

11) The community health nurse should function/serve as an important member of the

health team.

12) There should be provision for qualified nurse to make supervision for community health

services.

13) The community health nurse does not provide material relief to patients, but directs

the patient to appropriate community resources for necessary financial and social

assistance.

14) The community health nurse should not accept gifts or bribes from the patients

15) The community health nurse should not belong to one particular section or political

group.

16) Community health agency should provide a continuing education programme for

nurse

17) The nurses assume responsibilities of their own continuing professional development

through acquiring higher and higher education and forming and strengthening the

professional associations

18) The community health nursing services should develop proper guidelines, in

maintaining records and reports.

19) There should be proper facilities and job conditions.

20) The community health nurse should maintain professional relationship with all leaders

in the community and maintain ethics at all times.

Quality assurance in community health nursing

Define quality assurance

Quality assurance can be defined as ”the promise or guarantee that certain standards of

excellence are being met in care delivered.”

Goals of quality assurance:

1) To ensure the delivery of quality client care

2) To demonstrate the efforts of the health care provider for the best possible result.

Approaches for a quality assurance programme:

There are two major categories to approach the quality assurance programme:

1) General approach

2) Specific approach

1)General Approach

It involves examining the ability of the person or the agency to meet the criteria and

standard.

Assessing the credentials is defined as ” formal recognition of a person as a professional with

technical competence, or an agency that has met minimal standard of performance.”

The process of assessing the credentials has four goals:

1) To produce a quality product

2) To confer a unique identity.eg.registered nurse

3) To protect the provider and public

4) To control the profession

The agencies or person who have been found to posess sound credentials are put

through procedures like

1) Licensing

2) Accreditation

3) Certification

1)Licensure

Individual licensure is acontract between the profession and the state in which the profession

is granted control over entering in and out of profession and over the quality of professional

practice.

2) Accreditation

State boards of nursing accredit basic nursing programmes, since the graduates

become eligible for licensing examination.

Accreditation function is a voluntary approach which is connected to the

governamental regulation that encourages programmes to be involved in the

accrediting process.

3)Certification

It is another general approach which combines features of both, accreditation and

licensure.

Educational achievements, experience and performance in an examination

determine a person’s qualification for functioning in an identified specialty area such

as community health nursing.

Other general approaches:

1) Charter

It is a mechanism by which a governmental agency under state laws grants

corporate status to an institution with or without rights to award degrees.

2) Recognition

It is the process whereby one agency accepts the status of another agency as confirmed by

the assessment of its credentials from a known person in the community or organization.

3) Academic degrees

These are titles awarded to individuals by recognised institutions as having apred-

determined plan in the branch of learning.

There are four academic degrees awarded in nursing,with some variation at each

degree level,

i)Bachelor of Science in Nursing

ii)Master’s Degree-Master’s of Science in Nursing

iii)Doctoral degrees-Doctor of Philosophy,Doctorate of Nursing science and Doctorate in

Nursing.

2)Specific approach

Goals of specific approach are as follows:

I. To identify problems between provider and client

II. To intervene in problematic cases.

III. To provide feedback regarding the interaction between the client and the

provider.

IV. To document the interaction between the service provider and the client.

Specific approaches are usually implemented by agents and service providing groups who

are interested in the quality of interaction between the client and the service provider

Specific approaches to quality control are as follows:

1)staff review committees(Peer review)

2)utilization review committees

3)research studies

4)Client satisfaction surveys

5)malpractice litigation

MODEL QUALITY ASSURANCE PROGRAMME

Purpose-the primary purpose of a quality assurance programme is to ensure the results of an

organized activity are consistent with expectations

Structure

Value identification forms a very integral part of the quality assurance programme

In order to accompalish these formulated objectives the following steps need to be

followed:

1)identify the sources needed

2)Describe the nature of the personnel required to handle resources, supplies,

equipments, facilities and finance.

3)Once the resources are identified, then policies, procedures, job descriptions should

be clearly laid down for use

Standards of structure are evaluated internally by a group of people like

administrators,management and staff members.

Process

The primary approach used for process evaluation includes the peer group

committee and the client satisfaction survey.

Technique used for process evaluation is direct observation, questionnaire, interview,

written audit and videotape of client and provider.

Outcome:

For the purpose of evaluation the nurse uses client’s admission data, acuity of the

problem and discharge data that may point out changes in the level of dependence

and activity.

Direct physical examination and interview will help a lot measure the outcome.

This will help one to identify the causes and problems associated with health care.

Evaluation, Interpretation and Action:

Interpretation is one of the major components of quality assurance

Evaluation of the process should be carried out at major intervals and periodic reports

should be prepared.

Action is the final step in quality assurance model.

The action must be based upon their significance, economic benefits and timeliness.

Health provider evaluation:

It is essential to determine the individual service provider’s contribution to the quality

assurance programme.

Punctuality and performance are needed to evaluate the individual based on

traditional trait ratings.

Objective oriented action tools are developed in consultation with supervisor and the

nurse.

Nursing Audit

Staff review committees are the most common review committees designed to

assess the clent-specific aspects of certain levels of care.

The audit is the major tool used to ascertain the quality of care:

The audit process consists of 6 steps:

1) Selection of a topic for study.

2) Selection of a explicit criteria for quality care.

3) Review of records whether criteria are met.

4) Peer review of all the cases that do not meet the criteria.

5) Specific recommendations to correct the problems.

6) Follow-up to determine whether problems have been eliminated.

Two types of Audits are used in nursing peer review:

1) Concurrent audit

2) Retrospective audit

1) concurrent audit

concurrent audit is used by Medicare and Medicaid to evaluate care being

received by public health/home health clients.

The advantages of this method are as follows:

I. Identification of the problems at the time care is given.

II. Provision of a mechanism for identifying and meeting client needs during care

III. Implementation of measures to fulfill professional responsibilities.

IV. Provision of a mechanism for communicating on behalf of the client.

Disadvantages of this method are as follows:

i. Time consuming

ii. More costly than to implement the retrospective audit

iii. Because care is ongoing it does’t represent the total picture of the care that

the client will ultimately will receive.

Retrospective Audit

Retrospective audit or outcome audit evaluates the quality of care through

appraisal of the nursing process after the client’s discharge from the health

care system.

Advantages of retrospective audit are as follows:

1) Comparison of actual practice to standard of care

2) Analysis of actual practice findings

3) A total picture of the care given.

4) More accurate date for planning corrective action.

Disadvantages:

1) Focus of evaluation is directed away from ongoing care.

2) Client problems are identified after discharge,so corrective action can be

only used to improve the care of the future.

COMMUNITY NURSING THEORIES

The models or theories which are applicable to the educator in Community

health Nursing are as follows:

PRECEDE MODEL

Researcher green describes health education as a combination of

experiences to encourage healthy habits:

The model PRECEDE is an acronym for predisposing,reinforcing and

enabling causes in educational diagnosis and evaluation.

Two basic propositions underscore the outcome oriented PRECEDE

model.They are:

1)Health and health behaviours arecaused by multiple factors.

2)Health education designed to influence the behavior must be

multi-dimensional.

Health Belief Model

Health Belief Model is divided into three major components:

1) Individual Perception

2) Modifying Factors

3) Variables affecting the likelihood of initiating action.

A person’s perception means his/her perceived threat of an illness.

Contributory factors of these perceptions include demographic variables:

1) Age

2) Sex

3) Race

4) Ethnicity

5) Personality

6) Social class

7) Pressure

8) Reference group

This model is helpful in looking at health protection or disease-preventive

behavior.Data regarding health assessment is gathered together and

organized for looking at client status.

Health promotion model

Pender (1987) developed this model to be used as a complement to health

protecting models like Health Belief Model.determinants of health promotion

behavior are organized into:

Cognitive-Perceptual factors

They include factors like:

i. Importance of health

ii. Perceived self-efficacy

iii. Definition of health

iv. Barriers to health-promoting behavior.

Modifying factors

They include;

i. Demographic factors

ii. Biological characters like body weight,interpersonal influences, family

patterns of health care.

CONCEPTUAL MODELS FOR COMMUNITY HEALTH NURSING

A Conceptual Model is otherwise called as a “Conceptual Framework”.

A conceptual framework refers to global ides about individuals, groups,

situations and events of interest to a discipline. A conceptual model

provides a reference platform for members of a discipline to guide their

thinking, observation and interpretation.

Conceptual models are approximations or simplifications of reality

based on concepts. A conceptual model cannot be tested directly

because the concepts are not operationally defined and the

relationships are not observable.

People in the community have continuous interaction with environment.

Hence the conceptual model has significant application in community

health nursing.

Models applicable to Community Health Nursing Practice

1) System Model

2) Developmental Model

3) Interaction model

1)System Model

It focuses on the organization, interaction, interdependency and

integration of parts and elements.

It is postulated by Von Bertalanffy(1952).Accoding to “Von Bertalanffy”

Every organization represents a system, by which term we mean a

complex of elements in mutual interaction.”

Characteristics of system model:

The charachteristics of the system model are as follows i.e

wholeness,organization,openness,boundary and entropy.

Wholeness

Wholeness refers to property of asystem in which collection of parts responds

as an integral single unit

Openness

Openness refers to the extent to which it exchanges energy with the

environment,in an open system there is input and output of environment,but in

a closed system there is no exchange of energy.

Boundary

Boundary refers to a border that defines what elements comprise the system.

Entropy

Entropy is a concept based on a major implication of the second law

thermodynamics,which states that elements in a closed system will proceed

towards greater randomness or less order.

Feedback

Feedback is the process whereby the output of the system is redirected as the

input to the same system.

Application to Community Health Nursing

The community is a social system made of interrelated subsystems.

The subsystems include economic, educational, religious, health care,

political, welfare. law enforcement, energy and recreational systems

They are interrelated and have a specific orientation towards each

other.

2. Developmental Model

It is a way of thinking how changes occur based on theories of

development of the human organization.

According to Lewis,the change may be both reactive and structural.

The reactive theory emphasizes the influence of environment in

development programmes,and the structural theory emphasizes the

genetically determined programme for development

Application to Community Health Nursing Practice:

It is useful in working with infants and children,because the major role of

a nurse working with them is to assess the developmental progress and

to promote overall growth and development.

3.Interaction Model

These models are based upon theories that stem from philosophical

writings such as those of Cooley(1969) and Mead(1934).

The major concepts used in interaction models are

communication,perception,role playing and self conception.

Application to Community Health Nursing:

Interaction model is very useful in analyzing in Family dynamics.

1) In communication:

Effective communication pattern is an important element of commun ity

health nursing.

2) Self-Conception

This is an important aspect of health and well being.It influences the

person’s readiness to accept healthcare.

So it is important that the nurse is attentive for cues that lead towards

such realization and help the concept of self positively.

3) Perception

Persons having individual differences will perceive incidents differently.

Perception is affected by previous experience including attitude,beliefs

and socialization

Bibliography:

1) Lucita M. Public health and community health nursing in the new

millennium. 1st ed. Chennai: B.I Publications Private Limited; 2006. p.88-

93,136-43.

2) Gulani KK.Community health nursing: principles and practices. 1st ed.

Delhi: Kumar Publishing House; 2008.p.33-46.

3) Stanhope M,Lancaste J. Community Health Nursing:promoting health of

aggregates,families and individuals. 4th ed. St.Louis:Mosby;1996.p.