University of Tennessee, Knoxville

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University of Tennessee Honors Thesis Projects University of Tennessee Honors Program
5-1995
Concepts in Community Health Nursing: A
Family Study
Mary Margaret Rueff
University of Tennessee - Knoxville
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Recommended Citation
Rueff, Mary Margaret, "Concepts in Community Health Nursing: A Family Study" (1995). University of Tennessee Honors Thesis
Projects.
http://trace.tennessee.edu/utk_chanhonoproj/134
1 Community
Running head: COMMUNITY HEALTH
Concepts in Community Health Nursing:
A Family study
Mary Rueff
University of Tennessee, Knoxville
College of Nursing
2 Community
Abstract
This project will explore concepts in community health nursing
utilized in giving comprehensive nursing care to a client and
family in the Knoxville community. Each phase of the nursing
process will be discussed as well as appropriate tools and
methods used in each phase. It will describe methods commonly
used to assess the community environment, individual and family
group needs, family strengths and coping abilities, and current
and potential barriers to health care. It will also discuss
current and potential interventions or resources used to assist
the family and client toward a more optimum level of functioning.
This project will include recommendations for incorporating
community health concepts into the changing health care paradigm.
Finally,the author will reflect on her personal and professional
growth as a result of this nursing experience with the family
and the community as client.
3 Community
Concepts in Community Health Nursing:
A Family study
Community health nursing is a unique division of health
care in that its focus is on populations rather than individuals.
In this way, a nurse develops an awareness of health risks in
her clients by assessing those of the community as a whole.
Beddome, Clarke, and Whyte (1993) state that "health cannot
be viewed in isolation from the social, political, and physical
environments that people live" (p. 16). Rather, a health care
provider must consider many factors that influence the health
of a client "such as housing, literacy, nutrition, child care
and employment" (p. 16). Clemen-Stone, Eigsti, and McGuire
(1991) point out that by addressing "both the personal and
environmental aspects of health [the nurse can] deal with
community factors which either inhibit or facilitate healthy
living" (p. 50). By focusing on preventive care rather than
curative care, the community health nurse directs resources
toward high risk aggregates and families. Ruth and Partridge
(as cited in Clemen-Stone et al., 1991, p. 50) state that this
allows available resources to be managed more efficiently.
Historical Perspective
The concept inherent in community health nursing has been
in operation since before the turn of this century (Zerwekh,
1992, p. 84). Lillian Wald founded American Public Health
Nursing during the 1890s in response "to the needs of the
populations at greatest risk in our society" (p. 84). Wald
4 Community
described the public health nurse's role as providing an entry
point for health services into the lives of high risk populations
who otherwise were not exposed to health care (as cited in
Zerwekh, 1992, p. 84).
Zerwekh (1992) points out several characteristics of public
health nursing in Lillian Wald's era that continue to be
prevalent today. For example, Zerwekh describes the
responsibility of public health nurses in the early 1900s to
"make inquiries as to who was in need of help" (p. 86). She
then states that "finding people in the community who are in
need of services is a skill that still distinguishes community
health nursing from acute care nursing" (p. 90). Therefore
casefinding, a role unique to community health nurses today,
has been such since the days of Lillian Walde
The importance of building trust as the foundation for
the client-nurse working relationship is another characteristic
of community health nursing that remains unchanged. In the
writings of Lillian Wald (as cited in Zerwekh, 1992), public
health nurses are described as "steady, competent, and
continuous" (p. 87) as they developed trust through persistence.
Establishing trust continues to be essential in the therapeutic
relationship in that most clients encountered by the community
health nurse have little experience trusting outsiders (Zerwekh,
1992, p. 18).
Zerwekh (1992) states that the central goal of the public
health nurse remains the same today as in the days of Lillian
5 Community
Walde This goal is to "encourage self-help by promoting capacity
to make healthy choices" (p. 90). Clarke et ale (1993) refer
to this concept of enabling clients to make informed decisions
about their health as "empowerment" (p. 308). Zerwekh (1992)
gives an example of this when she refers to the impact of
community health nursing on maternal-child health care: "Instead
of learned helplessness, the woman begins to learn
self-helpfulness" (p. 19). In this way, the client plays an
active role in her health care by making choices for herself
and her family. This approach also preserves the client's rights
which are often infringed upon when one enters the health care
delivery system. These rights include "the right to be
autonomous, the right to make an informed decision, and the
right to one's domain, including one's body, life, property,
and privacy" (American Nurses' Association, 1986, p. 3).
Home Visiting
The primary technique for assessing a community's health
risks is home visiting. Despite the variations in family
structure that are present in the United states today, "the
family is still the basic social unit in our society"
(Clemen-Stone et al., 1991, p. 184). This is important to
consider in health care delivery due to the tremendous impact
that the family has on one's health choices and behaviors.
Through home visiting, "nurses enter the environment in which
people live, and they practice in this environment, in sharp
contrast to the situation where the client enters the nurse's
6 Community
environment in a hospital or clinic" (p. 50). This is an
especially valid point to consider when attempting to provide
preventive care to clients and families who are relatively
isolated and thus do not receive regular health care. Many
aggregates served by community health nursing would otherwise
have no or very little access to the health care delivery system.
By utilizing primary and secondary prevention strategies, high
cost emergency room visits may be avoided for these aggregates.
Unfortunately this is currently where most at risk groups enter
the health care system when they are "forced to by pain or
debility" (Reifsnider, 1992, p. 70). Home visiting also gives
the nurse an opportunity to assess the family in context. Using
this strategy allows the nurse to "uncover the causes of signs
and symptoms that present in isolation in a clinic examining
room" (Zerwekh, 1991, p. 30). Zerwekh (1991) points out that
the task oriented nature of medical clinics often overlooks
the biopsychosocial issues that impede health and well-being
(p. 30). She goes on to say that "morbidity can be diagnosed
in the clinic; [but] the environmental and psychosocial origins
of morbidity are found where people live and work" (Zerwekh,
1993. p. 1677).
Critical thinking and intuition are essential in doing
a home visit. Zerwekh (1991) emphasizes this point by studying
the stories of several public health nursing experts. In all
of the personal experiences of these nurses, there was one common
thread: potentially dangerous patterns were identified in a
7 Community
home visit that would not have been visible outside the client1s
environment. In other words, IIhome visits permit an accurate
ll
view of what is really going on (p. 32).
Nursing Process
Assessment
Environmental Assessment
In assessing the home atmosphere, however, the nurse must
do an equally accurate assessment of the environment surrounding
the home. Mary Bayer (1973) states that this assessment is
most telling when all of the nursels senses are used to get
a IIfeel
li
for the community (p. 712). There are numerous health
hazards present in the community environment that can only be
identified through this preliminary observation (Zerwekh, 1991,
p. 34). Examples of these include, but are not limited to,
inadequate sanitation, lack of proper waste disposal sites,
open ditches, lack of recreational areas, stray animals, and
unusual odors. One way for a community health nurse to complete
this initial observation is by doing a IIwindshield
li
assessment
of the client1s or family1s community (Stanhope & Knollmueller,
1992, p. 41). This type of evaluation is a process that helps
the community health nurse in lIidentifying objective data which
will help define the community, the trends, stability, and
changes that will affect the health of the populationll (p. 41).
This gives the nurse a data base on which to build with
additional information obtained from the family or client.
She can then identify strengths, weaknesses, and potential
8 Community
problems in the community, as well as available resources or
lack there of. This provides a "basis for health planning •
• • [and] a knowledge base to correct deficiencies in the health
care system" (Clemen-Stone et al., 1991, p. 85-86). Correction
of these deficiencies fulfills the community health nurse's
primary responsibility to the community as a whole. Clemen-Stone
et ale (1991) point out yet another use for this environmental
assessment in that it provides rationale for marketing decisions
about what nursing services are needed in a community and at
what depth these should be maintained (p. 86).
The following is an environmental assessment performed
in the community surrounding the horne of a Knox County Health
Department client on October 14, 1994. The residence is within
a group of public housing projects. These homes are red brick
dwellings connected to one another and in rows, surrounded by
a black iron fence. There are openings in the fence without
gates that give access to a busy two-lane street running in
front of the homes. This client's horne faces this busy street.
There is one opening between each row of homes for a car to
pass through into a concrete parking lot between each building.
Therefore each parking lot has only one entrance/exit. The
lawns of these homes are fairly well groomed. Most of the lawns
behind the homes contain clothes lines. The homes on either
side of the public housing projects are primarily wood homes.
The lawns of these homes are not kept, and there is considerable
debris and clutter visible around these houses. Many of them
9 Community
have boards over the windows and doors, and thus appear to be
condemned. Less than one street over (across the two-lane street
mentioned above) are considerably nicer homes. They are wood
homes close together, but these homes appear to be better
maintained as evidenced by the condition of the paint and lawn.
Many of these homes have bars on the windows or are surrounded
by chain-link fences that have signs indicating security company
protection.
The physical environment of the community is rather crowded
and cluttered. There appears to be no open play areas or parks
available for public use. Knoxville College is approximately
2 blocks from this home. Behind the college are two outdoor
basketball courts and a track and field area. However, the
college is surrounded by a chain-link fence and barbed wire.
Thus it does not appear to be for public use. There is also
a playground behind the Urban Community Vision establishment
about ~ mile from the home, but this too is fenced in. Several
undeveloped vacant areas are present in the community.
Approximately 100 yards from the home is a large gravel lot
about the size of a basketball court. There are three cars
parked in the area whose passengers seem to be conversing, so
this is presumed to be a vacant lot rather that a parking lot.
Adjacent to this area is another concrete vacant lot surrounded
by a chain-link fence. There is a net set up in the lot, but
a sign on the fence says, "No Trespassing." About 100-200 yards
down the two-lane street from the home is a large lot surrounded
10 Community
by a high chain-link fence. The lot is filled with hundreds
of tires and considerable debris. It appears to be associated
with an adjacent tire store, but tall weeds are visible growing
through and around the tires. This gives the impression that
this lot is essentially a junkyard. Less than a 1 ~ miles from
the home is a very large dirt hole that appears to be a swimming
pool under construction. There are no fences or ropes around
the area, and therefore this area may be hazardous.
There are several small community markets present in the
community within 2 miles from the home. These include a Bi-Lo
market, a snack bar, a supermarket, a Rexall drug store, and
a liquor store. All of these establishments are quite small
with virtually no available parking space. Most have bars on
the windows and do not appear clean from the outside (i.e. litter
and debris in front, broken sidewalks, unclean windows). There
are also several buildings in the community that appear to have
been stores at one time, but are now closed and boarded up.
There are three gas stations within this radius including Pilot,
Fina, and Phillips 66.
Various industrial establishments are observed within a
2 mile radius of the home. These include the Knox County
Extinguisher Company, a small furniture store, a window company,
ADF Welding Shop, and the Coca-Cola Bottling Company. All appear
to be in moderate to good repair from an outside windshield
observation. No land used for agricultural purposes is observed
in this community.
11 Community
The streets in the community are all paved, though many
potholes are present. These are the only type of geographical
or topographical obstacles to travel noted. The residential
streets are quite narrow with cars parked along the sides of
the streets in front of the homes. There are also children's
toys and bicycles along the curbs. The two-lane street running
in front of the home is the most obvious geographical boundary
noted. On one side of the street are the public housing
projects, vacant lots, and boarded up or condemned buildings.
On the opposite side are most of the nicer homes and small
markets.
The sanitation of the community appears to be adequate
from the windshield view. There is not a significant amount
of litter visible. There is considerable clutter noted around
the homes and in the lawns, but these items appear to be of
a residential nature (i.e. furniture, toys, car parts). There
is not as much clutter around the homes in the public housing
project as there is around the other homes. There is a large
trash receptacle behind each row of these homes. No unusual
odors are noted, but the assessment takes place through a
windshield.
Electric lines and utility poles are visible throughout
the community. There are two public pay telephones in front
of a market just across a street from this client's home. There
are several clothes lines hanging throughout the housing projects
and other homes in the community. A laundromat is located
12 Community
approximately 2 blocks from this client's home.
Multiple domestic animals are noted wandering freely
throughout the community. These are mostly dogs, and some are
wearing collars while others are not. Cats are noted as well.
In a few of the houses across the two-lane street from this
client's home, the pets are kept inside a chain-link fence.
Around the housing projects, however, the animals are not
restrained. It is not distinguishable whether these are stray
animals or pets belonging to people in the community.
The residents of this community are predominately black.
The social atmosphere appears to be quite casual rather than
structured. This is evidenced by the groups of adults and
adolescents clustered in various places conversing. In the
public housing sector, groups of adults sit on the porches while
children play in the lawns in front of the homes. Behind the
buildings, groups of young males stand talking to one another.
Quite a few adults and children can be seen walking along the
roads and sidewalks, some are in clusters and some are alone.
Small children are noted crossing the street without adult
supervision. As stated previously, Knoxville College is located
about 2 blocks from this home, but these grounds do not appear
to be open to the public. The Knoxville Police Academy Moses
Center is about 4 blocks from this home. A child development
center is in the vicinity of the home, approximately 3 blocks
from the public housing projects. There is playground equipment
visible behind this building enclosed in a chain-link fence.
13 Community
Several public elementary schools can be found in the community.
There is also a Head Start Program in the community less than
~ mile from this client's home. This building is adjacent to
a fenced in playground as well. About five to seven school
buses are parked in front of this building. There is a public
library located less than ~ mile from the home. It is a brick
one story building in good repair that is about the size of
a small house.
In driving through the community, approximately nine
churches are noted within no more than a 2 mile radius of the
home. These include four Baptist churches, one Trinity Chapel,
one AME Zion church, a House of Prayers, a Church of God in
Christ, and one Methodist church. All of these churches are
wood buildings in relatively good repair, but quite small and
located among the homes. The Methodist church is an exception
to this description. It is a much larger stone building located
away from the homes with a fence enclosing much larger grounds.
Several seemingly new vans are parked behind the church bearing
the name of the church.
There are several small establishments that possibly serve
as social gathering places for the members of this community.
These include several bars and taverns, a billiard hall, small
delis and cafes, and a lounge. Most of these establishments
have varying degrees of clutter around them, and the windows
are soiled with dirt and grease to the point that one cannot
see through them. No movie theatres or auditoriums are found
14 Community
in the community. The child development center mentioned
previously is the only possible children's recreational center
observed.
Several health centers are noted in the community in close
proximity to this client's horne. These include a community
horne health agency, a dental center, and an eye center within
2 miles. A medical clinic is within 1 mile. Its hours of
operation are Monday, Tuesday, Thursday, and Friday-- 9:30 A.M.
to 1 P.M. and 3 P.M. to 6 P.M. Wednesday-- 3 P.M. to 6 P.M.
and Saturday-- 9 A.M. to 1 P.M. The Knox County Health
Department Main Clinic is within 1 ~ miles. East Tennessee
Children's Hospital and its satellite Non-Emergency Care Center
as well as Fort Sanders Regional Medical Center are all within
1 ~ miles.
Many automobiles are observed parked along the streets
and driving through the community or behind the public housing
projects where this client lives. It is interesting to note
the wide variations in the value of cars observed. For example,
they range from rather expensive and highly customized cars
to inexpensive older cars in poor condition. At least two bus
stops are noted within 2 blocks of this client's horne, and this
community is located less than 1 mile from access to Interstates
640 and 40. It is also within mile of western Avenue and
Middlebrook Pike. There are at least two police cars noted
cruising through this community, and several cruisers are parked
in front of the police academy mentioned previously.
15 Community
Neighborhood crime prevention signs can be seen tacked to
numerous utility poles. There is a City Fire Department Station
about 3/4 mile from the home, but no fire hydrants can be seen
on the blocks containing rows of public housing projects.
The overall impression of this community is that of an
unhealthy subgroup of the population. This assumption is based
on the World Health Organization's definition of health as
"complete physical, mental and social well-being and not just
the absence of disease" (as cited in Clemen-Stone et al., 1991,
p. 24). The disease state of this community cannot be accurately
assessed in the windshield assessment. However, a glimpse into
the mental and social well-being of the community is possible.
The lack of recreational facilities or suitable play areas,
and the lack of proper supervision of many children is evidence
of incomplete social well-being. The bars on the windows of
almost all commercial establishments and the distinct differences
noted on either side of the two-lane street suggest impeded
mental well-being in that these suggest feelings of disparity
and insecurity. Clemen-Stone et ale (1991) state that the term
health "assumes that people always have the potential for higher
levels of functioning and that people in all stages of living,
. •• , are growing and developing" (p. 53). This potential
is not clearly represented in the community when one considers
its crowded living conditions and lack of social development.
However certain systems, such as the Head Start Program, numerous
neighborhood watch signs, health clinics, and education programs,
16 Community
are in place in the community as a possible attempt to promote
more complete health and well-being in this population. A
distinct opportunity exists for a community health nurse to
develop this potential further by such activities as lobbying
for a playground with safe equipment to replace the vacant lot,
organizing community supervised play groups, or providing
parenting education classes.
Multidimensional Family Assessment
After assessing the environment surrounding the client's
horne, the community health nurse must again employ all of her
senses to assess the other factors that influence the health
behaviors of her client. The next portion of this paper will
explore the multidimensional factors affecting the health of
J. R., a referral from the Pediatric Clinic of the Knox County
Health Department. J. R. is being followed for a possible
nutritional deficit and for a history of chronic otitis media.
The purpose of this assessment is to form a data base to refer
to when analyzing, planning, and intervening in the health
promotion and illness prevention of J. R.
According to Clemen-Stone et al. (1991), "the actions and
health status of one family member always affect the behavior
and health status of all other family members" (p. 267).
Therefore when attempting to positively influence the health
and well-being of an individual such as J. R., the community
health nurse cannot view the client in isolation. Clemen-Stone
et al. (1991) refer to this comprehensive examination of family
17 Community
health as discerning "functional and dysfunctional
characteristics of family dynamics" (p. 268). It is essential,
however, that when performing this assessment, the community
health nurse keeps her personal values and beliefs separate
from her clinical judgment (A. Blatnik, personal communication,
November 4, 1994). This is "because dysfunctional or maladaptive
behavior in one family can be functional or adaptive in another"
(Clemen-Stone et al., 1991, p. 270). Therefore, to accurately
determine whether the family unit is meeting the physical,
emotional, growth, and development needs of its members, the
"family's perceptions about how well it is functioning must
be the key factor which helps a nurse to determine whether or
not a family is reaching its potential" (p. 270).
Health needs.
The health needs of all family members must then be
addressed to determine the needs of individuals and of the family
unit as a whole (A. Blatnik, personal communication, November
4, 1994). If the community health nurse is attempting to provide
health care for one family member in isolation, while ignoring
the health concerns of other members, she may overlook an
important barrier to health promotion of the client she is
attempting to treat. Often all that is needed for another family
member is referral, but in this way the nurse has identified
other stressors in the family while emphasizing her role in
serving the family as a unit. J. R. is an 18 month old male
client with a history of anemia, chronic otitis media, chronic
18 Community
respiratory infections, and possible developmental delay. He
is currently enrolled in the WIC program, and WIC has been
involved in encouraging J. R.'s mother to supply iron-rich foods
for J. R. He underwent tube placement in both of his ears on
November 2, 1994 at East Tennessee Children's Hospital. He
receives breathing treatments at home every four hours which
his mother administers. The supplies for these treatments are
from Abbey Home Health Care. J. R. is believed to be
developmentally delayed in that he is not yet able to walk and
still drinks from a bottle. He receives primary care from Nancy
Jackson, PNP at the Knox County Health Department. J. R.'s
development seems to be his mother's biggest concern as evidenced
by the amount of time that she spends talking about this in
comparison with J. R.'s other apparent health needs. J. R.
is currently enrolled in day care when both of his parents are
working, and his mother states that he has adjusted quite well
to that environment. J. R.'s mother describes herself and J.
R.'s father as "pretty healthy" with no significant health
problems. J. R.'s parents do not have a primary care provider
and do not receive regular physical examinations. J. R.' s
family needs to be followed quite closely to assist them in
providing a more stimulating environment to foster J. R.'s
physical and psychosocial development. This might include
assisting the family in involving J. R. in a program for children
at high risk for developmental delay. J. R.'s mother also needs
guidance and support in providing appropriate food for J. R.
19 Community
and taking steps to prevent further respiratory and ear
infections. The parents need to be informed about the importance
of providing primary care for themselves as well.
Horne environment.
Upon entering the client's horne, the nurse must alert
herself to certain factors existing or not existing within the
internal horne environment that could affect the family's health
status. These include the number of persons living in the horne,
the size and condition of the horne, facilities for privacy,
and safety features or hazards present in the horne (A. Blatnik,
personal communication, November 4, 1994). These factors clearly
affect the health and opportunities for growth and development
of the family unit and of its members. Therefore, assessment
of this nature cannot be overlooked. J. R. and his mother and
father live in a two-room apartment. The entry room contains
a double bed, an end table with a television on it, a portable
electric heater, a high chair, a lounge chair, a cabinet with
stove and sink, a table, and a refrigerator. The room is very
small, and there is very little room to move about. There are
various items, such as a stroller, walker, and clothing, piled
on the floor and on the counter top. There is a full dish drain
on the counter and the sink is full of dishes as well. The
double bed is covered with a mattress pad, a thin brown blanket,
and two pillows without pillow cases. The mattress pad has
brown and yellow stains on it, and the child is sitting in the
middle of the bed eating cookies. Crumbs and dirt are noted
20 Community
on the mattress pad as well. The floor around the bed is covered
with a red carpet, which is soiled with crumbs, dust, and dirt.
Adjacent to the kitchen area is a smaller room containing a
crib, a couch, and a chest of drawers. A large portable radio
is on top of the chest. The floor is covered with several
laundry baskets and piles of clothing, and there is even less
space to move about in this room. Adjacent to this room is
a small bathroom with a sink, toilet, and bath tub. Insects
are noted crawling along the sink, and piles of clothing and
towels are noted in the floor. There is a window in the front
room with curtains, but the only electric light source in this
room is in the kitchen area. Therefore, the mother frequently
keeps the door to the apartment open. There is a burnt out
light bulb in the back room and a functioning electric light
in the bathroom. The family needs guidance and support in ways
that they can foster physical development in J. R. with the
little space that they have available. They also need
information regarding safety hazards in the home such as the
portable heater and leaving the apartment door open.
Family structure.
The structure of the family is important to assess in that
despite the recent societal changes in family life, the family
remains the "most fundamental, powerful, and lasting influence"
(White House Conference on Families as cited in Clemen-Stone
et al., 1991, p. 184) on the lives and choices of individuals.
However, the nurse cannot make assumptions about a family's
21 Community
ability to provide for its members physically and emotionally
based only on assessment of the family's organizational structure
(Clemen-Stone et al., 1991, p. 187). According to Orr (1992)
practitioners engaged in home visiting must be prepared to cope
with diverse patterns of family units without viewing "deviations
from the so-called 'normal' family unit. as problems needing
special attention" (p. 123). Instead the nurse uses her
information gathered about the family structure to analyze family
strengths and needs, and to enhance family growth and support
regardless of their family life-style. According to the
traditional family structures presented by the 1970 White House
Conference on Children and C. Ahrons (as cited in Clemen-Stone
et al., 1991), J. R.'s family would be considered a "Nuclear
family-- dual career" (p. 186). This conclusion is based on
J. R.'s mother's report that she and her husband are both
employed, and the two parents and one child are the only
individuals living in the household.
The nurse should also be aware of how family patterns shift
over time in relation to structure, function and circumstance
(Orr, 1992, p. 124). Stanhope & Knollmueller (1992) present
the stages of family development and the appropriate
interventions for the community health nurse "in assisting
families to move successfully through life stages, thereby
reducing the risk of illness or crises" (p. 97). J. R.'s family
is in the "family with preschool and school-age children" stage.
The role of the nurse with this family would include monitoring
- - - - - - ~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - . .
Community 22
early childhood development, coordinating with pediatric
services, counseling on nutrition and environmental safety in
the home, and teaching hygiene measures (p. 97).
Family culture.
Exploring the cultural beliefs of a family is essential
in the multidimensional assessment. This is because one's
cultural environment "greatly affects how growth progresses
and what decisions are made about how to handle activities of
daily living" (Clemen-Stone et al., 1991, p. 202). The purpose
of a cultural assessment in community health nursing is to gather
information relevant to health and health practices and to
identify patterns that assist or interfere with healthy behaviors
and intervention (P. Miller, personal communication, September
12, 1994). Relevant information may include nutritional
practices, "childrearing beliefs, attitudes toward health care,
and personal faith in a deity" (Whaley & Wong, 1991, p. 210).
An assessment of the religious orientation of the family must
be included in the cultural assessment because it "dictates
a code of morality as well as influencing the family's attitudes
toward education, male and female role identity, and attitudes
regarding their ultimate destiny" (p. 35). In addition to the
impact that these attitudes have on health, the family's
religious background has a direct impact on an individual's
beliefs regarding illness, injury, or death (p. 49). Even if
the family does not appear to be involved in an organized
religion, the community health nurse cannot assume that
23 Community
spirituality does not playa significant role in their life.
Personal spiritual beliefs are often a source of comfort for
a family dealing with crisis or an ill member (Clemen-Stone
et al., 1991, p. 205). When the nurse is sensitive to the
religious and spiritual implications of health-related treatment
and intervention, "it is comforting to the family ••• to have
this need recognized and respected" (Whaley & Wong, 1991, p.
49). The nurse can then individualize her planning and
implementation strategies for each family.
Several characteristics of the culture of poverty as
outlined by P. Miller (personal communication, September 12,
1994) are exhibited by the family of J. R. These include their
lack of privacy, low level of education, and sense of
confinement. However, these people do not seem to lack future
orientation as evidenced by J. R.'s mother's comments concerning
her desire to buy a house. This family does not appear to
be involved in an organized religion in that the mother states
that they go to a "Knoxville church every once in while but
not much." There are various items in the home that reflect
the family's spirituality such as a picture on the wall with
the phrase "God Bless Little Boys."
Developmental assessment.
Assessing the developmental level of family members is
essential in order to determine the family's perception of its
own health status (Clemen-Stone et al., 1991, p. 270). According
to Erikson's theory (as cited in Whaley & Wong, 1991), at
24 Community
progressing stages of psychosocial development an individual
is "confronted with a unique problem requiring the integration
of personal needs and skills with social demands and cultural
expectations" (p. 123). Erikson refers to the individual's
struggle to adjust in the face of this problem as a "crisis"
(p. 123), and believes that "the tension produced by societal
demands must be reduced in order that a favorable outcome can
be achieved" (p. 123). This outcome "provides the resources
for coping" (p. 123). It is therefore essential to evaluate
the developmental level of each family member, rather than only
that of the individual client, to give insight into the family
unit's resources for coping. Erikson describes the major task
of the infant from 1 to 3 years of age as "autonomy vs shame
and doubt" (p. 123). J. R. exhibits a few characteristics of
this stage of development in that he attempts to manipulate
his environment by crawling, reaching for things, and imitating
adults to a limited extent. Erikson's previous stage of "trust
vs mistrust" (p. 123) is characterized by an infant being able
to tolerate "little frustration or delay in gratification" (p.
545) and continuation of oral stimulation as the primary mode
of gratification (p. 545). J. R. continues to exhibit
characteristics of this stage as well, as evidenced by his
inability to accept delayed gratification and continuous use
of the bottle. Erikson's stage of "intimacy vs isolation"
(p. 124) is commonly associated with early adulthood. In this
stage the individual develops intimate relationships with friends
25 Community
and significant others rather than becoming socially isolated
(p. 124). J. R.'s mother, age 25, exhibits characteristics
of this stage in that socializing with neighbors seems to play
a significant role in her daily life. J. R.'s father, age 26,
is not present for this assessment. Based on Erikson's
description of the young and middle adulthood stage of
"generativity vs stagnation" (p. 124), in which an individual's
energy is directed toward nurturing the next generation, it
is possible that he would be included in this stage since he
currently holds two jobs.
J. R.'s family is in need of intervention to help them
cope with J. R.'s developmental delay. However, they also need
assistance with understanding the level that J. R. is currently
functioning and how this influences the kind of care that he
needs. For example, J. R.'s mother needs to be aware of his
emerging sense of autonomy and desire to manipulate his
environment. This would mean that her stepping outside to smoke
with her friends while J. R. plays on a bed is not appropriate,
especially if an electric heater is on near the bed.
Education.
The educational level of the family members is another
component of the multidimensional assessment of the client's
family. According to White (as cited in Clemen-Stone et al.,
1991), educative nursing is one of the main categories of
community health nursing intervention (p. 55). To be effective,
however, this intervention must be at an appropriate level for
26 Community
family members and/or the client to grasp. This requires
information about level of formal or informal education and
training or skills required for a particular occupation (Whaley
& Wong, 1991, p. 210). "This information is highly valuable
in planning implementation of care (e.g., counseling, guidance,
or teaching)" (p. 210). J. R.'s mother was a senior in high
school when she dropped out of school. She is currently enrolled
in GED classes and states that she will complete the program
about this time next year. She states that her husband plans
to enroll in the program when she finishes, but she does not
know the highest level of formal education he obtained.
Financial assessment.
Discussion about education often provides a smooth entry
into the sensitive area of assessing the family's economic
resources. This is imperative to address in the multidimensional
assessment because it ultimately affects how well a family can
provide essential items (e.g., food, shelter, and clothing)
for its members (A. Blatnik, personal communication, November
4, 1994). According to the U. S. Congress (as cited in Whaley
& Wong, 1991), "availability of financial assistance is directly
related to use of health care" (p. 209). Therefore, discussion
of medical insurance must be included in this assessment. The
community health nurse is in a position to determine if there
is a need for public resources not currently utilized by the
family. She can then operate as a referral agent or care
coordinator to assist the family in meeting its needs as a whole
27 Community
or the special needs of an individual member. This serves the
combined community health nursing purpose to "promote high-level
wellness and to enhance self-care capabilities" (Clemen-Stone
et al., 1991, p. 307). The family of J. R. is financially
supported by a variety of means. J. R.'s father works for
MCDonald's and Weigel's, and J. R.'s mother is employed at
Weigel's. The WIC program provides support in meeting the
nutritional needs of J. R. The family also receives food stamps,
though J. R.'s mother is unclear about how much the family
receives in food stamps. The family is medically insured by
Tenncare through Blue Cross & Blue Shield of Tennessee. J.
R.'s mother states that she is currently going through the
application process of acquiring Supplemental Security Income
for J. R. The needs of the family in this regard revolve around
referral and care coordination. J. R.'s parents need to be
referred to a primary care provider that is covered by their
Tenncare plan.
Family functioning.
Jayne Tapia (1972) developed a model for community health
nursing depicting five levels of family functioning. This model
is useful in application to families such as J. R.'s to determine
the "nursing service appropriate to the needs of a particular
family" (p. 267). J. R.'s family may be placed partially on
levels II and III. Tapia describes the second level of family
functioning as the "childhood or intermediate family" (p. 269).
This type of family is slightly more organized than the level
28 Community
one family, in that the family is more able to provide for the
physical and security needs of its members. However, the level
two family is "still unable to support and promote the growth
of its members •••• This family does not seek help actively
and requires much assistance before the members are able to
acknowledge their problems realistically" (p. 269). This family
is more able to trust the community health nurse than the level
one family, and thus "have more hope for a better way of life"
(p. 269). In this type of family the nurse would attempt to
promote the trust relationship which she uses as "a stepping
stone to help the family begin to understand itself more clearly"
(p. 269). Tapia describes the third level of family functioning
as the "adolescent or family with problems" (p. 269). While
she describes this family as "essentially normal" (p. 269),
she states that this family has an unusual amount of problems.
In this family, "members demonstrate greater trust in people,
have the knowledge and ability to utilize some community
resources, and are less openly hostile to outsiders" (p. 269).
This family is better able than the level two family to recognize
its problems and search for solutions through utilization of
resources outside of the family (p. 270). The nurse's function
in this type of family is aimed at helping the family to solve
those problems identified by the members (p. 270). She does
this "by providing teaching, information, coordination, referral,
team-work, or special technical skills" (p. 270). For placement
of J. R.'s family on Tapia's model of family functioning, refer
-----------------------------..."
Community 29
to Appendix A.
Family coping.
An assessment of family coping is another tool that is
useful in helping the community health nurse individualize her
care plan for a specific family. In 1964 Freeman and Heinrich
developed a family coping index "as an approach to identifying
the family need for nursing care and assessing the potential
for behavioral changes, and as a method of determining in a
more systematic way how the nurse can help the family to manage"
(as cited in Stanhope & Knollmueller, 1992, pp. 79-80). Nine
categories are included in the index. The first is "physical
independence" (p. 80). This category deals with the family's
competence in maintaining physical competence of its members.
Even if one member of the family is dependent on the family
unit for basic physical activities such as those of daily living,
"if the family is able to compensate for this the family may
be independent" (p. 80). The next category is "therapeutic
competence" (p. 81), and deals with a family's ability to provide
prescribed treatment of a medical condition. The third category
is "knowledge of health condition" (p. 81). In assessing this
category, the nurse evaluates a family's knowledge of "the
particular health condition that is the occasion for care" (p.
81). Without this knowledge, the family cannot be expected
to provide for the basic physical and developmental needs of
its members. The next category is concerned with the family's
independence in applying "principles of personal and general
30 Community
hygiene" (p. 82). Examples of these principles include proper
nutritional support, appropriate safety and sanitation in the
home, and preventive health activities (p. 82). The next
category deals with the family's general attitudes concerning
health care and public health intervention (p. 82). The sixth
category is "emotional competence" (p. 83). This deals with
"the maturity and integrity with which the members of the family
are able to meet the usual stresses and problems of life" (p.
83). This includes the members' ability to recognize the needs
of the family unit as well as their personal needs and the
discipline with which they accept behavior guidelines imposed
by the family unit and society (p. 83). "Family living patterns"
(p. 83) is the next category addressed in the coping index.
This is concerned with the interpersonal relationships among
the family members, the family process of decision making, issues
of discipline, displays of affection, and respect that each
member has for one another (p. 84). The eighth category is
concerned with the physical environment surrounding the family
and how this affects their health and well-being (p. 84). The
nurse would pay attention to "condition for housing, presence
of accident hazards, plumbing, [and] facilities for
cooking and for privacy" (p. 84). This category would also
include those factors affecting health noted by the nurse during
the assessment of the outside environment of the home such as
available schools and transportation and social hazards such
as gangs and pollution (p. 84). The final category addressed
31 Community
by the family coping index deals with "the degree to which the
family knows about and the wisdom with which they use available
community resources for health, education and welfare" (p. 85).
Whether or not a family has a particular need for such resources
has no bearing on the coping index. Instead this addresses
how well a family is able to cope when such services are needed,
even if the condition prompting the resource utilization is
not corrected (p. 85). Please refer to Appendix B for placement
of J. R.'s family on the coping index.
Family needs.
The needs of the family based on the coping index include
assistance with dealing with and providing for the special needs
of J. R. in regard to his developmental delay. J. R.'s parents
also need assistance with achievement of a higher level of
therapeutic competence in maintaining the proper environment
for a child with J. R.'s respiratory condition. They would
also benefit from a greater understanding of strategies to
prevent recurrent ear infections. Education about general
personal hygiene such as importance of adequate rest and
nutrition for all members of the famiy is needed. The parents
of J. R. also need encouragement to obtain appropriate health
care for themselves. strategies to enhance the mother's
emotional competence is needed as she appears unable to accept
the degree to which J. R. may be delayed. Intervention is needed
to assist the family in providing a safer horne environment for
J. R. in terms of awareness of physical safety hazards and
32 Community
possible problems that could arise with intoxicated neighbors
being with the child in the home. The family also needs further
intervention focused on fostering the trust relationship, as
they seem to feel threatened rather than assisted by community
health nursing interventions of the student.
Establishing trust.
Before the needs of the family can be effectively addressed,
the nurse and the family must build a working relationship.
This relationship must have trust as its foundation for tasks
to be accomplished (Zerwekh, 1992, p. 17). According to
Clemen-Stone et ale (1991), this trust relationship must be
established early because it is a "critical factor in helping
the client [and family] determine whether or not to accept the
assistance offered by the community health nurse" (p. 263).
However, the trust relationship must strengthen over time to
make a lasting impact in the life of the client and family.
Zerwekh (1992) points out that the clients served in community
health often "have little experience with trust" (p. 18). With
these clients, persistence and consistency are required for
the family to realize that the community health nurse will not
desert or betray them (p. 18). J. R.'S family seemed very
receptive to the student community health nurse initially.
On the first home visit, J. R.'S mother was eager to answer
questions about J. R.'S health status and agreed to make a list
before the next visit of what she thought would be important
to accomplish in the next home visit. At the second visit,
33 Community
however, she had not compiled such a list and was considerably
less receptive. This was evidenced by her hesitancy to make
eye contact with the student and her brief responses. It was
during this visit that a developmental screen was performed
on J. R. She may have perceived this as a test of herself and
her parenting abilities, and this possibly was why she was less
interactive with the student.
According to Clemen-Stone et ale (1991), promoting trust
involves "explaining the purpose of community health nursing
visits, describing services the community health nurse can
provide, and fostering a nonthreatening atmosphere which allows
the client to share data at his or her own pace" (p. 263).
These strategies were employed in the first visit with J. R.'s
family and were reinforced in the subsequent visits. Zerwekh
(1992) states that to build trust, the community health nurse
must foster "a sense of worth among those who often considered
themselves worthless" (p. 19). In order for J. R.'s mother
to have confidence in her abilities as a parent in the face
of J. R.'s considerable developmental delay, it was important
for the student nurse to affirm the positive aspects of the
care that she provides for J. R. The student was straightforward
and honest while avoiding false reassurance and displays of
disapproval. In this way the student's personal integrity was
demonstrated without negatively affecting the mother's self
esteem. Both purposes served to strengthen the trust
bond.
34 Community
Nursing Diagnosis
With trust as the foundation, the nurse and family can
then work together in analyzing the needs of the client and
family unit. In this phase of the relationship, data gathered
in the assessment phase of the nursing process is synthesized
to build on needs previously identified in order to make a
nursing diagnosis (A. Blatnik, personal communication, November
11, 1994). Gordon defines a nursing diagnosis as an inference
about "the individual's, the family's, or the community's health
problem/condition and the primary etiological or related
factor(s) contributing to the problem/condition that is the
focus of nursing treatment" (as cited in Clemen-Stone et al.,
1991, p. 272). In community health, nursing diagnoses are used
to examine actual or potential problems as well as strengths
of the client and family (A. Blatnik, personal communication,
November 11, 1994). Diagnoses that identify actual or potential
problems assist the nurse in providing needed anticipatory
guidance as a primary prevention strategy (Clemen-Stone et al.,
1991, p. 273). On the other hand, diagnosing strengths aids
the nurse in choosing activities that promote independence in
the family (p. 273). According to Clemen-Stone et ale (1991),
when the client is actively involved in determining health needs,
he or she is more likely to change health behaviors than one
who has no voice in such decisions (p. 281). The diagnoses,
therefore, must be validated by the client.
In working with J. R. and his family, it was important
35 Community
to determine early if J. R. was indeed developmentally delayed
and to what extent. The Denver Developmental Screening Test
[DDST] assesses "a child's performance on various age-appropriate
tasks •••. [and] is valuable in screening asymptomatic children
for possible problems, in confirming intuitive suspicions with
an objective measure and in monitoring children at risk for
developmental problems" (Frankenburg et al., 1992, p. 1). This
was considered an appropriate tool to use with J. R. in that
N. Jackson, PNP was suspicious of a delay. J. R.'s mother was
concerned about his development, but did not seem to accept
the reality of a delay. The objective nature of the DDST would
confirm the suspicion while providing concrete data to work
with in presenting the results to J. R.'s mother. According
to Frankenburg et ale (1992), the test result is suspect if
one or more delays are discovered (p. 13). Refer to Appendix
C for the suspect test result of the DDST performed on J. R.
Planning
After diagnoses are established by the nurse and client,
the relationship moves into the planning phase of the nursing
process (Clemen-Stone et al., 1991, p. 279). In this phase
client centered goals and objectives are formulated and
interventions are identified (p. 279). A goal is defined as
a "broad desired outcome toward which behavior is directed"
(p. 279), and an objective "delineates client behaviors which
reflect that a goal has been reached" (p. 279). The
interventions are activities to be carried out by the client,
36 Community
community health nurse, or other professional to help reach
the identified goal (p. 279). Clemen-Stone et ale (1991) set
forth three main principles to be considered in the planning
process: "(1) individualization of client care plans; (2) active
client participation; and (3) the client's right to self
determination" (p. 280). Therefore, since each client has unique
needs, the client must be actively involved in mutual goal
setting with the nurse (p. 280). According to Twinn (1991)
this philosophy of practitioner forming a partnership with the
client is quite different from the traditional health care
paradigm in which "practitioners generally work with clients
in a directive manner" (p. 969). This active participation
"also promotes client commitment to goal attainment and decreases
resistance to change" (Clemen-Stone et al., 1991, p. 280).
If the nurse were to enter the relationship and take over for
the family, she may decrease the family's self esteem while
fostering dependence or resentment of authority figures (p.
280). However, it is sometimes appropriate for the community
health nurse to develop a nurse centered goal. This would be
appropriate if the nurse identifies a problem that the family
is not aware of and determines by professional judgment that
it is necessary to increase the family's awareness of the problem
(A. Blatnik, personal communication, November 11, 1994). Refer
to Appendix D for a care plan containing nursing diagnoses,
goals, and interventions developed in working with the family
of J. R.
37 Community
Implementation
After diagnosing needs and setting goals, the client and
community health nurse must develop a contract which "clearly
identifies what each person in the relationship can expect from
the other person in the relationship" (Clemen-Stone, 1991, p.
281). This provides a framework from which to evaluate the
effectiveness of interaction between the family and the nurse
(p.281). The contract must be mutually agreed upon and must
be continuously negotiable (A. Blatnik, personal communication,
November 11, 1994). The nurse and client work together towards
an agreement, either written or oral, which outlines the
responsibilities of each member in achieving the stated goals
(Clemen-Stone et al., 1991, p. 281). In working with J. R.'s
family, a written contract explaining the purpose of the family
study and the duties of the student was signed by J. R.'s mother
and the student on the first home visit. This written contract
outlined the time parameter of the relationship, when visits
would take place, and how many visits were to occur. (Refer
to Appendix E for a sample contract.) There was also an oral
contract between J. R.'s mother and the student made at the
end of each visit regarding each party's duties in the week
before the next visit. Before each termination the student
and mother would come to a mutual agreement as to what would
be accomplished by each in the coming week.
With the contract as a framework, the client and nurse
move into the implementation phase of the nursing process in
38 Community
which "activities are carried out to achieve client goals"
(Clemen-Stone et al., 1991, p. 284). A supportive atmosphere
should be developed by the nurse to reinforce accomplishments
and provide positive feedback (p. 284). Throughout this phase,
new data may be gathered that must be analyzed to determine
the need for care plan revision (p. 284). As in all phases
of the nursing process, the client must be involved in
implementing the care plan. This aids the family in assuming
responsibility for themselves as a unit rather than fostering
dependency (p. 285). If the client fails to follow through
with an agreed upon intervention, the nurse must determine why
the client is not taking action (p. 285). Such a situation
may precede the need for modification of the mutual goals and
plans (p. 285).
Evaluation
Evaluation must take place throughout each phase of the
nursing process so that the community health nurse can accurately
identify what has or has not been accomplished (Clemen-Stone
et al., 1991, p. 285). This process is facilitated by
establishing objectives in the planning phase that contain the
potential for evaluation (p. 285). It is also imperative to
elicit ongoing feedback from the client and family in order
to determine if interaction remains focused and effective (p.
285). Clemen-Stone et ale (1991) state that when evaluation
is deleted from the relationship the process is prolonged (p.
285). Clearly this represents an ineffective use of resources.
39 Community
Evaluation also aids the community health nurse in determining
why goals have not been achieved (p. 286). However, outcomes
of interaction must be examined rather than simply observing
that the family is participating in the process (p. 286). When
coordinating services among professionals, evaluation aids the
nurse in determining the need for referrals or the need to
terminate nursing services (p. 286). It is then necessary "to
evaluate the effectiveness of referrals that have been made"
(p. 286). Refer to Appendix D for evaluation of nursing goals
and objectives in the care of J. R.
Termination
Through accurate evaluation, the community health nurse
can make decisions regarding when nursing services are no longer
needed. The client-nurse relationship then enters the
termination phase (A. Blatnik, personal communication, November
18, 1994). However, certain interventions must be implemented
by the nurse throughout the relationship in order to prepare
the family for termination. These include:
1. Stating the termination date, if known, in the beginning
of the relationship and throughout consecutive meetings
2. Discussing thoughts and feelings about termination
prior to the last meeting
3. Identifying signs of separation anxiety in the family
and personally
4. Encouraging the family to compare past separations
with the present one
40 Community
5. Promoting the family's evaluating and summarizing the
relationship in terms of its goals, expectations,
satisfactions, and dissatisfactions (Cronin-Stubbs, 1983,
p. 405).
Kelly defines termination as "the period when the client
and nurse deal with feelings associated with separation and
when they distance themselves" (as cited in Clemen-Stone et
al., 1991, p. 287). Strong feelings such as anger and sadness
are often experienced by the client and nurse, and these feelings
must be discussed and dealt with (p. 287). Clemen-Stone et
ale (1991) state that it is the nurse's responsibility to
initiate such a discussion in order to create a supportive
atmosphere for the client to express feelings and emotions
regarding the termination (p. 287). It is important for the
client and nurse to review what has and has not been accomplished
in their relationship and why termination is indicated (p. 288).
The nurse must remind the client of the continued availability
of health care services in the community even though the home
visits will not continue (A. Blatnik, personal communication,
November 18, 1994). Termination with J. R.'s family was less
than ideal in that the time frame was predetermined rather than
being based on evaluation of accomplishments. However,
termination was integrated throughout the relationship in that
a contract with a specified number of visits was signed by both
parties at the first visit, and J. R.'s mother was reminded
about the number of visits remaining upon each visit. At the
41 Community
final visit the student initiated discussion about termination,
and the client expressed little emotion about the reality of
termination. Progress made was reviewed with the client,
specifically that the mother was now more aware of age
appropriate tasks for J. R., and she was aware of the importance
of maintaining her own health. A list of family strengths
identified by the student was shared with the mother. She seemed
very pleased with the student's conclusions and added some items
to the list. Plans for the mother's continued effort towards
the goals identified were mutually agreed upon, specifically
that the mother would follow up with N. Jackson, PNP regarding
program placement for J. R., would obtain a thermometer, would
apply for the Empty Stocking Fund, and would obtain an
appointment for herself to have a physical exam. J. R.'s mother
was reminded that the services of the Knox County Health
Department are still available to the family despite the fact
that home visits by the student nurse would not continue.
Family Strengths
Inherent in each phase of the nursing process is utilization
of family strengths to increase successful achievement of goals.
Herbert otto (1973) defines family strengths as "those factors
or forces that contribute to family unity and solidarity and
that foster the development of the potentials inherent within
the family" (p. 88). Once strengths are identified they can
then be mobilized in working out problems that exist or arise
within the family (p. 87). The community health nurse is in
42 Community
a position "to support the family in exploring the application
of family strengths to the problem configuration" (pp. 92-93).
Pointing out the positive aspects of the family unit can prompt
clients to realize that they are not helpless, but in fact are
quite capable of developing more healthy patterns by making
use of available resources. Often the community health nurse
identifies "latent family strengths, or family potentials" (p.
92). otto (1973) defines these as strengths that are present
but not being utilized by the family (p. 92). Discovering and
building on these strengths provides a positive balance in the
community health setting. Often nurses become preoccupied with
the pathologic patterns occurring in the family, and too little
attention is paid to the positive potential of the family (p.
91). Recognizing strengths reminds clients that they are
valuable individuals despite their areas of need. Refer to
Appendix F for assessment of strengths in J. R.'s family.
Barriers to Health Care
In evaluating the progress that a client and/or family
is making toward a goal, it is important for the community health
nurse to be sensitive to the often invisible factors which
obstruct progress. Clemen-Stone et ale (1991) cite "various
reasons why clients are unable to alter their behavior in a
way to help them resolve their stress appropriately" (p. 244).
Often the family does not know why they are experiencing
difficulty in taking action, yet they are aware "that something
is wrong because symptoms of anxiety are present" (p. 244).
43 Community
In these situations, the community health nurse must explore
with the family the possible causes for their inability to take
action and obtain the appropriate health care. Clemen-Stone
et ale (1991) give examples of these causes which are primarily
psychosocial: the client has not identified the specific nature
of the problem; the client cannot acknowledge feelings or
distinguish between feeling and fact; the client does not assume
responsibility for feelings; the client has no problem solving
experience; or the client has missed successful completion of
tasks in skill development (pp. 244-245).
The community health nurse must also be aware of those
factors that adversely affect the family's use of referral
services. Clemen-Stone et ale (1991) define these factors as
"barriers to utilization of the referral process" (p. 322) and
give examples of barriers that are inherent in the resource
and those that exist within the client or family. Resource
barriers may include the attitudes of health care professionals,
the accessibility of the resource to the community, and the
cost of the service (pp. 322-323). Barriers within the client
or family may include where the service falls on their list
of priorities, how well they understand the need for the service,
the family's motivation to act on the need that initiated the
referral, the family's prior experience with utilization of
referral services, the family's awareness of available services,
the family's self image, cultural differences, and the family's
ability to pay for the service and/or get to the facility (pp.
44 Community
323-324). The community health nurse must be consciously looking
for these factors because clients may not bring them to her
attention due to embarrassment or their lack of awareness of
the barrier. For example, a client or family may acknowledge
a need but repeatedly fail to act on the need. The nurse must
be able to differentiate between their readiness to work on
the need as opposed to their awareness of the need. In this
situation the nurse can assist the family in prioritizing needs
that they are ready to act upon (p. 323). Refer to Appendix
G for barriers to obtaining health care identified when working
with J. R.'s family.
Utilization of Community Resources
Various agencies in the community are currently being used
by this family. The agency that they use most frequently is
the Pediatric Primary Care Clinic at the Knox County Health
Department [KCHD]. This is a clinic in which health care is
provided by physicians and nurse practitioners to those patients
who do not have a primary care physician (K. Boggan, personal
communication, August 26, 1994). The clinic offers "clinical
services, sick care, immunizations and WIC" (KCHD, 1994, p.
2). It is not designed to be a walk-in clinic, but rather its
purpose is to provide regular primary care. Without this
service, these clients would probably go to the emergency room
for sick care only. Here they would be seen by a different
physician who was not aware of their personal health history
on each visit (K. Boggan, personal communication, August 26,
45 Community
1994). Thus the clinic provides for continuity of care, and
it prevents unnecessary (and costly) visits to the emergency
room. Nancy Jackson, PNP is the primary care provider for J.
R., and Donna Richter is a social worker that operates through
this clinic. Both were consulted in this case to discuss
possible sources for obtaining developmentally stimulating toys
for J. R. and options regarding J. R.'s placement in a special
program for developmentally delayed children. This resource
has several positive effects on this family's level of
functioning. For example, the health care providers at the
Pediatric Clinic discovered J. R.'s health problems and initiated
home visits to this client by the student nurse. Without this
intervention, this child's developmental delay and need for
placement in a special program may have gone undetected until
much more lengthy and costly intervention would be required.
The family's ongoing rapport with the providers at the clinic
has been a positive experience for J. R.'s family as evidenced
by his mother's positive and affectionate comments about N.
Jackson, PNP. This experience has a positive influence on the
family's future use of health care services.
The Supplemental Food Program for Women, Infants, and
Children [WIC] is a federally funded program offered through
the KCHD that provides various food services to pregnant or
breast feeding women and children under the age of five (KCHD,
1994, p. 2). To be eligible for the program, "participants
must meet financial eligibility and have documented medical
46 Community
or nutritional risk" (p. 2). WIC offers vouchers redeemable
at local grocery stores for items such as milk, cheese and
cereal, and the program "includes mandatory nutrition education
and health assessment" (McGuire, 1994, p. 7). The role of the
community health nurse in WIC is be aware of possible
beneficiaries of the program and provide the client with
information about how to contact the program. J. R. is currently
enrolled in the WIC program due to his financial need and
documented iron-deficiency anemia. The program has intervened
to educate and encourage J. R.'s mother to feed him foods rich
in iron and Vitamin C. These interventions were supported and
reinforced by the student nurse.
J. R.'s family also receives nutritional support from the
food stamp program. This is a federal-state assistance program
designed "to improve the nutritional adequacy of low-income
individuals and families" (McGuire, 1994, p. 7). The community
health nurse should be able to identify possible candidates
for food stamps and direct these clients to the state Department
of Human or Social Services to apply for the program.
Supplemental Security Income [SSI] "is a federal-state
assistance program for qualifying aged, blind or disabled
individuals" (McGuire, 1994, p. 6). This program is designed
"to develop a uniform national minimum cash income for the
indigent aged, blind, and disabled" (Clemen-Stone et al., 1991,
p. 117). J. R.'s mother is in the application process for
obtaining SSI benefits for J. R. He has been evaluated for
47 Community
physical and mental disability to determine if he is eligible.
He has not been rejected or accepted by the program to date.
Children's Special Services [CSS] is a program offered
by the KCHD that "provides comprehensive medical care for
handicapped children from birth to 21 years of age who meet
the medical and financial eligibility requirements" (KCHD, 1994,
p. 3). CSS provides diagnostic evaluation, medical treatment,
and speech and hearing screening tests (p. 3). Community health
nurses play an essential role in CSS in that they identify
possible beneficiaries of the program and provide information
to the family. CSS nurses then act as care coordinators and
provide evaluation, assessment, and health education in the
home (p. 3). J. R. was referred by the student nurse to CSS
for evaluation due to his considerable developmental delay.
J. R.'s mother expressed concern that his inability to walk
may be due to an orthopedic problem. The student thought that
CSS would have resources to diagnose such a problem if it
existed. The student also felt that further home visits were
needed by this client, and that CSS would have the resources
to continue these visits. The CSS program was discussed with
J. R.'s mother, and she was given the phone number and instructed
to make an appointment for evaluation of J. R. The appointment
was made but not kept. When questioned about the missed
appointment, J. R.'s mother stated that after discussing CSS
with N. Jackson, PNP, she decided that she would explore other
programs. She agreed to follow up with N. Jackson, PNP regarding
48 Community
other options.
The Empty Stocking Fund is a program that "provides needy
individuals and families with a Christmas basket of food and
toys for children under 14 ("Milk Fund," 1994, p. A1). The
program is funded by contributions and conducted by the Knoxville
News-Sentinel. The program is designed to help those in the
Knoxville community who would otherwise have no means to help
them celebrate the holidays (Brown, 1994, p. A1). Individuals
must apply for the baskets, and information is documented and
verified to determine who will receive a basket (p. A1). It
is possible that J. R.'s family would be considered in need
of a basket due to their financial stress. Therefore, J. R.'s
mother was given information about where, when, and how she
could apply for the Empty Stocking Fund by the student nurse.
Recommendations
A commonly accepted opinion is that the American health
care delivery system needs restructuring due to its inability
to meet the health needs of many citizens (Knauth, 1994, p.
140). There appears to be "an oversupply of physician
specialists and an undersupply of primary care services" (p.
140)-- an imbalance that leads to high cost and often
inappropriate care for a few and inadequate care for many.
However, governments continue to emphasize high tech secondary
and tertiary health care and "lack faith in low-cost community­
based [health care] activities" (Clarke et al., 1993, p. 308).
As a result "public health nursing has been diverted from its
49 Community
ideal of primary prevention to provide damage control for
individuals and families already suffering from medical,
psychological, and social problems" (Zerwekh, 1993, p. 1676).
However, these health promotion and disease prevention strategies
have been proven to be cost effective in that they prevent the
need for more expensive forms of inpatient care (Hawkins &
Higgins, 1990, p. 117). In studies of home visits by nurses
in New York, cost effective outcomes included reduced emergency
visits, fewer days on public assistance, higher levels of
employment, and reduced instances of failure to thrive, foster
home placement, or child abuse (Zerwekh, 1993, p. 1676). Another
study of home visitation programs to socially disadvantaged
women and children succeeded in improving women's health-related
behavior during pregnancy resulting in increased birth weight
of their babies (Olds & Kitzman, 1990). In the same study,
postpartum intervention influenced improved childhood behavioral
and developmental status and decreased emergency room visits
and hospitalizations for injury, as well as decreased unintended
subsequent pregnancies (Olds & Kitzman, 1990).
As trusted health professionals, community health nurses
have the unique capability to move into communities and "bridge
the gaps between science, policy, and the people" (Salman, 1993,
p. 1675). In this way, communities that have previously not
been reached by the health care system will be accessed and
taught how to use the health care system. A reformed health
care system that boasts universal access is not sufficient.
50 Community
Salman (1993) uses school-aged children as an example and points
out that just because a parent is able to take a child in for
health care services does not ensure that this will take place
(p. 1675). But even if parents access health care delivery
(as J. R.'s parents have), "such services do not cover the scope
of health-related activities necessary to ensure the health
of all children" (p. 1675). There are many public health issues
not present in the clinic that can be overlooked. For example,
J. R. presented in the clinic with chronic respiratory and ear
infections and developmental delay. These symptoms were being
treated without getting to the root of the problem, which was ­
found in the community, home, and interpersonal family
environment. The root of J. R.'s chronic respiratory infections
was related to the fact that the apartment door was kept open,
and J. R. was dressed in inadequate clothing for the climate.
Upon visits to the clinic, J. R. was dressed appropriately and
the environment of his home could not be assessed. His chronic
ear infections were related to the fact that he was still being
bottle fed, and was often placed in his crib with a bottle
propped, causing a reflux of milk into the eustachian tube
creating a reservoir for bacteria to thrive. Insight into J.
R.'s delayed gross motor development was also gained only through
a visit to his environment. It is not surprising that the child
was unable to walk considering the lack of space in the crowded
apartment for him to move about. He spends most of his waking
hours playing on the double bed in the entrance room of the
51 Community
apartment which does not provide adequate opportunity for his
large muscles to strengthen and develop coordination necessary
for standing and walking. The contributing factors to J. R.'s
chronic anemia and reported lack of appetite were also
discovered through a visit to the home. Upon arriving to the
home on each visit, the child was found sitting on the double
bed nibbling on crackers, potato chips, candy, etc. It is not
surprising that he was then not interested in eating at mealtime,
and was not receiving the recommended amounts of essential
nutrients. Obviously, the potential for injury and infection
discovered only through a visit to his home, would not have
been realized in a visit to the clinic.
Community health nurses present in the community are able
to address these public health issues. studies have shown that
nurses, especially advanced practice nurses can provide
comparable primary care at a lower cost than doctors do (Aiken
& Fagin, 1993). Nurses are also more accessible to those
communities most in need of primary care when one considers
the current shortage of primary care physicians in the United
states (Aiken & Fagin, 1993). However, nurses, even advanced
practice nurses, are continually "restricted by the scope of
practice laws, malpractice costs, admitting privileges,
reimbursement procedures, and lack of prescriptive power"
(Reverby, 1993, p. 1663). These restrictions tend to limit
how the nation views and utilizes nurses for primary care.
In order to overcome these restrictions community health
52 Community
nurses must be prepared to present their services as an essential
piece in health care reform alternatives to the present system.
Beddome, Clarke, and Whyte (1993) point out that just because
preventive services have been identified as a key to better
health does not mean that people will actively seek these
services or that government will incorporate these services
into a reformed health care system (p. 16). Another important
concept in utilizing community health strategies more effectively
involves empowering the public. Nursing's Agenda for Health
Care Reform, a public policy statement written in 1991 by the
National League for Nursing and the American Nurses Association,
emphasizes the role of the consumer in health care decision
making and encourages consumers to become better informed about
the range of services and providers available (as cited in
Knau th, 1 994, p. 1 4 1 ) • Providing primary health care in
community-based settings is presented in this document as a
strategy for enhancing consumer access in a restructured health
care system (American Nurses Association, 1991). Public health
nurses are trained to foster client autonomy while "developing
mutually negotiable relationships" (Zerwekh, 1992, p. 104).
However, it is counterproductive to encourage self-care when
people lack environments conducive to health (Clarke et al.,
1993, p. 308). Public health nurses are also trained to enter
an unfamiliar environment, the patient's turf, and assess "the
social determinants of health (e.g., housing, employment,
literacy)" (p. 308). The nurse must then be prepared to use
53 Community
this assessment data to influence public health policy locally
and nationally (Twinn, 1991, p. 971). Clarke et ale (1993)
suggest that nurses become active in influencing public policy
towards an agenda that is focused more on prevention and health
promotion rather than the present system which has an acute
care focus (p. 308). This shift in focus would obviously require
a redistribution of health care funding.
Registered nurses represent the largest subgroup of the
healthcare work force ("The Nurses' Agenda", 1995). However,
"as a group, nurses have tended to be reactive rather than
proactive •.•• [and] choose not to be powerful or to become
involved politically" (Bushy & Smith, 1990, p. 39). However,
nurses are capable of using collective power to influence public
opinion and policy effectively. Nurses can begin with
"grass-roots activities to mobilize support and/or educate
legislators and/or constituents" (p. 39). They can organize
group power by writing letters to the editor of major newspapers
and magazines and engaging in media activities to raise public
awareness. Nurses can utilize their vast network of nursing
journals to raise awareness in their own profession and thus
elicit unity and group effort. Nurses can also use their
professional organizations to support a candidate for public
office that agrees with the nursing agenda for health care
reform. The possibilities are endless if nurses as a group
could combine creativity, knowledge, and professional strength
with a genuine concern for the health of the public.
54 Community
Author's Summary of Experience
In reflection on my experience with this family and
community, I feel that I grew both professionally and personally
as a result. I experienced a bit of a shock when I first
encountered this family and J. R. in that I had never experienced
such need in my own country. Through involvement in a mission
experience in Mexico, I had seen the face of poverty. But before
this community health experience I suppose I was under the
false notion that I had to leave America to serve the needy.
I realized, however, that community health nursing is not
charity. That is the unique beauty of it. When I first began
working with this family, I saw so many things that I wanted
to do for them. I wanted to bring them sheets and blankets.
I wanted to buy toys for J. R. I even wanted to clean their
apartment. However, I soon learned that while noble, these
gestures were far from therapeutic for this family. I was there
as a facilitator. My role was not to fix everything or even
point out all that needed to be fixed. Rather, I was there
to give the family information so that they could work with
me to mutually identify problems. I then worked with them to
set mutual goals for fixing those problems, and gave them the
tools they needed to do so. This concept reminds me of an
ancient Chinese proverb that was relayed to me by a very special
woman who taught me in high school. It says, "If you give a
man a fish, you feed him for a day. If you teach a man to fish,
you feed him for a lifetime" (cited by Sr. L. deMarillac,
55 Community
personal communication, 1989). In other words, empowering
clients to help themselves is much more effective in the long
run.
Nursing in the community had a positive influence on how
I am able to interact with those that come from a different
background and have different lifestyles than me. I often had
to make a conscious effort to remain nonjudgmental in the first
few visits with J. R.'s family. But as I became more familiar
with community health concepts, I began to realize how vital
this nonjudgmental attitude was to my relationship with this
family. I began to see how J. R.'s mother and father looked
to me for reassurance and reinforcement, and how my attitude
towards them affected their attitudes toward themselves and
their child. I realized that judging a family or client, either
with approval or disapproval, serves no therapeutic purpose.
Again, it was my role to supply them with information that they
could use to come to their own decisions regarding necessary
lifestyle adjustments.
Working with this family and community also helped me to
learn about the many resources that are available in the
community. I never really understood what the health department
was about until this experience, and now I am amazed at the
powerful impact it can have on people's health if they were
only aware of its wide range of services. I was not aware of
the WIC program either, and I believe this is a fantastic
resource in that it serves so many people in such an essential
56
I
Community
way. Resources such as these are intrinsically linked to
community health nursing. Referring clients to such agencies,
enables them to take initiative and help themselves.
Prior to this experience, I don't think I was aware of
the many factors that influence one's health behaviors. I became
aware of these factors while doing the multidimensional
assessment. I also was ignorant of the ways that nurses must
use all their senses in assessment. I had heard this concept
before, but reading about and implementing the strategies
described in Mary Bayer's (1973) article helped me to grasp
how useful my five senses could be in improving my assessment
skills.
Finally, this experience showed me yet another unique role
that nurses play in health promotion. Prior to this, I suppose
still placed nursing primarily in the hospital. But working
through the health department, and seeing how the satellite
clinics are run by nurses independently, I saw what a difference
nursing is making in preventive health. This experience opened
my eyes to many more opportunities that nurses have to be
independent professionals and influence public policy on a
national level.
57 Community
References
Aiken, L., & Fagin, C. (1993, March 11). More nurses,
better medicine. The New York Times, p. A23.
American Nurses' Association. (1986). Standards of
community health nursing practice. Kansas, MO: Author.
American Nurses' Association. (1991). Nursing's agenda
for health care reform: Executive summary. Washington, DC:
Author.
Bayer, M. (1973). Community diagnosis-- through sense,
sight, and sound. Nursing Outlook, 21(11),712-713.
Beddome, G., Clarke, H. F., & Whyte, N. B. (1993). Vision
for the future of public health nursing: A case for primary
health care. Public Health Nursing, 10(1), 13-18.
Brown, J. (1994, November 20). Sign up for fund begins
Monday. The Knoxville News-Sentinel, pp. A1, A17.
Bushy, A., & Smith, T. O. (1990). Lobbying: The hows
and wherefores. Nursing Management, 21(4), 39-45.
Clarke, H. F., Beddome, G., & Whyte, N. B. (1993). Public
health nurses' vision of their future reflects changing
paradigms. Image: Journal of Nursing Scholarship, 25(4),
305-310.
Clemen-Stone, S., Eigsti, D. G., & McGuire, S. L. (1991).
Comprehensive family and community health nursing (3rd ed.).
st. Louis, MO: Mosby.
58 Community
Cronin-stubbs, D. (1983). Interpersonal relationships
in community health nursing practice. In W. Burgess (Ed.),
Community health nursing: Philosophy, process, practice (pp.
393-418). Norwalk, CT: Appleton-Century-Crofts.
Frankenburg, W. K., Dodds, J., Archer, P., Bresnick, B.,
Maschka, P., Edelman, N., & Shapiro, H. (1992). Denver II
training manual. Denver, CO: Denver Developmental Materials,
Inc.
Hawkins, J. W., & Higgins, L. P. (1990). Financing health
care in American: Who pays? In S. J. Wold (Ed.), Community
health nursing: Issues and topics, (pp. 97-125). Norwalk,
CT: Appleton & Lange.
Knauth, D. G. (1994). Community nursing centers: Removing
impediments to success. Nursing Economics, 12(3), 140-145.
Knox County Health Department. (1994). Knox County health
department programs and services [Handout]. Knoxville, TN:
Author.
McGuire, S. L. (1994, August 29). Unites States health
care delivery system [Handout]. Knoxville, TN: UTK College
of Nursing.
Milk Fund donation drive coincides with ESF. (1994, November
28). The Knoxville News-Sentinel, p. A1.
Olds, D. L., & Kitzman, H. (1990). Can home visitation
improve the health of women and children at environmental risk?
Pediatrics, 86(1), 108-115.
59 Community
Orr, J. (1992). Health visiting and the community. In
K. Luker & J. Orr (Eds.), Health visiting: Towards community
health nursing (2nd ed., pp. 73-106). Oxford, England:
Blackwell Scientific Publications.
otto, H. A. (1973). A framework for assessing family
strengths. In A. Reinhardt & M. Quinn (Eds.), Family-centered
community nursing (pp. 87-93). st. Louis, MO: Mosby.
Reifsnider, E. (1992). Restructuring the American health
care system: An analysis of nursing's agenda for health care
reform. Nurse Practitioner, 17(5), 65-75.
Reverby, S. M. (1993). From Lillian Wald to Hillary Rodham
Clinton: What will happen to public health nursing? American
Journal of Public Health, 83(12), 1662-1663.
Salmon, M. E. (1993). Editorial: Public health
nursing-­ The opportunity of a century. American Journal of
Public Health, 83(12), 1674-1675.
Stanhope, M., & Knollmueller, R. N. (1992). Handbook
of community and home health nursing. st. Louis, MO: Mosby.
Tapia, J. A. (1972). The nursing process in family health.
Nursing Outlook, 20(4), 267-270.
The nurses' agenda: Priorities for 1995. (1995). Nursing
Management, 26(2), 21-23.
Twinn, S. F. (1991). Conflicting paradigms of health
visiting: A continuing debate for professional practice.
Journal of Advanced Nursing, 16(8), 966-973.
60 Community
Whaley, L. F., & Wong, D. L. (1991). Nursing care of
infants and children (4th ed.). st. Louis, MO: Mosby.
Zerwekh, J. V. (1991). Tales from public health nursing:
True detectives. American Journal of Nursing, 91(10), 30-36.
Zerwekh, J. V. (1992). Laying the groundwork for family
self-help: Locating families, building trust, and building
strength. Public Health Nursing, 9(1), 15-20.
Zerwekh, J. V. (1992). Public health nursing legacy:
Historical practical wisdom. Nursing & Health Care, 13(2),
84-91 .
Zerwekh, J. V. (1992). The practice of empowerment and
coercion by expert public health nurses. Image: Journal of
Nursing Scholarship, 24(2), 101-105.
Zerwekh, J. V. (1993). Commentary: Going to the
people-- Public health nursing today and tomorrow. American
Journal of Public Health, 83(12), 1676-1678.
61 Community
Appendix A
Tapia's Model
Level II-III
Family placed at this level because:
This family is partially in Level II (childhood stage)
because they are better able to meet their needs for security
and survival than a family in Level I (infancy stage). However
this family still seems unable to support the growth and
development of its members as evidenced by J. R.'s developmental
delay and his mother's lack of adequate rest. The family also
needs help with acknowledging their problems realistically as
evidenced by J. R.'s mother's inability to state her concerns
about J. R.'s health. This family also exhibits characteristics
of Level III (adolescent stage) as well in that they have the
knowledge and ability to utilize some community resources and
are not hostile to help from outside the family. The family
also shows signs of a future orientation such as J. R.'s mother's
comments about one day buying a house and her effort to obtain
a high school diploma.
Nursing services and activities appropriate for this family
based on the model:
Support of the trust relationship is very important, and
this must be used to help the family see its problems and
strengths more realistically. Activities must be performed
consistently and with genuine concern so the family can get
to the point where they are no longer speculative of the
62 Community
intervention and begin to work on their problems. The nurse
begins to help the family work through what they see as
problematic by teaching and referring them to community
resources. She works as a care coordinator, but constantly
encourages the family to make their own decisions. In J. R.'s
family, his mother is not hostile to the community health nurse
but doesn't realize that the nurse is there to help rather than
condemn. Therefore the trust relationship is the primary
concern. Then J. R.'s mother must be assisted to come to terms
with J. R.'s health problems as well as how those problems affect
her own health and well-being. Care coordination is the next
most important nursing service for this family by supporting
WIC intervention and hooking them up with programs aimed at
providing a more stimulating environment for J. R.'s development
and growth.
63 Community
Appendix B
Family Coping Estimate
Coping Area (Rating-- 0 Poor to 5 Excellent): Justification
1. Physical Independence (3): Mother is providing personal
care for herself and partial care for J. R. However, certain
physical care such as appropriate clothing and cleanliness are
not being provided for J. R.
2. Therapeutic Independence (3): Mother provides breathing
treatments for J. R. but leaves the door open to the apartment
and J. R.'s play area is soiled with dust and dirt. J. R. is
not kept properly clothed for the climate of the environment.
3. Knowledge of Condition (3): Mother understands the
need for placement of ear tubes (for J. R.) and how to care
for them, such as not emerging J. R. in water. She also is
aware of symptoms of complications to watch for. However, she
is not aware of how to prevent ear infections.
4. Application of Principles of Personal Hygiene (2):
Father carries two full time jobs. J. R. rarely sleeps more
than 3 hours at a time according to mother and is not dressed
adequately in relation to weather. There is dirty laundry and
dishes throughout the horne and the diet of J. R. is questionable.
Immunizations have been secured for J. R.
5. Attitude Toward Health Care (4): Mother accepts the
need for health care for J. R. However, she and her husband
do not receive preventive health care despite being insured
by Tenncare.
64 Community
6. Emotional Competence (3): Father has not been observed.
Mother seems unable to face the reality of J. R.'S developmental
delay. She also frequently leaves the child unattended while
outside smoking.
7. Family Living Patterns (3): Mother responds quickly
to J. R.'s needs, but leaves him alone in apartment playing.
Mother feels that she needs to discuss possible interventions
with her husband (J. R.'S father).
8. Physical Environment (1): Very little facilities for
privacy, neighborhood houses people that are questionable
intoxicated. No play space except parking lot. Very little
room to walk inside home. Electric portable heaters. Very
little covers for bed. Deteriorated building. No phone in
home.
9. Use of Community Resources (4): Mother is aware of
community resources such as W1C, SS1, food stamps, adult GED
program, and health department services. However she seems
to not realize that the community health nurse is there to help
rather than condemn.
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66 Community
Appendix D
Goals for Health Supervision and Interventions
Client Name: J. R. and family
The letter "M" indicates that the goal was mutually
identified with the client.
1. Nursing Diagnosis: Altered growth and development related
to lack of available play area and environmental stimulation,
possible mental handicap.
Goal #1- M: J. R.'s family will provide an environment
that maximizes the developmental potential of J. R.
Nursing Interventions:
a) Perform DDST to confirm delay. Discuss with mother
the implications of J. R.'s performance on the DDST and age
appropriate tasks of an 18 month old child.
b) Consult D. Richter, SW and N. Jackson, PNP about DDST
results and possibility of enrolling J. R. in a specialized
program for developmentally delayed children.
c) Suggest strategies to maximize J. R.'s developmental
potential with family such as giving him nontoxic crayons, giving
him a spoon at mealtime, providing simple toys that he can
manipulate easily. Suggest ways to make and places to obtain
age appropriate toys for J. R. Give information about applying
for Empty Stocking Fund.
d) Refer client to CSS. Give mother phone number and
encourage her to make and keep appointment for J. R.
Evaluation: Objectives met-- Mother is able to identify
67 Community
at least 4 tasks that an 18 month old child should have achieved
and a strategy to promote each with J. R., mother is able to
give examples of at least 2 age appropriate toys for J. R. and
how to make or obtain them, mother can verbalize reasons for
follow up with N. Jackson, PNP to discuss J. R.'s enrollment
in a special program, mother made appointment with CSS.
Objectives not met-- mother did not keep CSS appointment but
agrees to follow up with N. Jackson, PNP instead.
2. Nursing Diagnosis: High risk for injury related to safety
hazards present in the home and lack of appropriate protection
from outside environment.
Goal #2: J. R.'s family will provide a home environment
free from safety hazards.
Nursing Interventions:
a) Provide anticipatory guidance regarding J. R.'s
increasing mobility and curiosity and how certain physical
hazards in the home could be harmful.
b) Give suggestions about ways home environment can be
modified to reduce risks of injury.
c) Encourage mother not to leave child in apartment
unattended, especially if he is eating or playing on an elevated
surface (such as the bed in the front room).
Evaluation: Objectives met-- mother is able to identify
at least 3 age appropriate tasks of J. R. that require
modifications in his environment, mother can explain importance
of remaining inside apartment with J. R., mother keeps door
68 Community
to apartment closed, mother can identify at least 2 ways that
the horne environment can be modified to reduce risk of injury,
mother agrees to take the appropriate action to modify the horne
environment.
3. Nursing Diagnosis: High risk for infection related to
history of respiratory infections and otitis media (OM), lack
of appropriate clothing, frequent exposure to outside air,
insects in horne, and nutritional deficit.
Goal #3-M: J. R.'s family will provide environment that
reduces risk of infection.
Nursing Interventions:
a) Discuss importance of weaning J. R. from the bottle
including tendency toward OM. Suggest strategies for doing
so.
b) Discuss importance of and guidelines for dressing J.
R. appropriately for climate. Suggest resources to obtain warm
clothes if needed (Goodwill, Ladies of Charity).
c) Discuss importance of keeping door to apartment closed,
i.e. decreasing insects in horne and decreasing potential
respiratory irritants that J. R. is exposed to.
d) Provide information about where to obtain thermometer
and cost range.
e) Reinforce WIC interventions such as suggestions to
increase iron rich foods and Vitamin C.
f) Encourage to keep appointments at Pediatric Clinic
at KCHD.
69 Community
Evaluation: Objectives met-- mother keeps J. R.'s
appointments at Pediatric Clinic, mother states she is
implementing strategies to wean J. R. from bottle and can
describe them, mother can verbalize guidelines for dressing
J. R. appropriately and agrees to do so, mother keeping door
to apartment closed, mother states she will obtain thermometer,
mother verbalizes understanding of WIC interventions.
4. Nursing Diagnosis: High risk for altered parenting related
to physical exhaustion of mother, child's inability to sleep
more than 2-3 hours at a time.
Goal #4-M: Functional parenting patterns will be
maintained.
Nursing Interventions:
a) Discuss the importance of mother's own health
maintenance and her ability to meet J. R.'s needs. Assist her
in locating provider that accepts Blue Cross Tenncare and
encourage her to make appointment.
b) Discuss strategies for promoting prolonged nocturnal
sleep patterns for J. R. Encourage mother to establish
consistent bedtime rituals and to place child in crib while
he is awake. Suggest that bed be used for sleeping only.
Encourage mother to offer last feeding as close to bedtime as
possible (no bottles in bed) and increase daytime feeding
intervals to 4 hours or more (Whaley & Wong, 1991, p. 568).
Discourage allowing child to nibble between meals.
c) Discuss ways for mother to deal with nighttime crying
70 Community
such as entering room and reassuring child, but avoiding holding
or rocking, taking him to parents bed, or giving him bottle
(p. 568).
d) Warn mother that these strategies are difficult to
implement and encourage her to share them with her husband.
e) Identify sources of family support and encourage their
use.
Evaluation: Objectives met-- mother indicates awareness
of potential difficulties in parenting child with J. R.'s health
needs, mother can verbalize the impact that her health has on
caring for J. R. and the importance of maintaining her own
health. Objectives not met-- mother did not make appointment
with health care provider for herself before termination of
horne visits. Objectives in progress at termination: child
will be sleeping through the night by the end of December 1994.
71 Community
Appendix E
The University of Tennessee, Knoxville
College of Nursing
Nursing 403
Contract for Health Supervision in the Home
NAME OF CLIENT
CLIENT'S PHONE NUMBER
ADDRESS
CLINIC/PHYSICIAN
************************************************************
I hereby grant my permission to participate in a family study
and to be visited by a senior nursing student from The University
of Tennessee, Knoxville on a regular basis during the period
specified. I understand that any and all information obtained
by the student will be maintained in strict confidence and will
be utilized only for the purposes of developing appropriate
nursing care plans.
Guardian or Client's Signature
Date
I hereby assume responsibility for giving this family nursing
care under the guidance of faculty and in collaboration with
other members of the Health Team for the period of: (Date)
to
Signature of Student
72 Community
Appendix F
Family strengths
1. Parents are generally in good health
2. Parents seem genuinely concerned about child's welfare and
express strong desire to provide for him properly as evidenced
by their keeping appointments, their willingness to accept
outside assistance, and their application to obtain SSI for
J. R.
3. Parents are responsive to child's cues and speak to him
verbally
4. Role flexibility is present in that father supports mother's
efforts to obtain GED and plans to complete his GED when she
is finished; both parents work and assume responsiblity for
child care
5. Close supportive relationship with J. R.'s maternal
grandmother and aunts is described by J. R.'s mother; these
people are available to keep child
6. Parents are friendly with neighbors in that they are able
to use phone next door (could be weakness if substance abusing
neighbors spend time in home with child)
7. Mother expresses future orientation in that she has plans
to move into a larger home and is working on her GED
8. Parents encourage involvment of J. R. with other children
his age (i. e. day care, children of friends); this represents
an effort to broaden J. R.'s social development
Family's awareness of its strengths:
73 Community
This is evidenced by J. R.'S mother's ability to expand
on the above mentioned strengths and give specific examples
of them.
Ways that family can be helped to develop these strengths:
Positive reinforcement was provided by the student to help
J. R.'S parents realize that they are caring for their child
well despite his problems and needs. Examples of how these
strengths can be mobilized to foster J. R.'S developmental growth
were suggested by the student (i. e. obtaining preventive health
care for themselves, suggestions for providing a safer and more
stimulating environment for J. R., utilizing support systems
to allow time for physical and emotional rest).
Latent strengths in this family:
J. R.'S father was only present for about 10 minutes during
one of the visits. In this short period of time, however, he
seemed very eager to discuss J. R.'S condition and was very
interactive with the child. The student also noted that this
visit was the only one at which J. R. was dressed appropriately.
The father's willingness to work with the student and his
devotion to J. R. is a strength that was not able to be maximally
utilized in this relationship due to lack of contact with him.
74 Community
Appendix G
Barriers to Obtaining Health Care
Client Barriers:
1. Family has not specifically identified the nature of the
problem (i. e. lack of environmental stimulation of child,
possible mental disability)
2. Family has an interest in not identifying the problem
3. Family is unable to generate alternative options during
problem solving
4. Other needs considered higher priority than utilizing
referral services
5. Family is aware of problems but not yet ready to deal with
them (lack of motivation)
6. Lack of knowledge about available resources
7. Lack of understanding regarding the need for referral
8. Limited financial resources, limited transportation
9. Physical exhaustion of mother
10. Limited educational background and lack of familiarity
with patterns of growth and development
11. Mother doesn't give high priority to health care for herself
Resource Barriers:
1. Limited physical accessibility (not within walking distance)
*No other resource barriers identified as mother describes a
positive rapport with health care providers, there is no cost
for services rendered to J. R. at KCHD, and family is covered
by Blue Cross & Blue Shield Tenncare.

Community
Running head: COMMUNITY HEALTH Concepts in Community Health Nursing:
A Family study
Mary Rueff
University of Tennessee, Knoxville
College of Nursing

1

Community Abstract This project will explore concepts in community health nursing utilized in giving comprehensive nursing care to a client and family in the Knoxville community. Each phase of the nursing

2

process will be discussed as well as appropriate tools and methods used in each phase. It will describe methods commonly

used to assess the community environment, individual and family group needs, family strengths and coping abilities, and current and potential barriers to health care. It will also discuss

current and potential interventions or resources used to assist the family and client toward a more optimum level of functioning. This project will include recommendations for incorporating community health concepts into the changing health care paradigm. Finally,the author will reflect on her personal and professional growth as a result of this nursing experience with the family and the community as client.

and physical environments that people live" (p. In this way. child care and employment" (p. a health care provider must consider many factors that influence the health of a client "such as housing. Rather. nutrition. p. Clemen-Stone. Ruth and Partridge 50) state that this allows available resources to be managed more efficiently. (as cited in Clemen-Stone et al. By focusing on preventive care rather than curative care. the community health nurse directs resources toward high risk aggregates and families. 16). Beddome. Historical Perspective The concept inherent in community health nursing has been in operation since before the turn of this century (Zerwekh. Wald . 16). and McGuire (1991) point out that by addressing "both the personal and environmental aspects of health [the nurse can] deal with community factors which either inhibit or facilitate healthy living" (p. literacy. a nurse develops an awareness of health risks in her clients by assessing those of the community as a whole. 84). Eigsti. political. 1992.Community Concepts in Community Health Nursing: A Family study Community health nursing is a unique division of health 3 care in that its focus is on populations rather than individuals. 84). Clarke. Lillian Wald founded American Public Health Nursing during the 1890s in response "to the needs of the populations at greatest risk in our society" (p. 1991.. and Whyte (1993) state that "health cannot be viewed in isolation from the social. 50). p.

Establishing trust continues to be essential in the therapeutic relationship in that most clients encountered by the community health nurse have little experience trusting outsiders (Zerwekh. In the writings of Lillian Wald (as cited in Zerwekh. p. Therefore casefinding. 87) as they developed trust through persistence.Community described the public health nurse's role as providing an entry 4 point for health services into the lives of high risk populations who otherwise were not exposed to health care (as cited in Zerwekh. 1992). and continuous" (p. 90). p. 18). 1992. Zerwekh (1992) states that the central goal of the public health nurse remains the same today as in the days of Lillian . 1992. Zerwekh (1992) points out several characteristics of public health nursing in Lillian Wald's era that continue to be prevalent today. a role unique to community health nurses today. 84). competent. public health nurses are described as "steady. Zerwekh describes the responsibility of public health nurses in the early 1900s to "make inquiries as to who was in need of help" (p. 86). For example. She then states that "finding people in the community who are in need of services is a skill that still distinguishes community health nursing from acute care nursing" (p. has been such since the days of Lillian Walde The importance of building trust as the foundation for the client-nurse working relationship is another characteristic of community health nursing that remains unchanged.

1986. property. the woman begins to learn self-helpfulness" (p. 1991. life. In this way. 184). and the right to one's domain. in sharp contrast to the situation where the client enters the nurse's . Home Visiting The primary technique for assessing a community's health risks is home visiting. the client plays an "Instead active role in her health care by making choices for herself and her family. including one's body. "the family is still the basic social unit in our society" (Clemen-Stone et al. This is important to consider in health care delivery due to the tremendous impact that the family has on one's health choices and behaviors. 308). and privacy" (American Nurses' Association. and they practice in this environment. the right to make an informed decision.Community Walde 5 This goal is to "encourage self-help by promoting capacity Clarke et ale (1993) refer to make healthy choices" (p. Through home visiting.. 90). "nurses enter the environment in which people live. to this concept of enabling clients to make informed decisions about their health as "empowerment" (p. 3). Zerwekh (1992) gives an example of this when she refers to the impact of community health nursing on maternal-child health care: of learned helplessness. These rights include "the right to be autonomous. 19). This approach also preserves the client's rights which are often infringed upon when one enters the health care delivery system. Despite the variations in family structure that are present in the United states today. p. p.

1993. p. 1991. p. Unfortunately this is currently where most at risk groups enter the health care system when they are "forced to by pain or debility" (Reifsnider.Community environment in a hospital or clinic" (p. this strategy allows the nurse to "uncover the causes of signs and symptoms that present in isolation in a clinic examining room" (Zerwekh. 30). 30). Zerwekh (1991) points out that the task oriented nature of medical clinics often overlooks the biopsychosocial issues that impede health and well-being (p. She goes on to say that "morbidity can be diagnosed in the clinic. 50). This is an 6 especially valid point to consider when attempting to provide preventive care to clients and families who are relatively isolated and thus do not receive regular health care. [but] the environmental and psychosocial origins of morbidity are found where people live and work" (Zerwekh. Critical thinking and intuition are essential in doing a home visit. 70). 1677). there was one common thread: potentially dangerous patterns were identified in a . Zerwekh (1991) emphasizes this point by studying In all the stories of several public health nursing experts. 1992. Many aggregates served by community health nursing would otherwise have no or very little access to the health care delivery system. high cost emergency room visits may be avoided for these aggregates. of the personal experiences of these nurses. Home visiting also gives Using the nurse an opportunity to assess the family in context. By utilizing primary and secondary prevention strategies. p.

stability. and potential . lack of recreational areas. stray animals. Mary Bayer (1973) states that this assessment is most telling when all of the nursels senses are used to get a IIfeel li for the community (p. open ditches. and changes that will affect the health of the populationll (p. This type of evaluation is a process that helps the community health nurse in lIidentifying objective data which will help define the community. weaknesses. Nursing Process Assessment Environmental Assessment In assessing the home atmosphere. 712). p. IIhome visits permit an accurate view of what is really going on ll (p. This gives the nurse a data base on which to build with additional information obtained from the family or client. and unusual odors. p. 41). 1991. however. lack of proper waste disposal sites. the nurse must do an equally accurate assessment of the environment surrounding the home. the trends.Community 7 home visit that would not have been visible outside the client1s environment. She can then identify strengths. There are numerous health hazards present in the community environment that can only be identified through this preliminary observation (Zerwekh. 34). In other words. but are not limited to. Examples of these include. inadequate sanitation. 1992. 32). One way for a community health nurse to complete this initial observation is by doing a IIwindshield l i assessment of the client1s or family1s community (Stanhope & Knollmueller. 41).

Community problems in the community. and there is considerable debris and clutter visible around these houses. There are openings in the fence without gates that give access to a busy two-lane street running in front of the homes. This provides a "basis for health planning • 8 • • [and] a knowledge base to correct deficiencies in the health care system" (Clemen-Stone et al.. Correction of these deficiencies fulfills the community health nurse's primary responsibility to the community as a whole. Therefore each parking lot has only one entrance/exit. The Most of the lawns The homes on either side of the public housing projects are primarily wood homes. 1991. lawns of these homes are fairly well groomed. behind the homes contain clothes lines. 85-86). The residence is within These homes are red brick dwellings connected to one another and in rows. a group of public housing projects. surrounded by a black iron fence. as well as available resources or lack there of. This client's horne faces this busy street. There is one opening between each row of homes for a car to pass through into a concrete parking lot between each building. 1994. The lawns of these homes are not kept. Clemen-Stone et ale (1991) point out yet another use for this environmental assessment in that it provides rationale for marketing decisions about what nursing services are needed in a community and at what depth these should be maintained (p. 86). p. The following is an environmental assessment performed in the community surrounding the horne of a Knox County Health Department client on October 14. Many of them .

Many of these homes have bars on the windows or are surrounded by chain-link fences that have signs indicating security company protection. 9 Less than one street over (across the two-lane street They are wood mentioned above) are considerably nicer homes. Approximately 100 yards from the home is a large gravel lot about the size of a basketball court. so this is presumed to be a vacant lot rather that a parking lot. but About 100-200 yards a sign on the fence says. but this too is fenced in. There are three cars parked in the area whose passengers seem to be conversing. the available for public use. There is also a playground behind the Urban Community Vision establishment about ~ mile from the home.Community have boards over the windows and doors. and thus appear to be condemned. There is a net set up in the lot. Adjacent to this area is another concrete vacant lot surrounded by a chain-link fence. The physical environment of the community is rather crowded and cluttered. but these homes appear to be better maintained as evidenced by the condition of the paint and lawn. college is surrounded by a chain-link fence and barbed wire. Several undeveloped vacant areas are present in the community. 2 blocks from this home. There appears to be no open play areas or parks Knoxville College is approximately Behind the college are two outdoor However. Thus it does not appear to be for public use. basketball courts and a track and field area. homes close together. "No Trespassing." down the two-lane street from the home is a large lot surrounded .

Community by a high chain-link fence. broken sidewalks. These include the Knox County Extinguisher Company. ADF Welding Shop. All of these establishments are quite small Most have bars on with virtually no available parking space. and therefore this area may be hazardous. litter and debris in front. the windows and do not appear clean from the outside (i. Fina. a snack bar. a supermarket. There are also several buildings in the community that appear to have been stores at one time. unclean windows). but are now closed and boarded up. a small furniture store. but tall weeds are visible growing through and around the tires. a window company. and the Coca-Cola Bottling Company. This gives the impression that Less than a 1~ this lot is essentially a junkyard. and a liquor store. a Rexall drug store. There are three gas stations within this radius including Pilot. The lot is filled with hundreds It appears to be associated 10 of tires and considerable debris. These include a Bi-Lo market. miles from the home is a very large dirt hole that appears to be a swimming pool under construction. Various industrial establishments are observed within a 2 mile radius of the home. There are several small community markets present in the community within 2 miles from the home. All appear to be in moderate to good repair from an outside windshield observation. There are no fences or ropes around the area. with an adjacent tire store. and Phillips 66.e. No land used for agricultural purposes is observed in this community. .

toys. odors are noted. though many potholes are present. There is a large No unusual trash receptacle behind each row of these homes. These are the only type of geographical The residential 11 or topographical obstacles to travel noted.e. toys and bicycles along the curbs. A laundromat is located .Community The streets in the community are all paved. are several clothes lines hanging throughout the housing projects and other homes in the community. and boarded up or condemned buildings. There are two public pay telephones in front There of a market just across a street from this client's home. The sanitation of the community appears to be adequate from the windshield view. but the assessment takes place through a windshield. vacant lots. On the opposite side are most of the nicer homes and small markets. car parts). but these items appear to be of a residential nature (i. There is not a significant amount There is considerable clutter noted around the homes and in the lawns. On one side of the street are the public housing projects. streets are quite narrow with cars parked along the sides of the streets in front of the homes. furniture. There are also children's The two-lane street running in front of the home is the most obvious geographical boundary noted. Electric lines and utility poles are visible throughout the community. of litter visible. There is not as much clutter around the homes in the public housing project as there is around the other homes.

Behind the buildings. Small children are noted crossing the street without adult supervision. Quite a few adults and children can be seen walking along the roads and sidewalks. Around the housing projects. This is evidenced by the groups of adults and In the adolescents clustered in various places conversing.Community approximately 2 blocks from this client's home. however. center is in the vicinity of the home. 12 wearing collars while others are not. There is playground equipment visible behind this building enclosed in a chain-link fence. These are mostly dogs. groups of young males stand talking to one another. the animals are not restrained. In a few of the houses across the two-lane street from this client's home. It is not distinguishable whether these are stray animals or pets belonging to people in the community. . groups of adults sit on the porches while children play in the lawns in front of the homes. the pets are kept inside a chain-link fence. approximately 3 blocks from the public housing projects. The Knoxville Police Academy Moses A child development Center is about 4 blocks from this home. Multiple domestic animals are noted wandering freely throughout the community. and some are Cats are noted as well. As stated previously. The social atmosphere appears to be quite casual rather than structured. The residents of this community are predominately black. some are in clusters and some are alone. public housing sector. but these grounds do not appear to be open to the public. Knoxville College is located about 2 blocks from this home.

a Church of God in Christ. and one Methodist church. These include four Baptist churches. and a lounge.Community 13 Several public elementary schools can be found in the community. one Trinity Chapel. Most of these establishments have varying degrees of clutter around them. Several seemingly new vans are parked behind the church bearing the name of the church. a billiard hall. These include several bars and taverns. one story building in good repair that is about the size of a small house. library located less than ~ mile from the home. There are several small establishments that possibly serve as social gathering places for the members of this community. The Methodist church is an exception It is a much larger stone building located away from the homes with a fence enclosing much larger grounds. buses are parked in front of this building. No movie theatres or auditoriums are found . This building is adjacent to About five to seven school There is a public It is a brick a fenced in playground as well. All of these churches are wood buildings in relatively good repair. one AME Zion church. approximately nine churches are noted within no more than a 2 mile radius of the home. but quite small and located among the homes. small delis and cafes. There is also a Head Start Program in the community less than ~ mile from this client's home. and the windows are soiled with dirt and grease to the point that one cannot see through them. to this description. a House of Prayers. In driving through the community.

to 6 P.9 A. It is interesting to note For example.M.M. to 1 P. and several cruisers are parked in front of the police academy mentioned previously. The child development center mentioned 14 previously is the only possible children's recreational center observed. and Saturday-. a dental center. Several health centers are noted in the community in close proximity to this client's horne. the wide variations in the value of cars observed.M. There are at least two police cars noted cruising through this community. Tuesday. A medical clinic is within 1 mile.M.M. East Tennessee Children's Hospital and its satellite Non-Emergency Care Center as well as Fort Sanders Regional Medical Center are all within 1~ miles. and 3 P. Many automobiles are observed parked along the streets and driving through the community or behind the public housing projects where this client lives. to 1 P. and Friday-.M. These include a community horne health agency. Thursday. Its hours of operation are Monday. .3 P. Wednesday-. It is also within mile of western Avenue and Middlebrook Pike. they range from rather expensive and highly customized cars to inexpensive older cars in poor condition. and this community is located less than 1 mile from access to Interstates 640 and 40. At least two bus stops are noted within 2 blocks of this client's horne.M. Department Main Clinic is within The Knox County Health 1~ miles.9:30 A.Community in the community. to 6 P. and an eye center within 2 miles.M.

53). The lack of recreational facilities or suitable play areas. are growing and developing" (p.. the mental and social well-being of the community is possible. Clemen-Stone et ale (1991) state that the term health "assumes that people always have the potential for higher levels of functioning and that people in all stages of living. such as the Head Start Program. and education programs. The overall impression of this community is that of an unhealthy subgroup of the population. The bars on the windows of almost all commercial establishments and the distinct differences noted on either side of the two-lane street suggest impeded mental well-being in that these suggest feelings of disparity and insecurity. This potential is not clearly represented in the community when one considers its crowded living conditions and lack of social development.Community Neighborhood crime prevention signs can be seen tacked to numerous utility poles. 15 There is a City Fire Department Station about 3/4 mile from the home. However certain systems. and the lack of proper supervision of many children is evidence of incomplete social well-being. numerous neighborhood watch signs. The disease state of this community cannot be accurately However. mental and social well-being and not just the absence of disease" (as cited in Clemen-Stone et al. This assumption is based on the World Health Organization's definition of health as "complete physical. but no fire hydrants can be seen on the blocks containing rows of public housing projects. 1991. health clinics. p. . . 24). • • . a glimpse into assessed in the windshield assessment.

.. (1991) refer to this comprehensive examination of family . R. and intervening in the health promotion and illness prevention of J. planning. Clemen-Stone et al. R. 267). is being followed for a possible nutritional deficit and for a history of chronic otitis media. (1991).Community are in place in the community as a possible attempt to promote more complete health and well-being in this population. a referral from the Pediatric Clinic of the Knox County Health Department. organizing community supervised play groups. According to Clemen-Stone et al. the community health nurse cannot view the client in isolation. The purpose of this assessment is to form a data base to refer to when analyzing. "the actions and health status of one family member always affect the behavior and health status of all other family members" (p. J. R. or providing parenting education classes. Multidimensional Family Assessment After assessing the environment surrounding the client's horne. the community health nurse must again employ all of her senses to assess the other factors that influence the health behaviors of her client. R. Therefore when attempting to positively influence the health and well-being of an individual such as J. The next portion of this paper will explore the multidimensional factors affecting the health of J. A 16 distinct opportunity exists for a community health nurse to develop this potential further by such activities as lobbying for a playground with safe equipment to replace the vacant lot.

If the community health nurse is attempting to provide health care for one family member in isolation. chronic otitis media. chronic . 270). growth. Blatnik. personal communication. R. November 4. 268). emotional. personal communication.. 17 It is essential.Community health as discerning "functional and dysfunctional characteristics of family dynamics" (p. is an 18 month old male client with a history of anemia. 1991. J. 1994). The health needs of all family members must then be addressed to determine the needs of individuals and of the family unit as a whole (A. Blatnik. the "family's perceptions about how well it is functioning must be the key factor which helps a nurse to determine whether or not a family is reaching its potential" (p. while ignoring the health concerns of other members. however. and development needs of its members. November 4. the community health nurse keeps her personal values and beliefs separate from her clinical judgment (A. Therefore. Often all that is needed for another family member is referral. 270). p. but in this way the nurse has identified other stressors in the family while emphasizing her role in serving the family as a unit. that when performing this assessment. This is "because dysfunctional or maladaptive behavior in one family can be functional or adaptive in another" (Clemen-Stone et al. she may overlook an important barrier to health promotion of the client she is attempting to treat. 1994). Health needs. to accurately determine whether the family unit is meeting the physical.

R. is currently enrolled in the WIC program.'s physical and psychosocial development. R.' s and do not receive regular physical examinations.'s other apparent health needs. R. and WIC has been He 18 involved in encouraging J. J. family needs to be followed quite closely to assist them in providing a more stimulating environment to foster J.'s father as "pretty healthy" with no significant health problems. is believed to be from Abbey Home Health Care. . PNP at the Knox County Health Department. J. J. R. receives breathing treatments at home every four hours which his mother administers. R. R.Community respiratory infections. R. R.'s mother also needs guidance and support in providing appropriate food for J.'s mother describes herself and J. in a program for children at high risk for developmental delay. is currently enrolled in day care when both of his parents are working. R. The supplies for these treatments are J. and possible developmental delay. development seems to be his mother's biggest concern as evidenced by the amount of time that she spends talking about this in comparison with J.'s parents do not have a primary care provider J. R. developmentally delayed in that he is not yet able to walk and still drinks from a bottle. He underwent tube placement in both of his ears on He November 2. R.'s mother to supply iron-rich foods for J. R. He receives primary care from Nancy J. R. and his mother states that he has adjusted quite well to that environment. J.'s Jackson. This might include assisting the family in involving J. R. 1994 at East Tennessee Children's Hospital.

and the child is sitting in the middle of the bed eating cookies. These include the number of persons living in the horne. and two pillows without pillow cases. a table. Therefore. Upon entering the client's horne. and his mother and The entry room contains a double bed. These factors clearly affect the health and opportunities for growth and development of the family unit and of its members. various items. the nurse must alert herself to certain factors existing or not existing within the internal horne environment that could affect the family's health status. facilities for privacy. There is a full dish drain The on the counter and the sink is full of dishes as well. such as a stroller. R. and a refrigerator. and clothing. Blatnik. of this nature cannot be overlooked. personal communication. and safety features or hazards present in the horne (A. piled on the floor and on the counter top. a cabinet with stove and sink. Crumbs and dirt are noted . a portable electric heater.Community and taking steps to prevent further respiratory and ear infections. a thin brown blanket. The mattress pad has brown and yellow stains on it. an end table with a television on it. November 4. a lounge chair. Horne environment. the size and condition of the horne. and there is very little room to move about. assessment J. double bed is covered with a mattress pad. a high chair. The room is very There are small. 1994). father live in a two-room apartment. walker. 19 The parents need to be informed about the importance of providing primary care for themselves as well.

Family structure. However. p. A large portable radio The floor is covered with several laundry baskets and piles of clothing. The structure of the family is important to assess in that despite the recent societal changes in family life. which is soiled with crumbs. R. and dirt.Community on the mattress pad as well. dust. 20 The floor around the bed is covered with a red carpet. and there is even less space to move about in this room. 184) on the lives and choices of individuals. Therefore. with the little space that they have available. the nurse cannot make assumptions about a family's . and a chest of drawers. and lasting influence" (White House Conference on Families as cited in Clemen-Stone et al. There is a window in the front room with curtains. powerful. They also need information regarding safety hazards in the home such as the portable heater and leaving the apartment door open. and bath tub. light bulb in the back room and a functioning electric light in the bathroom. is on top of the chest. a couch.. are noted crawling along the sink. 1991. the family remains the "most fundamental. toilet. and piles of clothing and towels are noted in the floor. Adjacent to the kitchen area is a smaller room containing a crib. the mother frequently There is a burnt out keeps the door to the apartment open. The family needs guidance and support in ways that they can foster physical development in J. Adjacent to this room is Insects a small bathroom with a sink. but the only electric light source in this room is in the kitchen area.

's family would be considered a "Nuclear family-. 1992. The role of the nurse with this family would include monitoring . p.'s family is in the "family with preschool and school-age children" stage. This conclusion is based on J. 1991. special attention" (p. and to enhance family growth and support regardless of their family life-style. function and circumstance (Orr. R. 186).. thereby reducing the risk of illness or crises" (p. The nurse should also be aware of how family patterns shift over time in relation to structure. as problems needing Instead the nurse uses her information gathered about the family structure to analyze family strengths and needs. 124).'s mother's report that she and her husband are both employed. J. p. R.dual career" (p. 97). Stanhope & Knollmueller (1992) present the stages of family development and the appropriate interventions for the community health nurse "in assisting families to move successfully through life stages. According to the traditional family structures presented by the 1970 White House Conference on Children and C. Ahrons (as cited in Clemen-Stone et al. 187). J. R. 123).Community ability to provide for its members physically and emotionally 21 based only on assessment of the family's organizational structure (Clemen-Stone et al. According to Orr (1992) practitioners engaged in home visiting must be prepared to cope with diverse patterns of family units without viewing "deviations from the so-called 'normal' family unit.. and the two parents and one child are the only individuals living in the household. 1991).

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Community early childhood development, coordinating with pediatric services, counseling on nutrition and environmental safety in the home, and teaching hygiene measures (p. 97). Family culture. Exploring the cultural beliefs of a family is essential in the multidimensional assessment. This is because one's

22

cultural environment "greatly affects how growth progresses and what decisions are made about how to handle activities of daily living" (Clemen-Stone et al., 1991, p. 202). The purpose

of a cultural assessment in community health nursing is to gather information relevant to health and health practices and to identify patterns that assist or interfere with healthy behaviors and intervention (P. Miller, personal communication, September 12, 1994). Relevant information may include nutritional

practices, "childrearing beliefs, attitudes toward health care, and personal faith in a deity" (Whaley & Wong, 1991, p. 210). An assessment of the religious orientation of the family must be included in the cultural assessment because it "dictates a code of morality as well as influencing the family's attitudes toward education, male and female role identity, and attitudes regarding their ultimate destiny" (p. 35). In addition to the

impact that these attitudes have on health, the family's religious background has a direct impact on an individual's beliefs regarding illness, injury, or death (p. 49). Even if

the family does not appear to be involved in an organized religion, the community health nurse cannot assume that

Community spirituality does not playa significant role in their life. Personal spiritual beliefs are often a source of comfort for a family dealing with crisis or an ill member (Clemen-Stone et al., 1991, p. 205). When the nurse is sensitive to the

23

religious and spiritual implications of health-related treatment and intervention, "it is comforting to the family • • • to have this need recognized and respected" (Whaley & Wong, 1991, p. 49). The nurse can then individualize her planning and

implementation strategies for each family. Several characteristics of the culture of poverty as outlined by P. Miller (personal communication, September 12, 1994) are exhibited by the family of J. R. These include their

lack of privacy, low level of education, and sense of confinement. However, these people do not seem to lack future

orientation as evidenced by J. R.'s mother's comments concerning her desire to buy a house. This family does not appear to

be involved in an organized religion in that the mother states that they go to a "Knoxville church every once in while but not much." There are various items in the home that reflect

the family's spirituality such as a picture on the wall with the phrase "God Bless Little Boys." Developmental assessment. Assessing the developmental level of family members is essential in order to determine the family's perception of its own health status (Clemen-Stone et al., 1991, p. 270). According

to Erikson's theory (as cited in Whaley & Wong, 1991), at

Community progressing stages of psychosocial development an individual

24

is "confronted with a unique problem requiring the integration of personal needs and skills with social demands and cultural expectations" (p. 123). Erikson refers to the individual's

struggle to adjust in the face of this problem as a "crisis" (p. 123), and believes that "the tension produced by societal demands must be reduced in order that a favorable outcome can be achieved" (p. 123). for coping" (p. 123). This outcome "provides the resources It is therefore essential to evaluate

the developmental level of each family member, rather than only that of the individual client, to give insight into the family unit's resources for coping. Erikson describes the major task

of the infant from 1 to 3 years of age as "autonomy vs shame and doubt" (p. 123).

J. R. exhibits a few characteristics of

this stage of development in that he attempts to manipulate his environment by crawling, reaching for things, and imitating adults to a limited extent. Erikson's previous stage of "trust

vs mistrust" (p. 123) is characterized by an infant being able to tolerate "little frustration or delay in gratification" (p. 545) and continuation of oral stimulation as the primary mode of gratification (p. 545).
J. R. continues to exhibit

characteristics of this stage as well, as evidenced by his inability to accept delayed gratification and continuous use of the bottle. Erikson's stage of "intimacy vs isolation" In this

(p. 124) is commonly associated with early adulthood.

stage the individual develops intimate relationships with friends

's father. this intervention must be at an appropriate level for . J. however. plays on a bed is not appropriate.'s developmental delay. especially if an electric heater is on near the bed. is currently functioning needs.'s mother. R. R. exhibits characteristics of this stage in that socializing with neighbors seems to play a significant role in her daily life. 1991). R. R.'s family is in need of intervention to help them cope with J.'s mother needs to be aware of his emerging sense of autonomy and desire to manipulate his environment. they also need assistance with understanding the level that J. However. and how this influences the kind of care that he For example. This would mean that her stepping outside to smoke with her friends while J.Community and significant others rather than becoming socially isolated (p. According to White (as cited in Clemen-Stone et al. is not present for this assessment. 25 J. Education. R. age 25. J. Based on Erikson's description of the young and middle adulthood stage of "generativity vs stagnation" (p. 124). 55). The educational level of the family members is another component of the multidimensional assessment of the client's family. J. educative nursing is one of the main categories of community health nursing intervention (p. it is possible that he would be included in this stage since he currently holds two jobs. To be effective. 124). R. age 26. R.. in which an individual's energy is directed toward nurturing the next generation.

She can then operate as a referral agent or care coordinator to assist the family in meeting its needs as a whole .g. "This information is highly valuable in planning implementation of care (e.g. 1994). food. 210).'s mother was a senior in high She is currently enrolled school when she dropped out of school. 210). personal communication. 209). or teaching)" (p. Financial assessment. "availability of financial assistance is directly related to use of health care" (p. J. She states that her husband plans to enroll in the program when she finishes.. S. community health nurse is in a position to determine if there is a need for public resources not currently utilized by the family. Discussion about education often provides a smooth entry into the sensitive area of assessing the family's economic resources. According to the U. R. Congress (as cited in Whaley & Wong. Therefore. counseling. and clothing) for its members (A. 1991). discussion The of medical insurance must be included in this assessment. in GED classes and states that she will complete the program about this time next year. 1991.Community family members and/or the client to grasp. November 4. guidance. This is imperative to address in the multidimensional assessment because it ultimately affects how well a family can provide essential items (e. This requires 26 information about level of formal or informal education and training or skills required for a particular occupation (Whaley & Wong.. p. Blatnik. shelter. but she does not know the highest level of formal education he obtained.

R. The family of J. R. R. p.Community or the special needs of an individual member. R. R. The WIC program provides support in meeting the The family also receives food stamps.'s mother is employed at Weigel's. R. J. Family functioning. R.'s father works for MCDonald's and Weigel's. J. R. though J. 27 This serves the combined community health nursing purpose to "promote high-level wellness and to enhance self-care capabilities" (Clemen-Stone et al. This type of family is slightly more organized than the level ..'s mother states that she is currently going through the application process of acquiring Supplemental Security Income for J. referred to a primary Tenncare plan. 1991. 307). nutritional needs of J. This model is useful in application to families such as J. J.'s parents need to be care provider that is covered by their Jayne Tapia (1972) developed a model for community health nursing depicting five levels of family functioning. J. The needs of the family in this regard revolve around referral and care coordination. 269). R. and J. R.'s to determine the "nursing service appropriate to the needs of a particular family" (p. The family is medically insured by Tenncare through Blue Cross & Blue Shield of Tennessee. levels II and III. 267).'s mother is unclear about how much the family receives in food stamps. is financially supported by a variety of means.'s family may be placed partially on Tapia describes the second level of family functioning as the "childhood or intermediate family" (p.

in that the family is more able to provide for the physical and security needs of its members. In this type of family the nurse would attempt to promote the trust relationship which she uses as "a stepping stone to help the family begin to understand itself more clearly" (p. 269). 270). 269). This family is better able than the level two family to recognize its problems and search for solutions through utilization of resources outside of the family (p.'s family on Tapia's model of family functioning. 269). information. 270). In this family. and thus "have more hope for a better way of life" (p. "members demonstrate greater trust in people. Tapia describes the third level of family functioning While as the "adolescent or family with problems" (p. and are less openly hostile to outsiders" (p. She does this "by providing teaching. 269). refer . have the knowledge and ability to utilize some community resources.Community 28 one family. 270). R. coordination. the level two family is "still unable to support and promote the growth of its members • • • • This family does not seek help actively and requires much assistance before the members are able to acknowledge their problems realistically" (p. team-work. referral. 269). she describes this family as "essentially normal" (p. The nurse's function in this type of family is aimed at helping the family to solve those problems identified by the members (p. or special technical skills" (p. 269). For placement of J. she states that this family has an unusual amount of problems. This family is more able to trust the community health nurse than the level one family. However.

and as a method of determining in a more systematic way how the nurse can help the family to manage" (as cited in Stanhope & Knollmueller.. In 1964 Freeman and Heinrich developed a family coping index "as an approach to identifying the family need for nursing care and assessing the potential for behavioral changes.-----------------------------. pp. is "knowledge of health condition" (p. Even if one member of the family is dependent on the family unit for basic physical activities such as those of daily living. independence" (p. The next category is "therapeutic competence" (p. 81). 81). 81). "if the family is able to compensate for this the family may be independent" (p. An assessment of family coping is another tool that is 29 useful in helping the community health nurse individualize her care plan for a specific family. The third category In assessing this category. 80). and deals with a family's ability to provide prescribed treatment of a medical condition. Family coping. 79-80). the family cannot be expected to provide for the basic physical and developmental needs of its members.. 80). 1992. categories are included in the index. Without this knowledge." Community to Appendix A. The next category is concerned with the family's independence in applying "principles of personal and general . Nine The first is "physical This category deals with the family's competence in maintaining physical competence of its members. the nurse evaluates a family's knowledge of "the particular health condition that is the occasion for care" (p.

Community hygiene" (p. 83). 84). issues of discipline. The eighth category is concerned with the physical environment surrounding the family and how this affects their health and well-being (p. This is concerned with the interpersonal relationships among the family members. and respect that each member has for one another (p. 82). displays of affection. The sixth This deals with "the maturity and integrity with which the members of the family are able to meet the usual stresses and problems of life" (p. 30 Examples of these principles include proper nutritional support. s~reening. "Family living patterns" (p. [and] facilities for This category would also cooking and for privacy" (p. 83). 83) is the next category addressed in the coping index. The final category addressed . 82). presence of accident hazards. category is "emotional competence" (p. The nurse would pay attention to "condition for housing. The next category deals with the family's general attitudes concerning health care and public health intervention (p. 84). plumbing. 83). 84). and preventive health activities (p. This includes the members' ability to recognize the needs of the family unit as well as their personal needs and the discipline with which they accept behavior guidelines imposed by the family unit and society (p. the family process of decision making. 84). include those factors affecting health noted by the nurse during the assessment of the outside environment of the home such as available schools and transportation and social hazards such as gangs and pollution (p. 82). appropriate safety and sanitation in the home.

Whether or not a family has a particular need for such resources has no bearing on the coping index. in regard to his developmental delay. education and welfare" (p. R. Please refer to Appendix B for placement of J. The parents of J. R.Community 31 by the family coping index deals with "the degree to which the family knows about and the wisdom with which they use available community resources for health.'s respiratory condition. 85). strategies to enhance the mother's emotional competence is needed as she appears unable to accept the degree to which J. Instead this addresses how well a family is able to cope when such services are needed. R. They would also benefit from a greater understanding of strategies to prevent recurrent ear infections. J. 85). also need encouragement to obtain appropriate health care for themselves. Family needs. Education about general personal hygiene such as importance of adequate rest and nutrition for all members of the famiy is needed. in terms of awareness of physical safety hazards and . The needs of the family based on the coping index include assistance with dealing with and providing for the special needs of J. may be delayed.'s family on the coping index. R. even if the condition prompting the resource utilization is not corrected (p.'s parents also need assistance with achievement of a higher level of therapeutic competence in maintaining the proper environment for a child with J. R. R. R. Intervention is needed to assist the family in providing a safer horne environment for J.

this trust relationship must be established early because it is a "critical factor in helping the client [and family] determine whether or not to accept the assistance offered by the community health nurse" (p. J. p. 32 The family also needs further intervention focused on fostering the trust relationship. 1992. 17). these clients. persistence and consistency are required for the family to realize that the community health nurse will not desert or betray them (p. R. the trust relationship must strengthen over time to make a lasting impact in the life of the client and family. However. According to Clemen-Stone et ale (1991). R. . J. At the second visit. Before the needs of the family can be effectively addressed. On the first home visit.Community possible problems that could arise with intoxicated neighbors being with the child in the home.'S health status and agreed to make a list before the next visit of what she thought would be important to accomplish in the next home visit. the nurse and the family must build a working relationship. 18). This relationship must have trust as its foundation for tasks to be accomplished (Zerwekh.'S family seemed very With receptive to the student community health nurse initially. as they seem to feel threatened rather than assisted by community health nursing interventions of the student. Zerwekh (1992) points out that the clients served in community health often "have little experience with trust" (p. Establishing trust.'S mother was eager to answer questions about J. R. 18). 263).

and this possibly was why she was less interactive with the student. This was evidenced by her hesitancy to make It was eye contact with the student and her brief responses. Both purposes served to strengthen the trust . 263). According to Clemen-Stone et ale (1991). R. The student was straightforward and honest while avoiding false reassurance and displays of disapproval. Zerwekh (1992) states that to build trust. In this way the student's personal integrity was demonstrated without negatively affecting the mother's self esteem.'s family and were reinforced in the subsequent visits. promoting trust involves "explaining the purpose of community health nursing visits. she had not compiled such a list and was considerably less receptive. describing services the community health nurse can provide.'s considerable developmental delay. 19). bond. R. R. In order for J.Community 33 however. the community health nurse must foster "a sense of worth among those who often considered themselves worthless" (p. during this visit that a developmental screen was performed on J. R. She may have perceived this as a test of herself and her parenting abilities. These strategies were employed in the first visit with J.'s mother to have confidence in her abilities as a parent in the face of J. it was important for the student nurse to affirm the positive aspects of the care that she provides for J. R. and fostering a nonthreatening atmosphere which allows the client to share data at his or her own pace" (p.

. 281). . According to Clemen-Stone et ale (1991). Diagnoses that identify actual or potential problems assist the nurse in providing needed anticipatory guidance as a primary prevention strategy (Clemen-Stone et al. November 11. 1991. 1991. In community health. 34 In this phase of the relationship. 272). the nurse and family can then work together in analyzing the needs of the client and family unit. it was important The diagnoses.. nursing diagnoses are used to examine actual or potential problems as well as strengths of the client and family (A. On the other hand. November 11. personal communication. and his family. the family's. 273). 1994).Community Nursing Diagnosis With trust as the foundation. therefore. must be validated by the client. R. Blatnik. when the client is actively involved in determining health needs. or the community's health problem/condition and the primary etiological or related factor(s) contributing to the problem/condition that is the focus of nursing treatment" (as cited in Clemen-Stone et al. Gordon defines a nursing diagnosis as an inference about "the individual's. Blatnik. diagnosing strengths aids the nurse in choosing activities that promote independence in the family (p. personal communication. 273). 1994). In working with J. he or she is more likely to change health behaviors than one who has no voice in such decisions (p. p. data gathered in the assessment phase of the nursing process is synthesized to build on needs previously identified in order to make a nursing diagnosis (A. p.

the relationship moves into the planning phase of the nursing process (Clemen-Stone et al. Planning After diagnoses are established by the nurse and client. In this phase client centered goals and objectives are formulated and interventions are identified (p. 1992. PNP was suspicious of a delay. but did not seem to accept the reality of a delay. A goal is defined as a "broad desired outcome toward which behavior is directed" (p. Refer to Appendix C for the suspect test result of the DDST performed on J.'s mother was concerned about his development. p. p. in that N. The objective nature of the DDST would confirm the suspicion while providing concrete data to work with in presenting the results to J. 279). was indeed developmentally delayed and to what extent. The Denver Developmental Screening Test [DDST] assesses "a child's performance on various age-appropriate tasks • • • . The interventions are activities to be carried out by the client. According to Frankenburg et ale (1992). R. in confirming intuitive suspicions with an objective measure and in monitoring children at risk for developmental problems" (Frankenburg et al. 279). 1991. . J.. This was considered an appropriate tool to use with J. [and] is valuable in screening asymptomatic children for possible problems. R. and an objective "delineates client behaviors which reflect that a goal has been reached" (p. 279). 13). 279). R.'s mother.Community 35 to determine early if J. 1).. R. Jackson. the test result is suspect if one or more delays are discovered (p. R.

and interventions developed in working with the family of J. 1991. 280). 280). and (3) the client's right to self determination" (p. 280). personal communication. p. Clemen-Stone et ale (1991) set 36 forth three main principles to be considered in the planning process: "(1) individualization of client care plans. November 11. goals. This active participation "also promotes client commitment to goal attainment and decreases resistance to change" (Clemen-Stone et al. Therefore. (2) active client participation. 969). or other professional to help reach the identified goal (p. If the nurse were to enter the relationship and take over for the family. Refer to Appendix D for a care plan containing nursing diagnoses. it is sometimes appropriate for the community This would be health nurse to develop a nurse centered goal. However. . 280). 1994). R. since each client has unique needs. Blatnik. 279).. she may decrease the family's self esteem while fostering dependence or resentment of authority figures (p.Community community health nurse. appropriate if the nurse identifies a problem that the family is not aware of and determines by professional judgment that it is necessary to increase the family's awareness of the problem (A. the client must be actively involved in mutual goal setting with the nurse (p. According to Twinn (1991) this philosophy of practitioner forming a partnership with the client is quite different from the traditional health care paradigm in which "practitioners generally work with clients in a directive manner" (p.

's family.) (Refer There was also an oral contract between J. 1991.'s mother and the student made at the end of each visit regarding each party's duties in the week before the next visit. In working with J. R. The contract must be mutually agreed upon and must be continuously negotiable (A. p. R. 1991. This written contract outlined the time parameter of the relationship.. Blatnik. 281). November 11. R. to Appendix E for a sample contract.281). and how many visits were to occur. 1994). With the contract as a framework. Before each termination the student and mother would come to a mutual agreement as to what would be accomplished by each in the coming week. personal communication. either written or oral. 281). p.'s mother and the student on the first home visit. This provides a framework from which to evaluate the effectiveness of interaction between the family and the nurse (p. a written contract explaining the purpose of the family study and the duties of the student was signed by J. the client and community health nurse must develop a contract which "clearly 37 identifies what each person in the relationship can expect from the other person in the relationship" (Clemen-Stone.Community Implementation After diagnosing needs and setting goals. the client and nurse move into the implementation phase of the nursing process in . The nurse and client work together towards an agreement. when visits would take place. which outlines the responsibilities of each member in achieving the stated goals (Clemen-Stone et al.

285). 1991. Such a situation may precede the need for modification of the mutual goals and plans (p. This aids the family in assuming responsibility for themselves as a unit rather than fostering dependency (p. 285). 1991.Community which "activities are carried out to achieve client goals" (Clemen-Stone et al. new data may be gathered that must be analyzed to determine the need for care plan revision (p. 284). p. It is also imperative to elicit ongoing feedback from the client and family in order to determine if interaction remains focused and effective (p. 285). 285). Evaluation Evaluation must take place throughout each phase of the nursing process so that the community health nurse can accurately identify what has or has not been accomplished (Clemen-Stone et al. If the client fails to follow through with an agreed upon intervention. p.. 285). As in all phases of the nursing process. the nurse must determine why the client is not taking action (p. 284). 285). 284).. This process is facilitated by establishing objectives in the planning phase that contain the potential for evaluation (p. Clearly this represents an ineffective use of resources. Clemen-Stone et ale (1991) state that when evaluation is deleted from the relationship the process is prolonged (p. Throughout this phase. A supportive atmosphere 38 should be developed by the nurse to reinforce accomplishments and provide positive feedback (p. 285). . the client must be involved in implementing the care plan.

in the beginning of the relationship and throughout consecutive meetings 2. Termination Through accurate evaluation. These include: Stating the termination date. the community health nurse can make decisions regarding when nursing services are no longer needed. 286). However. The client-nurse relationship then enters the termination phase (A. evaluation aids the nurse in determining the need for referrals or the need to terminate nursing services (p. certain interventions must be implemented by the nurse throughout the relationship in order to prepare the family for termination. 286). 1. personal communication. Discussing thoughts and feelings about termination prior to the last meeting 3. Encouraging the family to compare past separations with the present one . November 18. 286). However. Refer to Appendix D for evaluation of nursing goals and objectives in the care of J. R.Community 39 Evaluation also aids the community health nurse in determining why goals have not been achieved (p. When coordinating services among professionals. 286). if known. 1994). Blatnik. Identifying signs of separation anxiety in the family and personally 4. outcomes of interaction must be examined rather than simply observing that the family is participating in the process (p. It is then necessary "to evaluate the effectiveness of referrals that have been made" (p.

satisfactions.. 287). 405). 1991. The nurse must remind the client of the continued availability of health care services in the community even though the home visits will not continue (A. Strong feelings such as anger and sadness are often experienced by the client and nurse.Community 5. Kelly defines termination as "the period when the client and nurse deal with feelings associated with separation and when they distance themselves" (as cited in Clemen-Stone et al.'s family was less than ideal in that the time frame was predetermined rather than being based on evaluation of accomplishments. and J. 1983. 288). p. November 18. R. Termination with J. personal communication. However. 40 Promoting the family's evaluating and summarizing the relationship in terms of its goals. 1994). 287). expectations. p. It is important for the client and nurse to review what has and has not been accomplished in their relationship and why termination is indicated (p. 287). At the .'s mother was reminded about the number of visits remaining upon each visit. termination was integrated throughout the relationship in that a contract with a specified number of visits was signed by both parties at the first visit. and these feelings must be discussed and dealt with (p. Clemen-Stone et ale (1991) state that it is the nurse's responsibility to initiate such a discussion in order to create a supportive atmosphere for the client to express feelings and emotions regarding the termination (p. Blatnik. R. and dissatisfactions (Cronin-Stubbs.

.. would apply for the Empty Stocking Fund. and she was aware of the importance of maintaining her own health. R. A list of family strengths She seemed identified by the student was shared with the mother. very pleased with the student's conclusions and added some items to the list. Jackson. 87). Family Strengths Inherent in each phase of the nursing process is utilization of family strengths to increase successful achievement of goals. and would obtain an appointment for herself to have a physical exam. and the client expressed little emotion about the reality of termination. Progress made was reviewed with the client. Plans for the mother's continued effort towards the goals identified were mutually agreed upon. R. 88). PNP regarding program placement for J.'s mother of the Knox County Health Department are still available to the family despite the fact that home visits by the student nurse would not continue. was reminded that the services J. specifically that the mother would follow up with N. Once strengths are identified they can then be mobilized in working out problems that exist or arise within the family (p. R.Community 41 final visit the student initiated discussion about termination. specifically that the mother was now more aware of age appropriate tasks for J. Herbert otto (1973) defines family strengths as "those factors or forces that contribute to family unity and solidarity and that foster the development of the potentials inherent within the family" (p. would obtain a thermometer. The community health nurse is in .

or family potentials" (p. R.Community 42 a position "to support the family in exploring the application of family strengths to the problem configuration" (pp. Barriers to Health Care In evaluating the progress that a client and/or family is making toward a goal. . Often nurses become preoccupied with the pathologic patterns occurring in the family.'s family. but in fact are quite capable of developing more healthy patterns by making use of available resources. Pointing out the positive aspects of the family unit can prompt clients to realize that they are not helpless. 92). 244). 92-93). and too little attention is paid to the positive potential of the family (p. Appendix F for assessment of strengths in J. Clemen-Stone et ale (1991) cite "various reasons why clients are unable to alter their behavior in a way to help them resolve their stress appropriately" (p. 91). Often the family does not know why they are experiencing difficulty in taking action. 244). yet they are aware "that something is wrong because symptoms of anxiety are present" (p. otto (1973) defines these as strengths that are present Discovering and but not being utilized by the family (p. Often the community health nurse identifies "latent family strengths. building on these strengths provides a positive balance in the community health setting. Recognizing strengths reminds clients that they are Refer to valuable individuals despite their areas of need. it is important for the community health nurse to be sensitive to the often invisible factors which obstruct progress. 92).

the family's self image. or the client has missed successful completion of tasks in skill development (pp. Resource barriers may include the attitudes of health care professionals. 322) and give examples of barriers that are inherent in the resource and those that exist within the client or family. and the family's ability to pay for the service and/or get to the facility (pp. Barriers within the client or family may include where the service falls on their list of priorities. and the cost of the service (pp. 322-323).Community In these situations. Clemen-Stone et ale (1991) give examples of these causes which are primarily psychosocial: the client has not identified the specific nature of the problem. the community health nurse must explore 43 with the family the possible causes for their inability to take action and obtain the appropriate health care. the client has no problem solving experience. the family's prior experience with utilization of referral services. the client does not assume responsibility for feelings. The community health nurse must also be aware of those factors that adversely affect the family's use of referral services. . how well they understand the need for the service. the accessibility of the resource to the community. the client cannot acknowledge feelings or distinguish between feeling and fact. Clemen-Stone et ale (1991) define these factors as "barriers to utilization of the referral process" (p. the family's motivation to act on the need that initiated the referral. the family's awareness of available services. cultural differences. 244-245).

August 26. Utilization of Community Resources Various agencies in the community are currently being used by this family. 44 The community health nurse must be consciously looking for these factors because clients may not bring them to her attention due to embarrassment or their lack of awareness of the barrier. It is not designed to be a walk-in clinic. sick care. service. services. Boggan. . immunizations and WIC" 2). p. In this situation the nurse can assist the family in prioritizing needs that they are ready to act upon (p. 1994. Refer to Appendix G for barriers to obtaining health care identified when working with J.'s family. The agency that they use most frequently is the Pediatric Primary Care Clinic at the Knox County Health Department [KCHD]. Boggan. For example. personal communication. August 26. The clinic offers "clinical (KCHD. a client or family may acknowledge The nurse must a need but repeatedly fail to act on the need. 323). these clients would probably go to the emergency room for sick care only. personal communication. R. This is a clinic in which health care is provided by physicians and nurse practitioners to those patients who do not have a primary care physician (K.Community 323-324). 1994). Here they would be seen by a different physician who was not aware of their personal health history on each visit (K. be able to differentiate between their readiness to work on the need as opposed to their awareness of the need. but rather its Without this purpose is to provide regular primary care.

and Children [WIC] is a federally funded program offered through the KCHD that provides various food services to pregnant or breast feeding women and children under the age of five (KCHD. Infants. Jackson.Community 1994). "participants must meet financial eligibility and have documented medical . this child's developmental delay and need for placement in a special program may have gone undetected until much more lengthy and costly intervention would be required. R. This resource has several positive effects on this family's level of functioning. the health care providers at the Pediatric Clinic discovered J. Without this intervention. Both were consulted in this case to discuss possible sources for obtaining developmentally stimulating toys for J. The family's ongoing rapport with the providers at the clinic has been a positive experience for J. R.'s health problems and initiated home visits to this client by the student nurse. For example. To be eligible for the program. p. and Donna Richter is a social worker that operates through this clinic. R. R. The Supplemental Food Program for Women.'s family as evidenced by his mother's positive and affectionate comments about N.'s placement in a special program for developmentally delayed children. PNP. R. and 45 it prevents unnecessary (and costly) visits to the emergency room. Thus the clinic provides for continuity of care. Nancy Jackson.. This experience has a positive influence on the family's future use of health care services. PNP is the primary care provider for J. 2). 1994. and options regarding J.

R..'s mother is in the application process for He has been evaluated for obtaining SSI benefits for J. The community health nurse should be able to identify possible candidates for food stamps and direct these clients to the state Department of Human or Social Services to apply for the program. . 117). WIC offers vouchers redeemable 46 at local grocery stores for items such as milk. R. J. 2). p.Community or nutritional risk" (p.'s family also receives nutritional support from the food stamp program. 1994. 1994. This is a federal-state assistance program designed "to improve the nutritional adequacy of low-income individuals and families" (McGuire. These interventions were supported and reinforced by the student nurse. p. blind or disabled individuals" (McGuire.'s mother to feed him foods rich in iron and Vitamin C. R. and disabled" (Clemen-Stone et al. p. R. 7). is currently enrolled in the WIC program due to his financial need and documented iron-deficiency anemia. blind. The program has intervened to educate and encourage J. cheese and cereal. 6). J. R. and the program "includes mandatory nutrition education and health assessment" (McGuire. The role of the community health nurse in WIC is be aware of possible beneficiaries of the program and provide the client with information about how to contact the program. 1994. Supplemental Security Income [SSI] "is a federal-state assistance program for qualifying aged. 7). J. p. 1991. This program is designed "to develop a uniform national minimum cash income for the indigent aged.

she decided that she would explore other programs. Jackson. R. 3). R. and she was given the phone number and instructed to make an appointment for evaluation of J. 3). Children's Special Services [CSS] is a program offered by the KCHD that "provides comprehensive medical care for handicapped children from birth to 21 years of age who meet the medical and financial eligibility requirements" (KCHD. medical treatment. p. assessment. J. was made but not kept. He has not been rejected or accepted by the program to date. R.'s mother expressed concern that his inability to walk may be due to an orthopedic problem. and that CSS would have the resources to continue these visits. 1994.'s mother stated that after discussing CSS with N. Community health and speech and hearing screening tests (p. CSS nurses then act as care coordinators and provide evaluation. R. was referred by the student nurse to CSS for evaluation due to his considerable developmental delay. The student also felt that further home visits were needed by this client. R. The appointment When questioned about the missed appointment.'s mother. nurses play an essential role in CSS in that they identify possible beneficiaries of the program and provide information to the family. She agreed to follow up with N. PNP. 3). J.Community 47 physical and mental disability to determine if he is eligible. CSS provides diagnostic evaluation. The student thought that CSS would have resources to diagnose such a problem if it existed. The CSS program was discussed with J. and health education in the home (p. J. PNP regarding . Jackson.

140)-. R.an imbalance that leads to high cost and often inappropriate care for a few and inadequate care for many. p. and how she could apply for the Empty Stocking Fund by the student nurse. Recommendations A commonly accepted opinion is that the American health care delivery system needs restructuring due to its inability to meet the health needs of many citizens (Knauth. R. J. Therefore. 140). A1). governments continue to emphasize high tech secondary and tertiary health care and "lack faith in low-cost community­ based [health care] activities" (Clarke et al. It is possible that J. p. However. p. when. 308). The program is designed to help those in the Knoxville community who would otherwise have no means to help them celebrate the holidays (Brown. 1994." 1994. As a result "public health nursing has been diverted from its . There appears to be "an oversupply of physician specialists and an undersupply of primary care services" (p. 1993.. A1). 48 The Empty Stocking Fund is a program that "provides needy individuals and families with a Christmas basket of food and toys for children under 14 ("Milk Fund. Individuals must apply for the baskets. and information is documented and verified to determine who will receive a basket (p.'s mother was given information about where. p. 1994. A1). The program is funded by contributions and conducted by the Knoxville News-Sentinel.'s family would be considered in need of a basket due to their financial stress.Community other options.

In the same study. postpartum intervention influenced improved childhood behavioral and developmental status and decreased emergency room visits and hospitalizations for injury. p. fewer days on public assistance. 1990. 1993. and social problems" (Zerwekh. 1676). higher levels of employment. communities that have previously not been reached by the health care system will be accessed and taught how to use the health care system. p. 1990). foster home placement. these health promotion and disease prevention strategies have been proven to be cost effective in that they prevent the need for more expensive forms of inpatient care (Hawkins & Higgins. psychological. or child abuse (Zerwekh. 1993. A reformed health care system that boasts universal access is not sufficient. As trusted health professionals. 117). 1675). and reduced instances of failure to thrive. 49 However. policy. 1993. Another study of home visitation programs to socially disadvantaged women and children succeeded in improving women's health-related behavior during pregnancy resulting in increased birth weight of their babies (Olds & Kitzman. In studies of home visits by nurses in New York. p. as well as decreased unintended subsequent pregnancies (Olds & Kitzman.Community ideal of primary prevention to provide damage control for individuals and families already suffering from medical. 1990). p. . cost effective outcomes included reduced emergency visits. In this way. 1676). community health nurses have the unique capability to move into communities and "bridge the gaps between science. and the people" (Salman.

was dressed appropriately and the environment of his home could not be assessed. and was often placed in his crib with a bottle propped.'s parents have). J. J. It is not surprising that the child was unable to walk considering the lack of space in the crowded apartment for him to move about. But even if parents access health care delivery (as J. R. R. R. There are many public health issues For example. These symptoms were being treated without getting to the root of the problem. His chronic ear infections were related to the fact that he was still being bottle fed. was dressed in inadequate clothing for the climate. Upon visits to the clinic. Insight into J.Community 50 Salman (1993) uses school-aged children as an example and points out that just because a parent is able to take a child in for health care services does not ensure that this will take place (p. 1675). "such services do not cover the scope of health-related activities necessary to ensure the health of all children" (p. and interpersonal family environment. He spends most of his waking hours playing on the double bed in the entrance room of the . R. not present in the clinic that can be overlooked. presented in the clinic with chronic respiratory and ear infections and developmental delay. R.'s chronic respiratory infections was related to the fact that the apartment door was kept open. R.'s delayed gross motor development was also gained only through a visit to his environment. 1675). home. The root of J. and J. which was ­ found in the community. causing a reflux of milk into the eustachian tube creating a reservoir for bacteria to thrive.

In order to overcome these restrictions community health . Upon arriving to the home on each visit. It is not surprising that he was then not interested in eating at mealtime. p. would not have been realized in a visit to the clinic. Obviously.'s also chronic anemia and reported lack of appetite were discovered through a visit to the home. the potential for injury and infection discovered only through a visit to his home. Community health nurses present in the community are able to address these public health issues. and lack of prescriptive power" (Reverby. studies have shown that nurses. especially advanced practice nurses can provide comparable primary care at a lower cost than doctors do (Aiken & Fagin.Community apartment which does not provide adequate opportunity for his 51 large muscles to strengthen and develop coordination necessary for standing and walking. the child was found sitting on the double bed nibbling on crackers. These restrictions tend to limit how the nation views and utilizes nurses for primary care. nurses. reimbursement procedures. The contributing factors to J. R. 1993). 1663). 1993). However. even advanced practice nurses. Nurses are also more accessible to those communities most in need of primary care when one considers the current shortage of primary care physicians in the United states (Aiken & Fagin. are continually "restricted by the scope of practice laws. potato chips. malpractice costs. 1993. and was not receiving the recommended amounts of essential nutrients. etc. admitting privileges. candy.

Clarke. literacy)" (p. p. housing. p. and Whyte (1993) point out that just because preventive services have been identified as a key to better health does not mean that people will actively seek these services or that government will incorporate these services into a reformed health care system (p. (Clarke et al. 104). 308)..Community 52 nurses must be prepared to present their services as an essential piece in health care reform alternatives to the present system. p. The nurse must then be prepared to use . Public health nurses are also trained to enter an unfamiliar environment. 1992. Public health nurses are trained to foster client autonomy while "developing mutually negotiable relationships" (Zerwekh. and assess "the social determinants of health (e. it is counterproductive to encourage self-care when people lack environments conducive to health 1993. Beddome. 16). the patient's turf. 1 994. 1 4 1 ) • Providing primary health care in community-based settings is presented in this document as a strategy for enhancing consumer access in a restructured health care system (American Nurses Association. 308). employment. However. Nursing's Agenda for Health Care Reform..g. a public policy statement written in 1991 by the National League for Nursing and the American Nurses Association. Another important concept in utilizing community health strategies more effectively involves empowering the public. 1991). emphasizes the role of the consumer in health care decision making and encourages consumers to become better informed about the range of services and providers available (as cited in Kna u th .

1990. However. Registered nurses represent the largest subgroup of the healthcare work force ("The Nurses' Agenda". 39). 308). p. . Clarke et ale (1993) suggest that nurses become active in influencing public policy towards an agenda that is focused more on prevention and health promotion rather than the present system which has an acute care focus (p. nurses are capable of using collective power to influence public opinion and policy effectively. 39). 971).Community 53 this assessment data to influence public health policy locally and nationally (Twinn. They can organize group power by writing letters to the editor of major newspapers and magazines and engaging in media activities to raise public awareness. This shift in focus would obviously require a redistribution of health care funding. 1995). Nurses can utilize their vast network of nursing journals to raise awareness in their own profession and thus elicit unity and group effort. Nurses can begin with "grass-roots activities to mobilize support and/or educate legislators and/or constituents" (p. • • [and] choose not to be powerful or to become involved politically" (Bushy & Smith. Nurses can also use their professional organizations to support a candidate for public office that agrees with the nursing agenda for health care reform. The possibilities are endless if nurses as a group could combine creativity. p. and professional strength with a genuine concern for the health of the public. However. nurses have tended to be reactive rather than proactive • . "as a group. 1991. knowledge.

man a fish. I even wanted to clean their I wanted to buy toys for J. these I was there gestures were far from therapeutic for this family. I then worked with them to set mutual goals for fixing those problems. in that I had never experienced such need in my own country. L. I saw so many things that I wanted to do for them. R. I soon learned that while noble. I had seen the face of poverty. My role was not to fix everything or even Rather. That is the unique beauty of it. I realized. and gave them the tools they needed to do so. This concept reminds me of an ancient Chinese proverb that was relayed to me by a very special woman who taught me in high school. apartment. however.Community Author's Summary of Experience In reflection on my experience with this family and 54 community. However. you feed him for a day. R. "If you give a If you teach a man to fish. When I first began working with this family. to give the family information so that they could work with me to mutually identify problems. I wanted to bring them sheets and blankets. that community health nursing is not charity. (cited by Sr. Through involvement in a mission But before experience in Mexico. this community health experience I suppose I was under the false notion that I had to leave America to serve the needy. deMarillac. you feed him for a lifetime" It says. I feel that I grew both professionally and personally as a result. I was there point out all that needed to be fixed. . as a facilitator. I experienced a bit of a shock when I first encountered this family and J.

I began to realize how vital this nonjudgmental attitude was to my relationship with this family. and I believe this is a fantastic resource in that it serves so many people in such an essential . and how my attitude towards them affected their attitudes toward themselves and their child. Again. Nursing in the community had a positive influence on how I am able to interact with those that come from a different background and have different lifestyles than me. In other words.'s mother and father looked to me for reassurance and reinforcement. it was my role to supply them with information that they could use to come to their own decisions regarding necessary lifestyle adjustments. empowering 55 clients to help themselves is much more effective in the long run. 1989). R.Community personal communication. serves no therapeutic purpose. R. and now I am amazed at the powerful impact it can have on people's health if they were only aware of its wide range of services.'s family. either with approval or disapproval. Working with this family and community also helped me to learn about the many resources that are available in the community. I began to see how J. I often had to make a conscious effort to remain nonjudgmental in the first few visits with J. But as I became more familiar with community health concepts. I was not aware of the WIC program either. I never really understood what the health department was about until this experience. I realized that judging a family or client.

Prior to this experience. Resources such as these are intrinsically linked to 56 community health nursing. I also was ignorant of the ways that nurses must I had heard this concept I became use all their senses in assessment. I saw what a difference nursing is making in preventive health. I suppose But working I still placed nursing primarily in the hospital. Prior to this. through the health department. . this experience showed me yet another unique role that nurses play in health promotion. enables them to take initiative and help themselves. Referring clients to such agencies. but reading about and implementing the strategies described in Mary Bayer's (1973) article helped me to grasp how useful my five senses could be in improving my assessment skills. I don't think I was aware of the many factors that influence one's health behaviors.Community way. aware of these factors while doing the multidimensional assessment. Finally. This experience opened my eyes to many more opportunities that nurses have to be independent professionals and influence public policy on a national level. before. and seeing how the satellite clinics are run by nurses independently.

G. 21(11). & McGuire. American Nurses' Association. & Smith. H. 25(4). sight. A17. and wherefores. Bayer. 21(4). F. 57 The New York Times. November 20). Nursing Management. Nursing's agenda Washington. DC: Executive summary.). T. & Fagin. Vision for the future of public health nursing: health care. Clarke. M. p. American Nurses' Association. (1990).... Public Clarke.. Eigsti. Lobbying: The hows Bushy.712-713. C. B.. Comprehensive family and community health nursing (3rd ed. 305-310.through sense. O. March 11). & Whyte. D. 39-45. G. A23. Monday. MO: Mosby. G. for health care reform: Author. J. (1993). health nurses' vision of their future reflects changing paradigms. (1994. st. Nursing Outlook. L. Louis. & Whyte. and sound.. N. 10(1). Brown. A. . S. N. 13-18. F. pp.Community References Aiken. More nurses.. Beddome. Community diagnosis-. Standards of Author. Sign up for fund begins The Knoxville News-Sentinel. community health nursing practice. Beddome. S. A case for primary Public Health Nursing. Clemen-Stone. A1. (1973). Image: Journal of Nursing Scholarship. Kansas. (1986). H.. (1993. (1991). L. MO: (1991). better medicine. (1993). B.

J.. Interpersonal relationships In W. L. 108-115. Inc. (1994. Knauth. Community Norwalk.. In S. B. of Nursing. 58 in community health nursing practice. Dodds. Denver II Denver Developmental Materials. Olds. (1990). TN: Knox County Health Department. Hawkins. process. Burgess (Ed.. training manual. August 29). Nursing Economics. Unites States health UTK College care delivery system [Handout]. P. & Shapiro. Appleton & Lange. Can home visitation improve the health of women and children at environmental risk? Pediatrics. & Kitzman. . practice Appleton-Century-Crofts.. Author. Archer. Knox County health Knoxville. Issues and topics. D. L. G. Knoxville. K. 86(1). 140-145.. Financing health Denver. CO: (1992). P. Maschka.Community Cronin-stubbs. H.). P. department programs and services [Handout]. Edelman. Community nursing centers: Removing impediments to success. 97-125). (1983).). Bresnick. H. CT: Philosophy. D. (1994. (1994). Wold (Ed. November 28). TN: Milk Fund donation drive coincides with ESF. (pp.. A1. The Knoxville News-Sentinel. Norwalk. S. McGuire. D. L.. (pp. 12(3). N. Community health nursing: 393-418). (1994). p. care in American: health nursing: CT: Who pays? (1990). J. Frankenburg. W. J. & Higgins. W..

visiting: (1991). (1995). F. Stanhope. & Knollmueller. community nursing (pp. M. M. Health visiting: health nursing (2nd ed. 83(12). Nursing Outlook. Public Health. 267-270. 17(5). otto. nursing-­ (1993). st. of community and home health nursing. N. Orr (Eds. Handbook Mosby. 16(8). 1662-1663. The nurses' agenda: Management. 83(12). (1973). Clinton: What will happen to public health nursing? Journal of Public Health.). strengths.. 26(2). Towards community Oxford. Twinn. 21-23. A. A. 87-93). Quinn (Eds. MO: The nursing process in family health. E. Editorial: Public health American Journal of The opportunity of a century. (1992). J. Luker & J. S.. (1992). 1674-1675. Journal of Advanced Nursing. 20(4). E. 65-75. Health visiting and the community. Reinhardt & M. (1972). S. R. (1992). . Blackwell Scientific Publications. Nursing A continuing debate for professional practice. (1993). Salmon. pp. Reifsnider. 73-106). MO: Mosby. M. Family-centered st. Tapia. Conflicting paradigms of health Priorities for 1995. In 59 K. J. 966-973. care system: reform. Louis.Community Orr. Restructuring the American health An analysis of nursing's agenda for health care Nurse Practitioner. Louis.). H. England: A framework for assessing family In A. From Lillian Wald to Hillary Rodham American Reverby.

V.). Locating families. J.Community Whaley. F. J. .Public health nursing today and tomorrow. J. infants and children (4th ed. Public health nursing legacy: Nursing & Health Care. 15-20. (1991). L. True detectives. (1992). Journal of Public Health. Commentary: Going to the American people-. 9(1). and building Public Health Nursing. & Wong. 60 st. Zerwekh. (1992). L. J. (1991). J. Nursing care of Mosby. Nursing Scholarship. Zerwekh. The practice of empowerment and Image: Journal of coercion by expert public health nurses. 101-105. self-help: strength. (1993). V. 84-91 . Historical practical wisdom. 91(10). V. MO: Tales from public health nursing: American Journal of Nursing. 24(2). D. Zerwekh. V. V. 30-36.. building trust. Laying the groundwork for family Zerwekh. Louis. 83(12). 13(2). Zerwekh. (1992). 1676-1678.

61 However this family still seems unable to support the growth and development of its members as evidenced by J.'s developmental delay and his mother's lack of adequate rest. R. R. R.Community Appendix A Tapia's Model Level II-III Family placed at this level because: This family is partially in Level II (childhood stage) because they are better able to meet their needs for security and survival than a family in Level I (infancy stage).'s mother's inability to state her concerns about J. The family also needs help with acknowledging their problems realistically as evidenced by J. Activities must be performed consistently and with genuine concern so the family can get to the point where they are no longer speculative of the . Nursing services and activities appropriate for this family based on the model: Support of the trust relationship is very important.'s health. The family also shows signs of a future orientation such as J. and this must be used to help the family see its problems and strengths more realistically. R.'s mother's comments about one day buying a house and her effort to obtain a high school diploma. This family also exhibits characteristics of Level III (adolescent stage) as well in that they have the knowledge and ability to utilize some community resources and are not hostile to help from outside the family.

R.'s encourages the family to make their own decisions. R. The nurse 62 begins to help the family work through what they see as problematic by teaching and referring them to community resources.Community intervention and begin to work on their problems.'s mother must be assisted to come to terms with J. concern. but constantly In J.'s health problems as well as how those problems affect her own health and well-being.'s development and growth. R. his mother is not hostile to the community health nurse but doesn't realize that the nurse is there to help rather than condemn. She works as a care coordinator. . family. R. Therefore the trust relationship is the primary Then J. Care coordination is the next most important nursing service for this family by supporting WIC intervention and hooking them up with programs aimed at providing a more stimulating environment for J.

However. Physical Independence (3): Justification 63 Mother is providing personal However. Knowledge of Condition (3): Mother understands the need for placement of ear tubes (for J. such as not emerging J. R. but leaves the door open to the apartment and J. Immunizations have been secured for J. Attitude Toward Health Care (4): Mother accepts the need for health care for J. Application of Principles of Personal Hygiene (2): She also is However. . in water. R. 5.) and how to care for them. rarely sleeps more than 3 hours at a time according to mother and is not dressed adequately in relation to weather. R. R. Therapeutic Independence (3): Mother provides breathing treatments for J. R. R. There is dirty laundry and dishes throughout the horne and the diet of J. 4. she and her husband do not receive preventive health care despite being insured by Tenncare. R. R. 3.0 Poor to 5 Excellent): 1. she Father carries two full time jobs. R.'s play area is soiled with dust and dirt. is not aware of how to prevent ear infections. R. aware of symptoms of complications to watch for. 2. R. is not kept properly clothed for the climate of the environment. physical care such as appropriate clothing and cleanliness are not being provided for J. is questionable.Community Appendix B Family Coping Estimate Coping Area (Rating-. J. certain care for herself and partial care for J. J.

R. Mother feels that she needs to discuss possible interventions with her husband (J. 7. adult GED program. Deteriorated building. . Electric portable heaters. However she seems to not realize that the community health nurse is there to help rather than condemn. Family Living Patterns (3): Mother responds quickly to J. Very little Very room to walk inside home. R. Physical Environment (1): Very little facilities for privacy.'s needs. No play space except parking lot. Mother seems unable to face the reality of J. home. but leaves him alone in apartment playing. No phone in Use of Community Resources (4): Mother is aware of community resources such as W1C. and health department services. She also frequently leaves the child unattended while outside smoking. 8.'S developmental delay. R. neighborhood houses people that are questionable intoxicated. little covers for bed. SS1.'S father). 64 Emotional Competence (3): Father has not been observed. 9. food stamps.Community 6.

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c) Suggest strategies to maximize J. possible mental handicap. Goal #1. 1.M: J. SW and N. giving him a spoon at mealtime. R.'s performance on the DDST and age appropriate tasks of an 18 month old child. providing simple toys that he can manipulate easily. Evaluation: Objectives met-Mother is able to identify . Nursing Interventions: a) Perform DDST to confirm delay.'s family will provide an environment that maximizes the developmental potential of J. R.Community Appendix D Goals for Health Supervision and Interventions Client Name: J. R. Discuss with mother the implications of J. Richter. R. Jackson.'s developmental potential with family such as giving him nontoxic crayons. b) Consult D. R. R. Give mother phone number and encourage her to make and keep appointment for J. Suggest ways to make and places to obtain Give information about applying age appropriate toys for J. PNP about DDST results and possibility of enrolling J. R. Nursing Diagnosis: Altered growth and development related to lack of available play area and environmental stimulation. R. d) Refer client to CSS. for Empty Stocking Fund. in a specialized program for developmentally delayed children. and family 66 The letter "M" indicates that the goal was mutually identified with the client.

R. Evaluation: Objectives met-. mother can verbalize reasons for follow up with N.'s increasing mobility and curiosity and how certain physical hazards in the home could be harmful. Nursing Interventions: a) Provide anticipatory guidance regarding J. PNP to discuss J. R.'s enrollment in a special program. mother made appointment with CSS. 2. R. Objectives not met-. Jackson. mother is able to give examples of at least 2 age appropriate toys for J. mother can explain importance of remaining inside apartment with J.mother is able to identify at least 3 age appropriate tasks of J. Jackson. that require modifications in his environment.'s family will provide a home environment free from safety hazards. R. mother keeps door .Community 67 at least 4 tasks that an 18 month old child should have achieved and a strategy to promote each with J. c) Encourage mother not to leave child in apartment unattended. R.mother did not keep CSS appointment but agrees to follow up with N. R. PNP instead. Goal #2: J.. and how to make or obtain them. R. especially if he is eating or playing on an elevated surface (such as the bed in the front room). b) Give suggestions about ways home environment can be modified to reduce risks of injury.. Nursing Diagnosis: High risk for injury related to safety hazards present in the home and lack of appropriate protection from outside environment.

Encourage to keep appointments at Pediatric Clinic .Community to apartment closed. Nursing Diagnosis: High risk for infection related to history of respiratory infections and otitis media (OM). insects in horne. 3. b) Discuss importance of and guidelines for dressing J. so. Goal #3-M: J. and nutritional deficit. e) Reinforce WIC interventions such as suggestions to increase iron rich foods and Vitamin C.e. from the bottle Suggest strategies for doing including tendency toward OM. mother can identify at least 2 ways that 68 the horne environment can be modified to reduce risk of injury. i. Suggest resources to obtain warm R. c) Discuss importance of keeping door to apartment closed. lack of appropriate clothing. Nursing Interventions: a) Discuss importance of weaning J. frequent exposure to outside air. f) at KCHD. mother agrees to take the appropriate action to modify the horne environment. d) Provide information about where to obtain thermometer and cost range. decreasing insects in horne and decreasing potential respiratory irritants that J. Ladies of Charity). R. R.'s family will provide environment that reduces risk of infection. clothes if needed (Goodwill. is exposed to. appropriately for climate. R.

's 69 appointments at Pediatric Clinic. Nursing Interventions: a) Discuss the importance of mother's own health Assist her Functional parenting patterns will be maintenance and her ability to meet J. R. Suggest that bed be used for sleeping only. Goal #4-M: maintained. R. Nursing Diagnosis: High risk for altered parenting related to physical exhaustion of mother. child's inability to sleep more than 2-3 hours at a time. R. mother states she will obtain thermometer. mother can verbalize guidelines for dressing J. mother verbalizes understanding of WIC interventions. consistent bedtime rituals and to place child in crib while he is awake. c) Discuss ways for mother to deal with nighttime crying . mother keeping door to apartment closed. b) Discuss strategies for promoting prolonged nocturnal Encourage mother to establish sleep patterns for J.'s needs. 1991.Community Evaluation: Objectives met-. R. p. Encourage mother to offer last feeding as close to bedtime as possible (no bottles in bed) and increase daytime feeding intervals to 4 hours or more (Whaley & Wong. R.mother keeps J. 4. mother states she is implementing strategies to wean J. in locating provider that accepts Blue Cross Tenncare and encourage her to make appointment. from bottle and can describe them. Discourage allowing child to nibble between meals. appropriately and agrees to do so. 568).

taking him to parents bed. 568). but avoiding holding or rocking.mother did not make appointment with health care provider for herself before termination of horne visits. . mother can verbalize the impact that her health has on caring for J.Community 70 such as entering room and reassuring child. and the importance of maintaining her own health. R.mother indicates awareness of potential difficulties in parenting child with J. Objectives not met-. or giving him bottle (p. e) use. R. Identify sources of family support and encourage their Evaluation: Objectives met-.'s health needs. Objectives in progress at termination: child will be sleeping through the night by the end of December 1994. d) Warn mother that these strategies are difficult to implement and encourage her to share them with her husband.

I understand that any and all information obtained by the student will be maintained in strict confidence and will be utilized only for the purposes of developing appropriate nursing care plans. Guardian or Client's Signature Date I hereby assume responsibility for giving this family nursing care under the guidance of faculty and in collaboration with other members of the Health Team for the period of: to Signature of Student (Date) . Knoxville on a regular basis during the period specified. Knoxville College of Nursing Nursing 403 Contract for Health Supervision in the Home NAME OF CLIENT CLIENT'S PHONE NUMBER ADDRESS CLINIC/PHYSICIAN 71 ************************************************************ I hereby grant my permission to participate in a family study and to be visited by a senior nursing student from The University of Tennessee.Community Appendix E The University of Tennessee.

these people are available to keep child 6. Parents encourage involvment of J.'s mother. 3. R. Parents are friendly with neighbors in that they are able to use phone next door (could be weakness if substance abusing neighbors spend time in home with child) 7. both parents work and assume responsiblity for child care 5. e. Mother expresses future orientation in that she has plans to move into a larger home and is working on her GED 8. day care.Community Appendix F 72 Family strengths 1. Close supportive relationship with J. 2.'s maternal grandmother and aunts is described by J. Parents are responsive to child's cues and speak to him verbally 4. their willingness to accept outside assistance. Role flexibility is present in that father supports mother's efforts to obtain GED and plans to complete his GED when she is finished. with other children his age (i. and their application to obtain SSI for J. this represents an effort to broaden J. children of friends). R. Parents are generally in good health Parents seem genuinely concerned about child's welfare and express strong desire to provide for him properly as evidenced by their keeping appointments.'s social development Family's awareness of its strengths: . R. R. R.

'S developmental growth were suggested by the student (i. . The father's willingness to work with the student and his devotion to J. obtaining preventive health care for themselves. Ways that family can be helped to develop these strengths: 73 Positive reinforcement was provided by the student to help J. utilizing support systems to allow time for physical and emotional rest). was dressed appropriately. The student also noted that this visit was the only one at which J. is a strength that was not able to be maximally utilized in this relationship due to lack of contact with him. Examples of how these strengths can be mobilized to foster J. suggestions for providing a safer and more stimulating environment for J. R.'S mother's ability to expand on the above mentioned strengths and give specific examples of them. R. In this short period of time. e. he seemed very eager to discuss J. R.Community This is evidenced by J.. R. however.'S father was only present for about 10 minutes during one of the visits. R. R. R.'S parents realize that they are caring for their child well despite his problems and needs. Latent strengths in this family: J.'S condition and was very interactive with the child. R.

there is no cost for services rendered to J. Other needs considered higher priority than utilizing referral services 5. Family is aware of problems but not yet ready to deal with them (lack of motivation) 6. Family has not specifically identified the nature of the 74 problem (i. limited transportation Physical exhaustion of mother Limited educational background and lack of familiarity with patterns of growth and development 11. lack of environmental stimulation of child. 3. Family has an interest in not identifying the problem Family is unable to generate alternative options during problem solving 4. at KCHD. 9. 8. Limited physical accessibility (not within walking distance) *No other resource barriers identified as mother describes a positive rapport with health care providers.Community Appendix G Barriers to Obtaining Health Care Client Barriers: 1. e. 7. Lack of knowledge about available resources Lack of understanding regarding the need for referral Limited financial resources. and family is covered by Blue Cross & Blue Shield Tenncare. possible mental disability) 2. . Mother doesn't give high priority to health care for herself Resource Barriers: 1. 10. R.

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