UNIT 4

COMMUNITY HEALTH NURSING APPROACHES, CONCEPTS AND ROLES AND

RESPONSIBILITIES OF NURSING PERSONNEL

APPROACHES
- NURSING PROCESS
The nursing process functions as a systematic guide to client-centered care with 5 sequential
steps. These are assessment, diagnosis, planning, implementation, and evaluation.

Assessment
Assessment is the first step and involves critical thinking skills and data collection; subjective
and objective. Subjective data involves verbal statements from the patient or caregiver.
Objective data is measurable, tangible data such as vital signs, intake and output, and height
and weight.
Data may come from the patient directly or from primary caregivers who may or may not be
direct relation family members. Friends can play a role in data collection. Electronic health
records may populate data and assist in assessment.
Critical thinking skills are essential to assessment, thus the need for concept-based
curriculum changes.

Diagnosis
The formulation of a nursing diagnosis by employing clinical judgment assists in the
planning and implementation of patient care.

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The North American Nursing Diagnosis Association (NANDA) provides nurses with an up-
to-date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a
clinical judgment about responses to actual or potential health problems on the part of the
patient, family, or community.
A nursing diagnosis encompasses Maslow's Hierarchy of Needs and helps to prioritize and
plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a
hierarchy based on basic fundamental needs innate to all individuals. Basic physiological
needs/goals must be met before higher needs/goals can be achieved such as self-esteem and
self-actualization. Physiological and safety needs provide the basis for the implementation of
nursing care and nursing interventions. Thus, they are at the base of Maslow's pyramid,
laying the foundation for physical and emotional health.

Maslow's Hierarchy of Needs

 Basic Physiological Needs: Nutrition (water and food), elimination (Toileting),
airway (suction)-breathing (oxygen)-circulation (pulse, cardiac monitor, blood
pressure) (ABCs), sleep, sex, shelter, and exercise.
 Safety and Security: Injury prevention (side rails, call lights, hand hygiene, isolation,
suicide precautions, fall precautions, car seats, helmets, seat belts), fostering a climate
of trust and safety (therapeutic relationship), patient education (modifiable risk factors
for stroke, heart disease).
 Love and Belonging: Foster supportive relationships, methods to avoid social
isolation (bullying), employ active listening techniques, therapeutic communication,
and sexual intimacy.
 Self-Esteem: Acceptance in the community, workforce, personal achievement, sense
of control or empowerment, accepting one's physical appearance or body habitus.
 Self-Actualization: Empowering environment, spiritual growth, ability to recognize
the point of view of others, reaching one's maximum potential.

Planning
The planning stage is where goals and outcomes are formulated that directly impact patient
care based on EDP guidelines. These patient-specific goals and the attainment of such assist
in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting.
Care plans provide a course of direction for personalized care tailored to an individual's
unique needs. Overall condition and comorbid conditions play a role in the construction of a
care plan. Care plans enhance communication, documentation, reimbursement, and continuity
of care across the healthcare continuum.
Goals should be:
1. Specific
2. Measurable or Meaningful
3. Attainable or Action-Oriented
4. Realistic or Results-Oriented
5. Timely or Time-Oriented

Implementation

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Implementation is the step that involves action or doing and the actual carrying out of nursing
interventions outlined in the plan of care. This phase requires nursing interventions such as
applying a cardiac monitor or oxygen, direct or indirect care, medication administration,
standard treatment protocols, and EDP standards.

Evaluation
This final step of the nursing process is vital to a positive patient outcome. Whenever a
healthcare provider intervenes or implements care, they must reassess or evaluate to ensure
the desired outcome has been met. Reassessment may frequently be needed depending upon
overall patient condition. The plan of care may be adapted based on new assessment data.

NURSING THEORIES
Nursing theories are organized bodies of knowledge to define what nursing is, what nurses
do, and why they do it. Nursing theories provide a way to define nursing as a unique
discipline that is separate from other disciplines (e.g., medicine). It is a framework of
concepts and purposes intended to guide nursing practice at a more concrete and specific
level.

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Grand Nursing Theories
 Grand theories are abstract, broad in scope, and complex, therefore requiring further
research for clarification.
 Grand nursing theories do not guide specific nursing interventions but rather provide a
general framework and nursing ideas.
 Grand nursing theorists develop their works based on their own experiences and their
time, explaining why there is so much variation among theories.
 Address the nursing metaparadigm components of person, nursing, health, and
environment.
Middle-Range Nursing Theories
 More limited in scope (compared to grand theories) and present concepts and
propositions at a lower level of abstraction. They address a specific phenomenon in
nursing.
 Due to the difficulty of testing grand theories, nursing scholars proposed using this
level of theory.
 Most middle-range theories are based on a grand theorist’s works, but they can be
conceived from research, nursing practice, or the theories of other disciplines.
Practice-Level Nursing Theories
 Practice nursing theories are situation-specific theories that are narrow in scope and
focuses on a specific patient population at a specific time.
 Practice-level nursing theories provide frameworks for nursing interventions and
suggest outcomes or the effect of nursing practice.

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  Theories developed at this level have a more direct effect on nursing practice
than more abstract theories.
 These theories are interrelated with concepts from middle-range theories or
grand theories.

NURSING THEORIES

Betty Neuman: Neuman Systems Model

Dorothea Orem: Self-Care Deficit Theory
Dorothy Johnson: Behavioral System Model
Faye Abdellah: 21 Nursing Problems Theory
Florence Nightingale: Environmental Theory
Hildegard Peplau: Interpersonal Relations Theory
Ida Jean Orlando: Deliberative Nursing Process Theory
Imogene King: Theory of Goal Attainment
Jean Watson: Theory of Human Caring
Lydia Hall: Care, Cure, Core Nursing Theory
Madeleine Leininger: Transcultural Nursing Theory
Martha Rogers: Science of Unitary Human Beings
Myra Estrin Levine: The Conservation Model of Nursing
Nola Pender: Health Promotion Model
Sister Callista Roy: Adaptation Model of Nursing
Virginia Henderson: Nursing Need Theory

- EPIDEMIOLOGICAL APPROACH
The epidemiological approach to problems of health and disease is based on two major
foundations: -

Making Asking Epidemiological

Comparison Questions Approaches

ASKING QUESTIONS
RELATED TO HEALTH EVENTS
a. What is the event? (The problem)
b. What is its magnitude?

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 c. Where did it happen?
d. When did it happen?
e. Who are affected?
f. Why did it happen?

RELATED TO HEALTH ACTION

a. What can be done to reduce this problem and its consequences?
b. How can it be prevented in the future?
c. What action should be taken by the community? By the health services? By other sectors?
Where and for whom these activities be carried out?
d. What resources are required? How are the activities to be organized?
e. What difficulties may arise, and how might they be overcome?

MAKING COMPARISONS
 To find out the crucial differences in the host and environmental factors between those
affected and not affected.
 Ensure “comparability” between the study and control groups.
 Best method for comparability – “Randomization or Random allocation”/ “Matching” for
selected characteristics.

 For facts to be comparable-

1) They must be accurate
2) They must be gathered in a uniform way.

- PROBLEM SOLVING APPROACH

 Step 1) Define the Problem – Identify problems through problem formulation and
questioning. The key is asking the right questions to discover root causes.
 Step 2) Determine the Root Cause – During this process, assumptions are uncovered and
underlying problems are further revealed. Also, this is an opportunity to collect and
analyze data.
 Step 3) Develop Alternative Solutions – Decisions are made within the group to
determine the appropriate solution and process through creative selection.

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  Step 4) Select a Solution – Once the group has formed solutions and alternatives to the
problem(s), they need to explore the pros and cons of each option through forecasting
consequences.
 Step 5) Implement the Solution – Develop an action plan to implement and execute the
solution process.
 Step 6) Evaluate the Outcome – This final stage requires an evaluation of the outcomes
and results of the solution process. Ask questions such as: Did the option answer the
questions we were working on? Did this process address the findings that came out of the
assumptions? This process helps keep groups on track, and enables a thorough
investigation of the problem and solution search.

- EVIDENCE BASED APPROACH

EBP is “the conscientious, explicit and judicious use of current best evidence in making
decisions about the care of the individual patient. It means integrating individual clinical
expertise with the best available external clinical evidence from systematic research” by Dr
David Sackett.

EBP has developed over time to now integrate the best research evidence, clinical expertise,
the patient's individual values and circumstances, and the characteristics of the practice in
which the health professional works.

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- EMPOWERING PEOPLE TO CARE FOR THEMSELVES
 Community empowerment refers to the process of enabling communities to increase
control over their lives. "Communities" are groups of people that may or may not be
spatially connected, but who share common interests, concerns or identities. These
communities could be local, national or international, with specific or broad interests.
'Empowerment' refers to the process by which people gain control over the factors and
decisions that shape their lives. It is the process by which they increase their assets and
attributes and build capacities to gain access, partners, networks and/or a voice, in order
to gain control. "Enabling" implies that people cannot "be empowered" by others; they
can only empower themselves by acquiring more of power's different forms. It assumes
that people are their own assets, and the role of the external agent is to catalyse, facilitate
or "accompany" the community in acquiring power.
 Community empowerment, therefore, is more than the involvement, participation or
engagement of communities. It implies community ownership and action that explicitly
aims at social and political change. Community empowerment is a process of re-
negotiating power in order to gain more control. It recognizes that if some people are
going to be empowered, then others will be sharing their existing power and giving some

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 of it up. Power is a central concept in community empowerment and health promotion
invariably operates within the arena of a power struggle.
 Community empowerment necessarily addresses the social, cultural, political and
economic determinants that underpin health, and seeks to build partnerships with other
sectors in finding solutions.
 Globalization adds another dimension to the process of community empowerment. In
today’s world, the local and global are inextricably linked. Action on one cannot ignore
the influence of or impact on the other. Community empowerment recognizes and
strategically acts upon this inter-linkage and ensures that power is shared at both local and
global levels.
 Communication plays a vital role in ensuring community empowerment. Participatory
approaches in communication that encourage discussion and debate result in increased
knowledge and awareness, and a higher level of critical thinking. Critical thinking enables
communities to understand the interplay of forces operating on their lives, and helps them
take their own decisions.
 This track of the conference will focus on the conceptual and practical issues in building
empowered communities. Through examples and case studies it will analyse how
successful partnerships with communities can be forged even in the environment of
vertical health programming. It will examine how empowerment-oriented health
promotion can be practiced both in local and global settings.

COMMUNITY EMPOWERMENT IN ACTION: SELF-EMPLOYED WOMEN’S

ASSOCIATION (SEWA)
 SEWA is a trade union of nearly a million self-employed women in Gujarat, India. Like
most self-employed vegetable vendors, cart pullers, embroidery workers, these women
would live in poor conditions and practice their trade in vulnerable conditions. Frequently
harassed by local authorities, with no insurance or other social security and forced to take
loans at exploitative rates, these women got organized to increase control over their lives.
Vegetable sellers and growers linked together to start their own vegetable shop, cutting
out the exploitative middle man, to mutual gain.
 SEWA women started their own bank, and solved the problem of access to credit,
avoiding the huge interest rates demanded by private loan agents. Collectively organized
health insurance is used to pay for health costs, which earlier used to drive them further
into poverty. SEWA women also organize child-care, running centres for infants and
young children, and campaign with state and national level authorities for child care as an
entitlement for all women workers.

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