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Course: Health Assessment�Unit Title: Community Health – Individual-Focused

Linda Frothinger, RN, MSN

Developed: June 2018 Copyright Nurses International 2018

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Student Objectives:

Identify at least five attributes of community health nursing.
Distinguish among individual-oriented care, delivery-oriented, and population-oriented community health nursing roles.
Describe at least five client-oriented roles performed by community health nurses.
Describe at least three delivery-oriented roles performed by community health nurses.
Describe at least four population-oriented roles performed by community health nurses.

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Community Health Elements

Health: Is state of complete physical, mental, and social well- being and it is not merely the absence of disease or infirmity (WHO, 2010).

Community: A collection of people who share important features in their lives, who interact with each other, and who function collectively within a defined social structure to address common concerns

Geography
Culture
Values
Spiritual
Interests

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Aims of Community Health

A Community Health Worker (CHW) is a key player in community health:

Promotes community’s voice about health by providing resources and strategies.
A trusted community member, linking to health/social services, facilitating access and delivery of care.
Builds capacity by increasing knowledge about:

outreach, education, counseling, social support, and advocacy.

Goal: community and individual empowerment over influences on health (e.g., exposure to disease, safety, environment, et al.)

(APHA, 2018):

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Community and Public Health

Objectives:

Definitions of community health, population, public health
Basic concepts of community health
Community-Based levels of prevention

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Population

Collection of individuals who share one or more personal or environmental characteristics (geography, common interest, community issue, etc.)
Interchangeable with the term aggregate

(Allender, et. al., 2010)

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Community Health

“The meeting of collective needs by identifying problems and managing behaviors within the community itself and between the community and the larger society”

Like a river can collect debris as it flows downstream, health can be impacted when risks are not addressed ‘upstream’—that is, before a person gets sick. A community is affected in the same way (e.g., by climate, disasters, lack of healthcare access.
This ‘Upstream’approach is about early intervention

(Stanhope & Lancaster, 2012)

(Current Nursing: Nursing Theories, 2010)

We may define community utilizing a multidisciplinary approach. The discipline of Biology may define community as a group of interacting organisms sharing an environment, where human communities may include beliefs, resources, risks, and needs. Sociology may consider the social cohesion based on shared values; they may also consider the geographical definition of space. CHN requires us to bring together definitions of community and health, where health is defined as a balanced state of well-being, including body, mind, and spirit. We may therefore, define Community Health Nursing as an approach to health for all individuals by meeting their needs through identification and management of health states while considering individual interactions within the community (Theories Used in Community Health Nursing, http://currentnursing.com/nursing_theory/theories_community_health_nursing.htm, 2009). Concepts of belonging, knowledge, and health become integral to this definition.

Most of us rely on a sense of community without considering how our lives might play out if we did not have a group within which to belong or participate. Consideration of marginalized or displaced individuals gives us pause at how reliant we actually may be on our families, neighborhoods, organizations of membership, or informal groups to which we belong. We may begin to realize how life without a community may truly alter our sense of identity. Likewise, not giving back to a community, imparting knowledge, and contributing, may equally alter individual sense of belonging and health.

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Community-Based Nursing – �A nurse who runs a maternity support services clinic in a community clinic�

Assessment:
Screens pregnant and breastfeeding clients
Identifies at-risk clients (e.g., Women who come to the clinic for OB care).

Interventions:
Provides information regarding Vitamin D and refers high-risk clients to nutritionist
Discusses with the Somali interpreter culturally appropriate suggestions to encourage more sun exposure.
Hangs educational posters in multiple languages throughout the clinic.

Evaluation:
Collects data regarding the number of clients who report increased sunshine exposure.

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Community Health Nursing – �Works at PH Center�Case Management - Home & Office Visits

Assessment:
Screens pregnant and breastfeeding clients and identifies at-risk clients
Conducts interviews with East African community leaders and culture brokers regarding community awareness and appropriate interventions

Interventions:
Develops and provides educational material with appropriate language and cultural sensitivity
Recruits interpreters for a train-the-trainer session
Sponsors a staff in-service regarding rickets, client assessment and education
Holds an informational booth at the next Mother/Baby Fair

Evaluation:
Keeps tracks of the number of encounters of community education

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Public Health Nurse –�Works at a Department of Health (DOH)

Assessment: Tracks village/state/district/country incidences

Tracks confirmed cases of rickets through voluntary reports
Matches incidents with birth statistics

Interventions:

Develops educational material for providers regarding assessment and current trends
Writes an update for the State Perinatal Report
Chairs a committee to address the local concerns and consider policy regarding routine supplementation of Vitamin D
Consults with the National Institute of Health regarding national trends

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What is the Difference?

What is the nurse's role?

Hospital Nurse

PHN

CHN

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Community Health Nursing

“…community health practice refers to a focus on specific, designated communities. It is a part of the larger public health effort and recognizes the fundamental concepts and principles of public health as its birthright and foundation of practice.”

Source: Allender, Rector & Warner (2010).

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Community-Based Nursing

Setting-specific practice in which care is provided for "sick" individuals and families where they live, work, and go to school.

Community-based nurses are generalists or specialists (maternal-infant, pediatric, adult, or psychiatric-mental health).

Emphasis:

acute and chronic care
comprehensive, coordinated, and continuous services

(Stanhope & Lancaster, 2012)

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All nurses who practice in the community, whether or not they have had preparation in public health nursing.

A community health nurse may/may not have specialized education and training in the area of public health/community health nursing.

Use nursing and public health principles to promote

and sustain the health of populations in neighborhood

and community settings.

(Stanhope & Lancaster, 2007)

Community Health Nurse

Chapter 1: Population-Focused Practice: The Foundation of Specialization in Public Health Nursing

Key Points

PUBLIC HEALTH

what we, as a society, do collectively to ensure the conditions in which people can be healthy.

CORE PUBLIC HEALTH FUNCTIONS

Assessment, policy development, and assurance; they are employed at all levels of government.

ASSESSMENT

refers to systematically collecting data on the population, monitoring the population’s health status, and making available information about the health of the community.

POLICY DEVELOPMENT

refers to the need to provide leadership in developing policies that support the health of the population; it involves using scientific knowledge in making decisions about policy.

ASSURANCE

refers to the role of public health in making sure that essential community-wide health services are available, which may include providing essential personal health services for those who would otherwise not receive them. Assurance also refers to ensuring that a competent public health and personal health care workforce is available.

Its setting is frequently viewed as the feature that distinguishes public health nursing from other specialties. A more useful approach is to use the following characteristics: a focus on populations that are free living in the community, an emphasis on prevention, a concern for the interface between the health status of the population and the living environment (physical, biological, sociocultural), and the use of political processes to affect public policy as a major intervention strategy for achieving goals.

According to the 1985 Consensus Conference sponsored by the Nursing Division of the U.S. Department of Health and Human Services, specialists in public health nursing are defined as those who are prepared at the graduate level, either master’s or doctoral, “with a focus in the public health sciences” (Consensus Conference, 1985).

Population-focused practice is the focus of specialists in public health nursing. This focus on populations and the emphasis on health protection, health promotion, and disease prevention are the fundamental factors that distinguish public health nursing from other nursing specialties.

POPULATION

collection of individuals who share one or more personal or environmental characteristics. The term population may be used interchangeably with the term aggregate.

IOM

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Public Health Nursing

Synthesis of nursing theory and public health theory applied to promote and preserve the health of populations.
Focus: whole community

and community's health status

Health Promotion and

Disease Prevention

Care in the context of

preventing disease and

disability and promoting and

protecting the health of the

community as a whole.

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Role of Public Health

Determinants of Health

Behavioral, social, physical, mental and

environmental health concerns of

communities and populations at risk

for compromised health.

Mission is to assure health promotion through safe and healthy environments.
Assure Health: Government, society, and health departments
Assessment: PH Nurse assessment of individuals and communities becomes data for policy development and program implementation
Policy: Address assessment issues, help prevent disease through program implementation ‘upstream’

(Stanhope & Lancaster, 2007)

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What Impacts Individual Health?

The individual is part of a broader community.
Individual health can be adversely affected when ”health determinants” are missing, unsafe, or impose a risk (i.e., education, social services, health services, employment, et al.)

(CDC, 2013)

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Individual Health Assessment

Health assessment may include questions and observations about determinanta:

Exposure to environmental toxins
Safety risks

Violence in home
Violence in community
Climate: (e.g., Tornadoes, Hurricanes, Fires, Monsoons)

Resource access and utilization
Education, knowledge, and understanding about how to prevent disease/adverse outcomes

CDC, 2018

Stanhope, M & Lancaster, J (2012).

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Health Promotion and Disease Prevention: ”Upstream” Approach to Health

A way for nurses to think about keeping people healthy before they become exposed and/or sick—nursing intervention is early in the causal process.
The fundamental approach by the nurse is health protection, promotion, and disease prevention:

Primary Prevention
Secondary Prevention
Tertiary Prevention

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Population-Focused & Individual-Focused

Health protection, health promotion, disease prevention
Upstream thinking: 1° 2° 3° Prevention
Focus is on care at individual level, while data tracking at a population level.

Example:

vaccinations of children to prevent disease

CDC, 2012

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Primary Prevention

Vaccination:

measles, mumps, rubella, chicken pox, tuberculosis, diptheria, tetanus, pertussis, et al.

Changing behavior to avoid risk:

Educating on the dangers of drug use, smoking, unprotected sex
Wearing a seatbelt to prevent injury
Teaching women about self-breast exam and when to see a provider

Activities that take place before a disease or injury is present to prevent it from occurring:

(CDC, 2018)

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Secondary Prevention

Screening to identify disease early

Blood pressure
Mammograam
Teaching women to conduct self breast exam (SBE) and when to contact a provider

Treating disease (e.g., diabetes)
Individual awareness of what to do if symptoms re-occur following treatment (e.g., cancer)

Activities that take place once the disease has already occurred to help treat, reverse, or stop the illness:

(CDC, 2018)

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Tertiary Prevention

Physical therapy after an accident
Screening after surgery (e.g., breast cancer)

Rehabilitation activities that will help the patient lead a normal life once the disease has already caused illness or injury:

(CDC, 2018)

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What Determines a Person’s Behavior About Health? �How does this impact the Community?

What is learned
Emotions
Education
Social status
Environment
Perceptions of risk

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Nursing Role in Levels of Health Promotion and Disease Prevention

Know policies and interventions to address risks to health
Make individuals and families aware of programs and resources
Educate Individuals about behavior and risk:

Infectious diseases and ways to prevent:

HIV/AIDS: Safe sexual practices
Vaccinations: measles, polio, mumps, et al.

Identify risks and respond if the individual is exposed

Assess the individuals living environment and access to resources
Connect the individual to necessary services

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Health Belief Model

Psychology-focused approach to explaining and predicting behaviors:

Focus on attitudes and beliefs of the individual as they relate to health and risk

Individual perspective:

Perceived susceptibility-chances of getting the condition
Perceived severity-seriousness and consequences of the condition
Perceived benefits-efficacy if action is taken to reduce risk
Perceived barriers-tangible and psychological cost of taking action
Cues to act: strategies of readiness
Self-efficacy: confidence in the ability to act

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Socio-Ecological Model –Mother-Baby

The health of mother and baby are influenced by surrounding systems

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Socio-Ecological Model

Emphasizes the links and relationships amongst health determinants and community systems

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Socio-Ecological Model

Mother and Baby are affected by the interaction of systems:

Microsystem: Family, Religious or spiritual practices, peers, employment
Exosystem: School, community, healthcare, military, information (e.g., media/news)
Macrosystem:

Cultural/Societal norms and practices
Climate and environment (e.g., hurricanes, tornadoes, monsoons, fires)
Socio-economic factors (e.g., trade and development)
Government and policy (e.g., health policies, education policies, military)

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Impact on individual health is dependent on multiple factors…

Culture

Individual Behavior

Family History & Genetics

Social opportunities

Resource Availability

Health and social services

Age & gender

Government

Education opportunities

Climate

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Critical Thinking Exercise

You are taking care of a woman with a newborn. How would you assess her situation? What health determinants will you prioritize? How will you instruct her (i.e., what resources will you use)

How would you modify your teaching plan if she was visually impaired? Unable to read? Had a cognitive or physical challenge? Develop a plan of approach

Use a model to develop a plan for your patient based on a specific need they may have.

Define the patient (e.g., mother with newborn)
Assess and determine needs
Develop a plan to address the need
Discuss the implementation of your plan
Discuss how and when you would evaluate the implementation of your plan
If you were a public health nurse, what data would you want to track and follow over time to promote health for future generations of women living in your community?

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References

Allender, J. A., Warner, K. D., Rector, C. L., & Allender, J. A. (2014). Community and public health nursing: Promoting the public's health. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health.

Bronfenbrenner, U. (1986) Ecology of the family as a context for human development: Research perspectives. Developmental Psychology, 22(6), 723–742.

Centers for Disease Control and Prevention, Department of Health and Human Services (2009). Retrieved July 18, 2018 http://www.cdc.gov/od/ocphp/nphpsp/essentialphservices.htm

Centers for Disease Control, (2013). Health impact assessment. Retrieved July 17, 2018 http://www.cdc.gov/healthyplaces/hia.htm.

Centers for Disease Control, National Public Health Performance Standards Program (2009). Retrieved July 18, 2018

http://www.cdc.gov/od/ocphp/nphpsp/EssentialPublicHealthServices.htm#es2

Public Health in America. (2009). Public Health Functions Project. Retrieved http://www.health.gov/phfunctions/project.htm

Smeltzer, S.C., & Bare, B.G. (2010). Brunner and Suddarth’s Textbook of Medical Surgical Nursing. (12^th ed.). Philadelphia, PA: Lippincott Williams and Wilkins.

Stanhope, M & Lancaster, J (2012). Public Health Nursing (8^th ed.). St. Louis: Mosby.

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