Community Health Nursing Care Plan concepts

Rationale for Nursing Involvement in the Health Planning Process

Florence Nightingale and Lillian Wald pioneered health planning based on an assessment of the
health needs of the communities they served (see Chapter 2). Additionally, nurses have long
been involved in implementing programs planned by other disciplines. Both the American
Nurses Association (ANA) (2007) and the American Public Health Association (APHA) (1996)
state that the primary responsibility of community/public health nurses is to the community or
population as a whole and that nurses must acknowledge the need for comprehensive health
planning to implement this responsibility. Both professional organizations identify program
planning as a primary function of the community/public health nurse.

In addition to mandates from professional organizations, nurses should be involved in program

planning for several reasons. Nurses make up more than one-third of all health care workers in
the United States and implement the majority of health care programs. Our involvement in
numerous and diverse health programs has given us experience in seeing what works and what
does not. This experience helps identify difficulties that can be avoided in the future.

Nurses spend a greater amount of time in direct contact with their clients than do any other
health care professionals. We are with the clients in the community, gaining first-hand
information about their health, their lifestyles, their needs, and what it is like to be a member of
that community. This exposure to the community places us in the unique position of possessing
valuable information that is useful to the planning and implementation of successful health
programs.

Not only do nurses make up a large portion of health care providers, they also make up a large
portion of health care consumers in the United States. With the emphasis on consumer
participation in health planning, nurses are in a unique position to make an impact in the
planning of population-focused health programs.

Planning for community change

To plan and implement programs at a community level effectively, the community/public health
nurse must understand how the community works, how it is organized, who its key leaders are,
how the community has approached similar problems, and how other programs have been
introduced in the past. The health care professional who is facilitating the community
 Community Health Nursing Care Plan concepts
organization process with regard to a specific health need or problem must work with the
community members. To be an effective change agent in applying the nursing process, the nurse
must be aware not only of the community and how it works, but also of methods of community
organization that facilitate change.

Three Models of Community Organization Practice According to Selected Practice

Variables

Community
Variables Social Planning Social Action
Empowerment
Problem solving with Shifting of power
Goal categories Self-help; community
regard to substantive relationships and resources;
of community capacity and integration
community problems basic institutional change
action (process goals)
(task goals) (task or process goals)
Broad cross-section of Fact gathering about Crystallization of issues
Basic change people involved in problems and decisions and organization of people
strategy determining and solving on the most logical to take action against
their own problems course of action obstructive targets
Enabler-catalyst; Fact gatherer and
Salient Activist or advocate;
coordinator; teacher of analyst; program and
practitioner agitator; broker; negotiator;
problem-solving skills policy designer and
role partisan
and ethical values implementer; facilitator
Guiding of formal Guiding ongoing action
Medium of Guiding of small task-
organizations and of groups and mobilizing of
change oriented groups
data ad hoc mass action groups

Adapted from Rothman, J. (1978). Three models of community organization practice. In F. Cox,
J. Erlich, J. Rothman, et al. (Eds.), Strategies of community organization: A book of readings
(pp. 25-45). Itasca, IL: Peacock Publications; and Rothman, J. (2008). Approaches to community
intervention. In J. Rothman, J. Erlich, & J. Tropman (Eds.), Strategies of community intervention
(7th ed., p. 163). Peosta, IA: Eddie Bowers Publishing Company.

Diagnosis

After analyzing the data, the next step is to make a definitive statement (diagnosis) identifying
what the problem is or the needs are. Nursing diagnoses for communities may be formulated
regarding the following issues:

• Inaccessible and unavailable services

• Mortality and morbidity rates

• Communicable disease rates

• Specific populations at risk for physical or emotional problems

 Community Health Nursing Care Plan concepts
• Health-promotion needs for specific populations

• Community dysfunction

• Environmental hazards (ANA, 1986)

The format of the problem statement varies, depending on the philosophy of the agency
conducting the assessment. For example, problems or needs may be stated simply in
epidemiological terms, such as a high rate of adolescent pregnancies, whereas in other instances
you may be asked to state the problem or need as a nursing diagnostic statement.

Nursing diagnosis has evolved since 1973 as a result of the efforts of the North American
Nursing Diagnosis Association (NANDA) (NANDA, 2009). The initial North American
Nursing Diagnosis Association (NANDA) classification system of nursing diagnoses focused
on the physical needs of individual clients but was not applicable to the family and community
situations faced by community health nurses. Over the years, the NANDA classification system
has expanded to include biological, psychological, and social needs of individuals and families.
Because of ongoing refinement, the taxonomy of nursing diagnoses at present has 11 functional
health patterns. Tools have been developed to assess the community using the functional health
pattern typology (Gikow & Kucharski, 1987; Wright, 1985). Newer NANDA diagnoses may
also apply to communities; examples include the diagnoses impaired home maintenance and
impaired social interaction.

Other classification systems have been developed in an attempt to address the community. One
example is the Omaha System, written by community/public health nurses for
community/public health nursing practice (Martin, 2005). The system was designed by the
Omaha Visiting Nurse Association and has been used in home care, public health, and school
health practice settings, among others. Client problems/needs/concerns are organized into four
domains: physiological, psychosocial, health-related behaviors, and environmental. Each domain
may involve actual or potential problems or opportunities for health promotion. The system
includes four categories of interventions: teaching, guidance, and counseling; treatments and
procedures; case management; and surveillance. Although originally developed for application
with individuals or families, users are now applying the problem domains and interventions with
communities (Martin, 2005).The Omaha System includes more environmental and community
factors than are considered in the NANDA system.

Because of the multiple nursing diagnostic and classification systems, the NNN Alliance has
formed to develop a consistent classification system. The NNN Alliance is a collaboration of
NANDA and the Center for Nursing Classification and Clinical Effectiveness (CNC). The
taxonomy developed by the NNN Alliance has four domains (Dochterman & Jones, 2003). The
one relevant to community health practice is the environmental domain, with three subsets:
health care system, populations, and aggregates. All three subsets have diagnosis, outcome, and
intervention arenas.

Because community/public health nursing is concerned with health promotion, other nurses have
developed ways to add wellness diagnoses to the problem-focused diagnoses of NANDA.
 Community Health Nursing Care Plan concepts
Neufield and Harrison (1990) recommend that wellness nursing diagnoses for populations and
groups include three components: the name of the specific target population, the healthful
response desired, and related host and environmental factors. For example, high school students
with children (target population) have the potential for responsible parenting (desired response);
this potential is related to a desire to learn about child development (host factor) and the presence
of a family life education curriculum and an availability of teachers (environmental factor).

During the late 1990s and early 2000s, NANDA added several community-focused diagnoses:
readiness for enhanced community coping, ineffective community coping (NANDA, 2002) and
risk for contamination (NANDA, 2007). These diagnoses address a community’s ability to adapt
and solve problems.

How does the nurse formulate a community-focused nursing diagnosis? A diagnosis is a

statement that synthesizes assessment data; it is a label that describes a situation (state) and
implies an etiological component (reason). A nursing diagnosis limits the diagnostic process to
the diagnoses that represent human responses to actual or potential health problems that are
within the legal scope of nursing practice.

A nursing diagnosis has three components: a descriptive statement of the problem, response, or
state; identification of factors etiologically related to the problem; and signs and symptoms that
are characteristic of the problem (Carpenito, 2000).

Using this information, let us take a moment to try to state nursing diagnoses for some problems
on the community level.

Situation 1

Howard County is a suburban county with a rapidly increasing number of older adults. The
assessment data indicate the presence of only one taxicab company serving that area. No public
bus system is available.

Obviously, the problem is lack of transportation; but how might this be worded in nursing
diagnosis format?

Suggestion:

Altered health-seeking behaviors related to inadequate transportation services for senior citizens

However, inadequate transportation probably also affects other areas of seniors’ lives, such as
socialization and community participation. If this factor were validated through further
assessment, an additional diagnosis might be as follows:

Impaired social interactions related to inadequate transportation for senior citizens

Situation 2
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Students in Johnson High test very low on an acquired immunodeficiency syndrome (AIDS)
awareness survey. Further investigation reveals that no information is provided to the students,
and the parents do not want information taught in the school. Ninety-eight percent of the
students stated that they do not believe they are in any danger of getting human
immunodeficiency virus (HIV).

Suggestion:

Lack of knowledge about HIV/AIDS in high school students related to:

• Inadequate information provided in school curriculum

• Parental attitudes about the disease

• Perception that they are not at risk for the disease