Community Nursing Process
The nursing process is a systematic way of determining a client health status, isolating health concern and problems, developing the plans to remediate them, initiating actions to implement the plan, and finally evaluating the adequacy of the plan in promoting wellness and problem resolution. The nursing process defines interactions and interventions with the client system, whether that system is an individual, a family, an integrate or a community. The nursing process commonly consists of five phases:
Community assessment;
Community diagnosis;
Planning;
Implementation and;
Evaluation.
It is employed to respond and address the health needs of the community when the community is the client. The community as a client refers to the broader concept of wide community as people for the nursing services in focus.
Community as a Client For community health nurses, working with communities has two important missions: The community directly influences the health of the individuals; families, groups, and populations who may be a part of it, Provision of the most important health services at the community level.
Dimensions of the Community as Client A community has three features
Location
A population
A social system
It is useful to think of these dimensions of every community as a rough map to follow for assessing needs or planning for service provision.
Location Every physical community carries out daily existence in a specific geographic location. The health of a community is affected by this location including the placement of health services, the geographic features, plants, animals and animals and the human made environment.
Six Location Variables
Community boundaries To talk about community in any sense, one must first describe its boundaries. It serves as basis for measuring incidence of wellness and illness and for determining spread of a disease.
Location of health services When assessing a community, the community health nurse will want to identify the major health centers and know they are located. Use of health services depends on availability and accessibility.
Geographic features Communities have been constructed in every suitable physical environment and that environment certainly can affect the health of a community. Injury, death, and destruction may be caused by floods, cyclones, earthquakes volcanoes…etc. recreational activities at lakes, seashores, mountains promote health and wellness.
Climate Climate has a direct effect on health of a community e.g., extreme heat and cold).
Flora and Fauna Poisonous plants and disease carrying animals can affect community health.
Human made environment All human influences on environment (housing, dams, farming, types of industry, chemical wastes, air pollution…etc.) can influence levels of community wellness.
Population Population consists not only of a specialized aggregate, but also of all the diverse people, who live within the boundaries of the community. The health of any community is greatly influenced by the population that lives in it. Different features of the population suggest the health needs and provide bases for health planning.
Population variables
Size: the size of a population influences the number and size of health care institutions. Knowing community size provides important information for planning.
Density: increased population density may increase stress. Similarly when people are spread out health care provision may become difficult.
Composition: composition of the population often determines types of health needs. A health community is one that takes full account of and provides for differences in age, sex, educational level, and occupation of its members, all of which may affect health concerns. Determining a community composition is an important early step in determining its level of health.
Rate of growth or decline: rapidly growing communities may place extensive demands on health services. Marked decline in population may signal of poorly functioning community.
Cultural difference: health needs may vary among sub-cultural and ethnic populations. Cultural difference can create conflicting or competing demands for resources and services or create inter-group hostility.
Social class and educational levels: social class refers to the ranking of groups within society by income, education, occupation, prestige or a combination of these factors. Educational level is a powerful determinant of health related behavior. Health promotion and preventive health services are most needed for people with low income and educational levels.
Mobility: mobility of the population affects continuity of care and availability of services. Mobility has a direct effect on the health of a community.
Social system: in addition to location and population, every community has a third dimension, a social system. The various parts of community social system that interact and influence the system are called social system variables. These variables include the health, family, economic, educational, religious, welfare, legal, communication, recreational, and the political systems. Although community health nurses must examine all the systems in the community and how they interact, the health system is of particular importance to promote the health of the community.
Phases of Nursing Process in the Community
Assessment
Assessment is the first step of the nursing process, which means to collect and evaluate data/information about a community’s health status to discover existing or potential needs as a basis for planning.
Community Assessment
This is the process of searching for and validating relevant community based data according to a specified method, to learn about the interaction among the people, resources and environment. Community assessment includes;
Collecting pertinent community data
Analyzing and interpreting the collected data.
Community need assessment:- is the process of determining the real or perceived needs of a defined community of people. In some situation; an extensive community study becomes first priority. In others, all that is needed is a study of one system (e.g., health system, educational system …etc.) or organization (e.g., women association …etc).
Major Aspects of Community Assessment (Eight sub-system)
A. Physical Environment Just as physical examination is important to individual patients, so is examination of the community physical environment. Five senses are used in physical assessment: inspection, auscultation, vital signs, system review, and laboratory studies. Inspection: inspection uses all sense organs and is done by walking survey in the community, or micro-assessment of housing, open spaces, boundaries, transportation service centers, markets places, meeting street people, signs of decay, ethnicity, religion, health and morbidity, political media.
Auscultation: is listening to the community residents about the physical environment.
Vital signs: observe the climate, terrain, natural boundaries such as rivers and hills.
Community resources: look for signs of life such as notices, posters, new housing and buildings.
System review: hosing age, architecture, building materials used, signs of disrepair, running water, plumbing, sanitation, windows (glasses)..etc. Also business facilities and churches.
Laboratory studies: census data or planning studies for community mapping.
B. Health and social system Differentiate between facilities located within the community and those located outside. Hospital: number of beds, staffing, budget, health center, clinics, or health posts, public health services, private clinics, pharmacies, dental and other services. Signs of drugs or substance abuse, alcoholism. Social services include counseling and support, clothing, food, shelter and special needs as well as markets and shops.
C. Economics Financial characteristics median household income, percentage of households living in poverty less than 100 Birr per month. Labor force characteristics, employment status of the general population greater than 18 years of age. Occupational categories and percentage of persons employed by government, farmers, skilled, unskilled, professional, types of business/industry.
D. safety and transportation police, sanitation (water source, solid waste disposal, sewage and air quality) and fire services. Primary means of transportation; walking, mule, taxi, bus, train, private car, and air services. Frequency and affordability of public/private transport, and standard of roads.
E. politics and government kebele, peasant association, business alliances, religious groups, youth and women’s associations, professional associations, ethical associations, political activism…etc. describe the associations’ objectives and activities.
F. Communication Bulletin boards, posters, oral messages, radio, television, newspapers, postal services, telephone. Look for TV aeries, telephone wires, magazines, and satellite dishes.
G. Education Types of schools, colleges and universities. Note languages used, grades, courses offered, percentage of attendants (male, female), adequacy, accessibility, and acceptability of education. Average number of years completed by people at school.
H. Recreation Note facilities such as stadium, recreational areas, volley balls court, playground, picnic areas, museum, music/dancing, theatre/cinema. Who is going out about during the evening and in the morning? Teenagers, mothers and children, the homeless?
Community Assessment Tool (Questionnaires)
The following areas are of nursing concerns when making community assessment that helps to reach a community nursing diagnosis. The point under each sub-heading may be modified to meet the need of individual practice. The questions are modified under the following sub-headings.
Location perspectives
Where is the community located?
What is the boundary?
Where is the major health institutions located?
What major landforms are in or near the community?
What geographic features offer opportunities for healthful activities?
What are the average temperature and precipitation?
What climatic features affect health and fitness(extreme temperatures)?
What plants and animals pose possible threats to health?
What are the major industries?
How have air, land, and water been affected by humans?
What is the quality of housing?
Do highways allow access to health institutions?
Population perspectives
What is the population of the communities (urban, rural)?
What is the density of the population per square kilometer?
What is the age and composition of thecommunity?
What is the marital status of the community?
What occupations are presented in the community? In what percent?
How has the population size changed over the past two decades?
What are the health implications of the changes?
What are the ethnic compositions of the community?
What percentage of the population falls into each social class?
What is the average income per family member?
Are there any specific population such as migrant workers that are highly mobile ?
Is the community organized to meet the health needs of the mobile group?
Social system perspectives
What are the functions of each major system?
What are the major organizations in each sub-system?
Is there adequate communications among the major systems?
Does the education system offer equal eduacational opportunities to all children in the community?
What is the level of health promotion in the community?
Are there mechanisms for resolving conflicts?
Does any part of the total system dominate the others?
What community needs is not being met?
What recreational facilities are available?
What types of health services are available?
What health services and resources are available?
Community core
The definition of core is “that which is essential, basic, and enduring.” The core of a community is its people- their history, characteristics, values and beliefs. The first stage of assessing a community, then, is to about its people.
Major components of community core
History- history of that society Demography- age, sex, ethnicity, marital status Vital statistics- birth, death Values beliefs, and religious practice of the people.
Community Analysis and Nursing diagnosis
Community Analysis
Analysis is the study and examination of data. Analysis is necessary to determine community health needs and strength as well as to identify patterns of health responses and trends in health care use. Community analysis, like so many procedures we carry out, may be viewed as a process with multiple steps. The phases of analysis include:
Data categorization (demographic, geographic, socioeconomic, health resource and services…etc)
Data summarization (rates, charts graphs…etc.)
Comparing data (with similar data, identification of data gaps, incongruence…etc)
Draw inferences (draw logical conclusions from the evidence) that lead to community diagnosis.
Community nursing diagnosis
This is a statement that defines the health strength, health problems or health risks of the community. Nursing diagnosis is a real clinical judgment or conclusions about human response to actual or potential problems (ANA). A community diagnosis forms the basis for community based intervention. A nursing diagnosis has three parts • Description of the problem (specific target or groups) • Identification of factors/etiology related to (r/t) the problem • The sign and symptoms (the manifestations) that characteristics of the problem.
Examples;
Inadequate ANC r/t inadequate health information or service accessibility as evidenced by 70% of female delivering at hospital with no antenatal care.
Poor nutritional status of under five children in the community r/t knowledge deficit regarding weaning diet as evidenced by growth monitoring chart.
High infant mortality r/t inadequate ANC, maternal nutrition, and unhygienic delivery practice as evidenced by IMR 75 /1000 live births.
Planning
It is a logical, decision making process of design an orderly, detailed programs of action to accomplish specific goals an objectives base d on assessment of the community and the nursing diagnosis formulated.
Activities in planning:
Setting priorities involves: Assigning rank/importance to client’s needs Determining the order in which the goal should be addressed. The goal can be immediate, intermediate or long range goal.
Establishing goal and objectives Goal is a broad statement of desired end results. Objectives are specific statement of the desired outcomes. Characteristics of good objectives
Specific- target specific population
Measurable- when the results are stated
Achievable- within the capacity of the available resources.
Relevant- fits with the general police Time bound- that is achieved within specified time frame.
Planed actions are specific activities or methods of accomplishing the objectives or expected outcomes.
Outcome measurements Is judging of the effectiveness of goal attainment. How and when was each objective met, why not?
Recording the plan
Implementation
Implementation is putting the plan into actions and actually carrying out the activities delineated in the plan, either by nurse or other professionals. It is the action phase of the nursing process. Community interventions are the therapeutic actions designed to promote and protect the community health, treat and remediate community health problems and support the community as it changes over time.
Key areas of nursing intervention in the community are:
link the community members with the available resources
pulls together information and resources to assist community in addressing its health concern and problems
marinating its strength through facilitation, education, organization, consultation and direct care.
Evaluation
It is systematic, continuous process of comparing the community’s response with the outcome as defined by the plan of care. The ultimate purpose of evaluating interventions in community health nursing is to determine weather planned actions met client needs, if so how well they were met, and if not why not. Evaluation requires a stated purpose, specific standards and criteria by which to judge and judgment skills.
Community assessment;
Community diagnosis;
Planning;
Implementation and;
Evaluation.
It is employed to respond and address the health needs of the community when the community is the client. The community as a client refers to the broader concept of wide community as people for the nursing services in focus.
Community as a Client For community health nurses, working with communities has two important missions: The community directly influences the health of the individuals; families, groups, and populations who may be a part of it, Provision of the most important health services at the community level.
Dimensions of the Community as Client A community has three features
Location
A population
A social system
It is useful to think of these dimensions of every community as a rough map to follow for assessing needs or planning for service provision.
Location Every physical community carries out daily existence in a specific geographic location. The health of a community is affected by this location including the placement of health services, the geographic features, plants, animals and animals and the human made environment.
Six Location Variables
Community boundaries To talk about community in any sense, one must first describe its boundaries. It serves as basis for measuring incidence of wellness and illness and for determining spread of a disease.
Location of health services When assessing a community, the community health nurse will want to identify the major health centers and know they are located. Use of health services depends on availability and accessibility.
Geographic features Communities have been constructed in every suitable physical environment and that environment certainly can affect the health of a community. Injury, death, and destruction may be caused by floods, cyclones, earthquakes volcanoes…etc. recreational activities at lakes, seashores, mountains promote health and wellness.
Climate Climate has a direct effect on health of a community e.g., extreme heat and cold).
Flora and Fauna Poisonous plants and disease carrying animals can affect community health.
Human made environment All human influences on environment (housing, dams, farming, types of industry, chemical wastes, air pollution…etc.) can influence levels of community wellness.
Population Population consists not only of a specialized aggregate, but also of all the diverse people, who live within the boundaries of the community. The health of any community is greatly influenced by the population that lives in it. Different features of the population suggest the health needs and provide bases for health planning.
Population variables
Size: the size of a population influences the number and size of health care institutions. Knowing community size provides important information for planning.
Density: increased population density may increase stress. Similarly when people are spread out health care provision may become difficult.
Composition: composition of the population often determines types of health needs. A health community is one that takes full account of and provides for differences in age, sex, educational level, and occupation of its members, all of which may affect health concerns. Determining a community composition is an important early step in determining its level of health.
Rate of growth or decline: rapidly growing communities may place extensive demands on health services. Marked decline in population may signal of poorly functioning community.
Cultural difference: health needs may vary among sub-cultural and ethnic populations. Cultural difference can create conflicting or competing demands for resources and services or create inter-group hostility.
Social class and educational levels: social class refers to the ranking of groups within society by income, education, occupation, prestige or a combination of these factors. Educational level is a powerful determinant of health related behavior. Health promotion and preventive health services are most needed for people with low income and educational levels.
Mobility: mobility of the population affects continuity of care and availability of services. Mobility has a direct effect on the health of a community.
Social system: in addition to location and population, every community has a third dimension, a social system. The various parts of community social system that interact and influence the system are called social system variables. These variables include the health, family, economic, educational, religious, welfare, legal, communication, recreational, and the political systems. Although community health nurses must examine all the systems in the community and how they interact, the health system is of particular importance to promote the health of the community.
Phases of Nursing Process in the Community
Assessment
Assessment is the first step of the nursing process, which means to collect and evaluate data/information about a community’s health status to discover existing or potential needs as a basis for planning.
Community Assessment
This is the process of searching for and validating relevant community based data according to a specified method, to learn about the interaction among the people, resources and environment. Community assessment includes;
Collecting pertinent community data
Analyzing and interpreting the collected data.
Community need assessment:- is the process of determining the real or perceived needs of a defined community of people. In some situation; an extensive community study becomes first priority. In others, all that is needed is a study of one system (e.g., health system, educational system …etc.) or organization (e.g., women association …etc).
Major Aspects of Community Assessment (Eight sub-system)
A. Physical Environment Just as physical examination is important to individual patients, so is examination of the community physical environment. Five senses are used in physical assessment: inspection, auscultation, vital signs, system review, and laboratory studies. Inspection: inspection uses all sense organs and is done by walking survey in the community, or micro-assessment of housing, open spaces, boundaries, transportation service centers, markets places, meeting street people, signs of decay, ethnicity, religion, health and morbidity, political media.
Auscultation: is listening to the community residents about the physical environment.
Vital signs: observe the climate, terrain, natural boundaries such as rivers and hills.
Community resources: look for signs of life such as notices, posters, new housing and buildings.
System review: hosing age, architecture, building materials used, signs of disrepair, running water, plumbing, sanitation, windows (glasses)..etc. Also business facilities and churches.
Laboratory studies: census data or planning studies for community mapping.
B. Health and social system Differentiate between facilities located within the community and those located outside. Hospital: number of beds, staffing, budget, health center, clinics, or health posts, public health services, private clinics, pharmacies, dental and other services. Signs of drugs or substance abuse, alcoholism. Social services include counseling and support, clothing, food, shelter and special needs as well as markets and shops.
C. Economics Financial characteristics median household income, percentage of households living in poverty less than 100 Birr per month. Labor force characteristics, employment status of the general population greater than 18 years of age. Occupational categories and percentage of persons employed by government, farmers, skilled, unskilled, professional, types of business/industry.
D. safety and transportation police, sanitation (water source, solid waste disposal, sewage and air quality) and fire services. Primary means of transportation; walking, mule, taxi, bus, train, private car, and air services. Frequency and affordability of public/private transport, and standard of roads.
E. politics and government kebele, peasant association, business alliances, religious groups, youth and women’s associations, professional associations, ethical associations, political activism…etc. describe the associations’ objectives and activities.
F. Communication Bulletin boards, posters, oral messages, radio, television, newspapers, postal services, telephone. Look for TV aeries, telephone wires, magazines, and satellite dishes.
G. Education Types of schools, colleges and universities. Note languages used, grades, courses offered, percentage of attendants (male, female), adequacy, accessibility, and acceptability of education. Average number of years completed by people at school.
H. Recreation Note facilities such as stadium, recreational areas, volley balls court, playground, picnic areas, museum, music/dancing, theatre/cinema. Who is going out about during the evening and in the morning? Teenagers, mothers and children, the homeless?
Community Assessment Tool (Questionnaires)
The following areas are of nursing concerns when making community assessment that helps to reach a community nursing diagnosis. The point under each sub-heading may be modified to meet the need of individual practice. The questions are modified under the following sub-headings.
Location perspectives
Where is the community located?
What is the boundary?
Where is the major health institutions located?
What major landforms are in or near the community?
What geographic features offer opportunities for healthful activities?
What are the average temperature and precipitation?
What climatic features affect health and fitness(extreme temperatures)?
What plants and animals pose possible threats to health?
What are the major industries?
How have air, land, and water been affected by humans?
What is the quality of housing?
Do highways allow access to health institutions?
Population perspectives
What is the population of the communities (urban, rural)?
What is the density of the population per square kilometer?
What is the age and composition of thecommunity?
What is the marital status of the community?
What occupations are presented in the community? In what percent?
How has the population size changed over the past two decades?
What are the health implications of the changes?
What are the ethnic compositions of the community?
What percentage of the population falls into each social class?
What is the average income per family member?
Are there any specific population such as migrant workers that are highly mobile ?
Is the community organized to meet the health needs of the mobile group?
Social system perspectives
What are the functions of each major system?
What are the major organizations in each sub-system?
Is there adequate communications among the major systems?
Does the education system offer equal eduacational opportunities to all children in the community?
What is the level of health promotion in the community?
Are there mechanisms for resolving conflicts?
Does any part of the total system dominate the others?
What community needs is not being met?
What recreational facilities are available?
What types of health services are available?
What health services and resources are available?
Community core
The definition of core is “that which is essential, basic, and enduring.” The core of a community is its people- their history, characteristics, values and beliefs. The first stage of assessing a community, then, is to about its people.
Major components of community core
History- history of that society Demography- age, sex, ethnicity, marital status Vital statistics- birth, death Values beliefs, and religious practice of the people.
Community Analysis and Nursing diagnosis
Community Analysis
Analysis is the study and examination of data. Analysis is necessary to determine community health needs and strength as well as to identify patterns of health responses and trends in health care use. Community analysis, like so many procedures we carry out, may be viewed as a process with multiple steps. The phases of analysis include:
Data categorization (demographic, geographic, socioeconomic, health resource and services…etc)
Data summarization (rates, charts graphs…etc.)
Comparing data (with similar data, identification of data gaps, incongruence…etc)
Draw inferences (draw logical conclusions from the evidence) that lead to community diagnosis.
Community nursing diagnosis
This is a statement that defines the health strength, health problems or health risks of the community. Nursing diagnosis is a real clinical judgment or conclusions about human response to actual or potential problems (ANA). A community diagnosis forms the basis for community based intervention. A nursing diagnosis has three parts • Description of the problem (specific target or groups) • Identification of factors/etiology related to (r/t) the problem • The sign and symptoms (the manifestations) that characteristics of the problem.
Examples;
Inadequate ANC r/t inadequate health information or service accessibility as evidenced by 70% of female delivering at hospital with no antenatal care.
Poor nutritional status of under five children in the community r/t knowledge deficit regarding weaning diet as evidenced by growth monitoring chart.
High infant mortality r/t inadequate ANC, maternal nutrition, and unhygienic delivery practice as evidenced by IMR 75 /1000 live births.
Planning
It is a logical, decision making process of design an orderly, detailed programs of action to accomplish specific goals an objectives base d on assessment of the community and the nursing diagnosis formulated.
Activities in planning:
Setting priorities involves: Assigning rank/importance to client’s needs Determining the order in which the goal should be addressed. The goal can be immediate, intermediate or long range goal.
Establishing goal and objectives Goal is a broad statement of desired end results. Objectives are specific statement of the desired outcomes. Characteristics of good objectives
Specific- target specific population
Measurable- when the results are stated
Achievable- within the capacity of the available resources.
Relevant- fits with the general police Time bound- that is achieved within specified time frame.
Planed actions are specific activities or methods of accomplishing the objectives or expected outcomes.
Outcome measurements Is judging of the effectiveness of goal attainment. How and when was each objective met, why not?
Recording the plan
Implementation
Implementation is putting the plan into actions and actually carrying out the activities delineated in the plan, either by nurse or other professionals. It is the action phase of the nursing process. Community interventions are the therapeutic actions designed to promote and protect the community health, treat and remediate community health problems and support the community as it changes over time.
Key areas of nursing intervention in the community are:
link the community members with the available resources
pulls together information and resources to assist community in addressing its health concern and problems
marinating its strength through facilitation, education, organization, consultation and direct care.
Evaluation
It is systematic, continuous process of comparing the community’s response with the outcome as defined by the plan of care. The ultimate purpose of evaluating interventions in community health nursing is to determine weather planned actions met client needs, if so how well they were met, and if not why not. Evaluation requires a stated purpose, specific standards and criteria by which to judge and judgment skills.
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