COMMUNITY HEALTH NURSINGAccording to American Nursing Association,“Community health nursing is a synthesis of nursing practice and public healthpractice applied in promoting and preserving the health of populations. thenature of this practice is general and comprehensive. it is not limited to aparticular age or diagnostic group. It is continuous and not episodic. Thedominant responsibility is to the population as a whole. Therefore Nursingdirected to individuals, families or groups contributes to the health of the totalpopulation. Health promotion, health maintenance, health education,coordination and continuity of care are utilized in a holistic approach to themanagement of the individual, family group and community. The nurse’sactions acknowledge the need for comprehensive health planning, recognizethe influences of social and ecological issues, give attention to populations atrisk and utilize 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 andinternationally 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,economicaspects, 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 meettheir needs. The basis of modern community health nursing is to share responsibility of helpingeach other. When it comes to considering a organization, equal participation of the peopleworking through the community groups/people with the people,for the people fortheir mutual benefit,change in behavior and health practices. A democratic team functioning is essential for effective delivery of health careservices.3)Philosophy that people in the community have the potential for continual developmentand 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 tosolve his or her problems. On the basis of this philosophy ,emphasis is placed on health education projectedtowards individuals in home,health centre, place of work, school, community placesor 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 productionand 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, preventand control diseases and disabilities and prolong life by providing need based, wellbalanced comprehensive health care services to community at large through organizedcommunity 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 issuescan increase the community’s capability to deal with the health problems in aeffective mannerPeople can be taught “how to care for themselves” through education,guidanceand 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 ofchildren.Continuous need based health educationnot only improves health knowledge andskills but also helps in developing positive attitude which brings change in healthbehavior.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 astrong political, legal and administrative support.3.To control and counteract environmentIt includes environment protection measures and changing reaction to environmentwhen some protection measures are not feasible.Protection measures are as follows:i. Safe drinking waterii. Clean air and soiliii. Safe disposal of refuse and excretaiv. Good social security and safetyChanging reactionsi. Mass Immunizationsii. Mass screeningiii. Mass prophylactic treatment4. To prevent and control communicable and non-communicable diseasesThis includes application all the three levels of preventive measures i.e:1) Primary level2) Secondary level3) Tertiary level
5.To provide specialized servicesIt provides specialized services for mothers,children,workers,elderly, handicapped andeligible couples,etc.6.To conduct researchTo conduct research to build up knowledge and contribute to further refinement andimprovement of community health practice.7.To prepare Health personnelTo prepare health personnel in the community for community health care services.Ultimate aim of community health care services is to reduce morbidity, mortality anddisability, improve nutritional status and increase life-expectancy at birth.Principles of community Health Nursing1) Community health nursing is an established based on recognized needs andfunctioning within the total health programme.2) The community health nursing agency has clearly defined objectives and purposesfor it’s services3) An active organized citizens group of the community group is an integral part of thecommunity health programme.4) Community health nursing services are available to the entire community regardlessof origin, culture or social and economic resources, and age, sex, creed, nationality,political affiliation5) Community health nursing recognized the family and community as units of service.
6) Health education and counseling for the individual, family and community are theintegral part of community health nursing.7) Recipients of health care should participate in planning relating to goals for theattainment of health8) 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 patientand there should be proper continuity of services to patients.10) Periodic and continuous appraisal and evaluation of health situation of the patientsare basic to community health nursing.11) The community health nurse should function/serve as an important member of thehealth team.12) There should be provision for qualified nurse to make supervision for community healthservices.13) The community health nurse does not provide material relief to patients, but directsthe patient to appropriate community resources for necessary financial and socialassistance.14) The community health nurse should not accept gifts or bribes from the patients15) The community health nurse should not belong to one particular section or politicalgroup.16) Community health agency should provide a continuing education programme fornurse17) The nurses assume responsibilities of their own continuing professional developmentthrough acquiring higher and higher education and forming and strengthening theprofessional associations
18) The community health nursing services should develop proper guidelines, inmaintaining records and reports.19) There should be proper facilities and job conditions.20) The community health nurse should maintain professional relationship with all leadersin the community and maintain ethics at all times.Quality assurance in community health nursingDefine quality assuranceQuality assurance can be defined as ”the promise or guarantee that certain standards ofexcellence are being met in care delivered.”Goals of quality assurance:1) To ensure the delivery of quality client care2) 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 approach2) Specific approach1)General ApproachIt involves examining the ability of the person or the agency to meet the criteria andstandard.
Assessing the credentials is defined as ” formal recognition of a person as a professional withtechnical 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 product2) To confer a unique identity.eg.registered nurse3) To protect the provider and public4) To control the professionThe agencies or person who have been found to posess sound credentials are putthrough procedures like1) Licensing2) Accreditation3) Certification1)LicensureIndividual licensure is acontract between the profession and the state in which the professionis granted control over entering in and out of profession and over the quality of professionalpractice.2) AccreditationState boards of nursing accredit basic nursing programmes, since the graduatesbecome eligible for licensing examination.
Accreditation function is a voluntary approach which is connected to thegovernamental regulation that encourages programmes to be involved in theaccrediting process.3)CertificationIt is another general approach which combines features of both, accreditation andlicensure.Educational achievements, experience and performance in an examinationdetermine a person’s qualification for functioning in an identified specialty area suchas community health nursing.Other general approaches:1) CharterIt is a mechanism by which a governmental agency under state laws grantscorporate status to an institution with or without rights to award degrees.2) RecognitionIt is the process whereby one agency accepts the status of another agency as confirmed bythe assessment of its credentials from a known person in the community or organization.3) Academic degreesThese 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 eachdegree level,
i)Bachelor of Science in Nursingii)Master’s Degree-Master’s of Science in Nursingiii)Doctoral degrees-Doctor of Philosophy,Doctorate of Nursing science and Doctorate inNursing.2)Specific approachGoals of specific approach are as follows:I. To identify problems between provider and clientII. To intervene in problematic cases.III. To provide feedback regarding the interaction between the client and theprovider.IV. To document the interaction between the service provider and the client.Specific approaches are usually implemented by agents and service providing groups whoare interested in the quality of interaction between the client and the service providerSpecific approaches to quality control are as follows:1)staff review committees(Peer review)2)utilization review committees3)research studies4)Client satisfaction surveys5)malpractice litigationMODEL QUALITY ASSURANCE PROGRAMME
Purpose-the primary purpose of a quality assurance programme is to ensure the results of anorganized activity are consistent with expectationsStructureValue identification forms a very integral part of the quality assurance programmeIn order to accompalish these formulated objectives the following steps need to befollowed:1)identify the sources needed2)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 shouldbe clearly laid down for useStandards of structure are evaluated internally by a group of people likeadministrators,management and staff members.ProcessThe primary approach used for process evaluation includes the peer groupcommittee 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 theproblem and discharge data that may point out changes in the level of dependenceand 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 assuranceEvaluation of the process should be carried out at major intervals and periodic reportsshould 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 qualityassurance programme.Punctuality and performance are needed to evaluate the individual based ontraditional trait ratings.Objective oriented action tools are developed in consultation with supervisor and thenurse.Nursing AuditStaff review committees are the most common review committees designed toassess 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 audit2) Retrospective audit1) concurrent auditconcurrent audit is used by Medicare and Medicaid to evaluate care beingreceived 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 careIII. 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 consumingii. More costly than to implement the retrospective auditiii. Because care is ongoing it does’t represent the total picture of the care thatthe client will ultimately will receive.Retrospective AuditRetrospective audit or outcome audit evaluates the quality of care throughappraisal of the nursing process after the client’s discharge from the healthcare system.Advantages of retrospective audit are as follows:1) Comparison of actual practice to standard of care2) Analysis of actual practice findings3) 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 beonly used to improve the care of the future.COMMUNITY NURSING THEORIESThe models or theories which are applicable to the educator in Communityhealth Nursing are as follows:PRECEDE MODELResearcher green describes health education as a combination ofexperiences to encourage healthy habits:The model PRECEDE is an acronym for predisposing,reinforcing andenabling causes in educational diagnosis and evaluation.Two basic propositions underscore the outcome oriented PRECEDEmodel.They are:1)Health and health behaviours arecaused by multiple factors.2)Health education designed to influence the behavior must bemulti-dimensional.Health Belief ModelHealth Belief Model is divided into three major components:1) Individual Perception
2) Modifying Factors3) 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) Age2) Sex3) Race4) Ethnicity5) Personality6) Social class7) Pressure8) Reference groupThis model is helpful in looking at health protection or disease-preventivebehavior.Data regarding health assessment is gathered together andorganized for looking at client status.Health promotion model
Pender (1987) developed this model to be used as a complement to healthprotecting models like Health Belief Model.determinants of health promotionbehavior are organized into:Cognitive-Perceptual factorsThey include factors like:i. Importance of healthii. Perceived self-efficacyiii. Definition of healthiv. Barriers to health-promoting behavior.Modifying factorsThey include;i. Demographic factorsii. Biological characters like body weight,interpersonal influences, familypatterns of health care.CONCEPTUAL MODELS FOR COMMUNITY HEALTH NURSINGA 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 theirthinking, observation and interpretation.Conceptual models are approximations or simplifications of realitybased on concepts. A conceptual model cannot be tested directlybecause the concepts are not operationally defined and therelationships are not observable.People in the community have continuous interaction with environment.Hence the conceptual model has significant application in communityhealth nursing.Models applicable to Community Health Nursing Practice1) System Model2) Developmental Model3) Interaction model1)System ModelIt focuses on the organization, interaction, interdependency andintegration 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 acomplex of elements in mutual interaction.”
Characteristics of system model:The charachteristics of the system model are as follows i.ewholeness,organization,openness,boundary and entropy.WholenessWholeness refers to property of asystem in which collection of parts respondsas an integral single unitOpennessOpenness refers to the extent to which it exchanges energy with theenvironment,in an open system there is input and output of environment,but ina closed system there is no exchange of energy.BoundaryBoundary refers to a border that defines what elements comprise the system.EntropyEntropy is a concept based on a major implication of the second lawthermodynamics,which states that elements in a closed system will proceedtowards greater randomness or less order.Feedback
Feedback is the process whereby the output of the system is redirected as theinput to the same system.Application to Community Health NursingThe community is a social system made of interrelated subsystems.The subsystems include economic, educational, religious, health care,political, welfare. law enforcement, energy and recreational systemsThey are interrelated and have a specific orientation towards eachother.2. Developmental ModelIt is a way of thinking how changes occur based on theories ofdevelopment of the human organization.According to Lewis,the change may be both reactive and structural.The reactive theory emphasizes the influence of environment indevelopment programmes,and the structural theory emphasizes thegenetically determined programme for developmentApplication to Community Health Nursing Practice:It is useful in working with infants and children,because the major role ofa nurse working with them is to assess the developmental progress andto promote overall growth and development.
3.Interaction ModelThese models are based upon theories that stem from philosophicalwritings such as those of Cooley(1969) and Mead(1934).The major concepts used in interaction models arecommunication,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 ityhealth nursing.2) Self-ConceptionThis is an important aspect of health and well being.It influences theperson’s readiness to accept healthcare.So it is important that the nurse is attentive for cues that lead towardssuch realization and help the concept of self positively.3) PerceptionPersons having individual differences will perceive incidents differently.
Perception is affected by previous experience including attitude,beliefsand socializationBibliography:1) Lucita M. Public health and community health nursing in the newmillennium. 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 ofaggregates,families and individuals. 4th ed. St.Louis:Mosby;1996.p.