Chapter 15 (Community Assessment)
Community defined
Community can be simply defined as people in relationships with others, or it can be defined to include a bounded geographical setting and/or common values or interests;
it can also include emotional, geographical, and functional relationships.
Most definitions of community include the dimensions of people, place, and function.
The conceptual definition of community is used in this chapter.
Community is a locality-based entity composed of systems of formal organizations reflecting society's institutions, informal groups, and aggregates.
The components of community are interdependent, and their function is to meet a wide variety of collective needs.
What Is Community Assessment?
The first step of the nursing process Provides a framework to gather information
Healthy Communities: Environmental, social, & economic conditions in which people can thrive
Meaning of Community
The community as client has been described as the setting, unit, and target of service.
Community: Open social system, people in a place over time with common goals
Aggregate: Any number of individuals with at least one common characteristic
Population: Individuals sharing personal or environmental characteristics (geography)
The community is considered the client or target of service when nursing practice, regardless of setting or unit of service, is community oriented. Healthful change is sought for the community's benefit.
The community as client and partner in nursing practice. The direct care of clients can occur within the context of a community orientation when change in clients' health will affect the health of the community.
The improved health of the collective members of the community is the nursing goal.
Change for the benefit of the community client often must occur at several levels, ranging from the individual to society as a whole.
Viewing the community client as partner and thus as the target of service means embracing the concepts of community health and partnership for community health.
Goals and means of community-oriented practice
Community health.
The goal of community-oriented practice is community health. Common characteristics include status, structure, and process.
The status dimension includes physical, emotional, and social parameters.
Physical parameters include measures of morbidity and mortality, life expectancy indexes, and risk factor profiles.
Emotional parameters include consumer satisfaction and mental health indexes. Crime rates and function levels are social parameters.
The structural dimension includes community health services and resources and attributes of the community structure itself, commonly identified as social indicators or correlates of health.
Community health is the process of effective community functioning or problem solving.
The definition offered in this chapter is the meeting of collective needs by identifying problems and managing interactions within the community itself and between the community and the larger society.
Specific strategies to improve community health depend on which dimension is being emphasized.
Most changes aimed at improving community health involve partnerships between health care providers and community residents.
Community partnership is crucial because community members and professionals who are active participants have a vested interest in the success of efforts to improve the health of their community.
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Partnership defined: The informed, flexible, and negotiated distribution (and redistribution) of power among all participants in the process of change for improved community health
Partnership is important because health is generated, not given.
Optimally, health is created from the interaction among providers, recipients, and their environments.
Providers have preferred compliance to collaboration and have kept consumers of health care in a subservient position.
The goal of community health nursing is to form a partnership with consumers to work toward improved health.
Assessing community health
Community assessment is the process of critically thinking about the community and involves getting to know and understand the community client as partner.
Community assessment helps to identify community needs, clarify problems, and identify strengths and resources.
Data collection.
The goal is to acquire usable information about the community and its health. Data collection should provide information about community health problems and community abilities.
Data gathering is the process of obtaining existing, readily available data, such as age and gender of residents.
Data generation is the process of developing data that do not already exist, such as values, norms, leadership, and influence structures.
Database analysis seeks to make sense of the data.
Data collection methods. Five key data collection methods are the following:
Informant interviewing
Participant observation
Windshield surveys
Secondary analyses of existing data
Surveys
Assessment issues. Gaining entry or acceptance is a major hurdle to assessment.
Confidentiality is important but is affected by the legal requirement to disclose information in some cases, such as child abuse.
Tools for Data CollectionPersonal observation: Windshield survey
Existing data; national sources: Census
State and local data
Surveys
Interviews, meetings, maps
Geographical information systems (GIS)
Approaches to Community Assessment
Comprehensive needs assessment
Problem-oriented approach
Single-population approach
Familiarization approach
Analysis
Community assets
Major problems
Major health-related problems
Current/proposed action for resolution
Community's pattern of action for past problems
Chapter 16 (Community Diagnosis, Planning, and Intervention)
Identifying community problems
The community problem consists of the following:
Clear identification of the specific problem faced by the community
Specifying the persons in the community affected by the problem
The factors that led to the problem
When a number of problems are identified, priorities must be set based on several things, such as difficulty of addressing the problem,
what happens if the problem is not resolved, cost to implement solutions, and community expectations.
What Is Health Planning?
Continuous social process
Collect and analyze data about clients
Develop a plan
Generate new ideas, meet needs, solve problems, guide change
Health care delivery
Population-Focused Health Planning
Applying the problem-solving process to a particular population Target population: Persons for whom you desire change to occur
Program planning: Planning care at the community level
History of Health Planning
1966: Comprehensive health planning; communities/states plan for health resources
1974: National network of Health System Agencies (HSAs); assess regional needs
1980s: Federal influence reduced; set health objectives for communities/states
Health Planning: Economically Focused
Controlling costs: Changing reimbursement
Federal government mandates health care services in specific programs
1980s: Home health; prospective payment
1990s-2000s: Reforming health care system
Affordable Care Act of 2010: Requires access to health care for most Americans
Health Planning:
States & Communities
States are passing health care legislation to ensure access
Applying Healthy People 2020 objectives
Assessing community needs
Developing plans to meet needs
Nursing Role in Health and Program Planning
This phase includes analyzing and assigning priorities to the community health problems previously identified by the nursing diagnosis,
establishing goals and objectives, and identifying interventions to accomplish the objectives.
Problem analysis and prioritization.
Problem analysis seeks to clarify the nature of the problem and should be undertaken for each identified problem;
this requires the assistance of a group rather than the work of an individual.
Problems must be ranked, and this process also involves the community members, experts, administrators, and other resource controllers. Criteria helpful in ranking identified problems include the following:
1. Community awareness of the problem
2. Community motivation to resolve or better manage the problem
3. Nursing's ability to influence the problem solution
4. Availability of expertise to solve the problem
5. Severity of the outcomes if the problem is not resolved
6. The speed with which the problem can be solved
Establishing goals and objectives. The goal is generally a broad statement of the desired outcome. Objectives are precise, behaviorally stated, incremental, and measurable.
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Identifying intervention activities. Intervention activities are the means by which objectives are met.
They reflect strategies that spell out what must be done to achieve the objectives, the ways in which change is effected, and how the problem cycle can be interrupted.
Nursing Role in Program Planning
Interdisciplinary Approach:
Collaborating
Coordinating
Facilitating
Involving the community from the beginning to the end
Program planning: Primary function of the C/PHN
Nurses have a major role in implementing programs
Nurses are direct providers of health care
Nurses are consumers of health care
Implementation
This phase includes the work and activities aimed at achieving the goals and objectives. Factors influencing implementation:
Nurse's preferred role.
The nurse can act as a content expert, helping communities select and attain task-related goals;
serve as a process expert by increasing the community's ability to solve the problem; and serve as fact gatherer, analyst, program implementer, enabler-catalyst, teacher of problem-solving skills, and activist advocate.
The problem and the nurse's role. The nurse's role depends on the nature of the health problem, the community's decision-making ability, and professional and personal choices.
The nurse's role also depends on the social change process and how receptive the community is to innovation.
The action portion of the plan
Partnerships with others
Collaborate, coordinate, & consult with others
Facilitate community's ownership of program
Resistance to change is normal
Types of Interventions
Health-education programs
Screening
Establish services
Set policy & implement
Community self-help & empowerment
Changing power structures
Strategies for Implementing Programs
Single action: One-time program
Phasing: Over a period of time
Collaborations & Networks: Partnerships
Coalitions: Temporary union for common purpose
Chapter 17 (Evaluation of Nursing Care with Communities)
Evaluating intervention for community health
Evaluation is the appraisal of the effects of some organized activity or program.
It begins in the planning phase of community action when goals and measurable objectives are established and goal-attaining activities are identified.
Role of outcomes.
The measurement of outcomes is particularly important because outcomes measures answer questions about results of the intervention.
Questions to ask concern whether or not the intervention itself was appropriate, whether it was implemented effectively or ineffectively, and whether the problem has been resolved or the risk reduced.
Personal safety in community practice. An awareness of the community and common sense are the two best guidelines for safety. Three sources of information related to personal safety are the following:
Other nurses, social workers, or health care providers who are familiar with the community
Community members
The nurse's own observations
What Are the Steps in Evaluation?
Evaluation
Process: Nurse judges the value of nursing care provided
Measurement: Were the planned goals achieved?
Interpretation: Quality of the results
Appropriate: Suitable
Adequate: Sufficient
Effective: Productive
Responsibilities of C/PHN
Work with advanced-practice C/PHN, interdisciplinary teams, & community members in evaluating responses of the community to nursing interventions
Geopolitical communities
Phenomenological communities
Formative & Summative Evaluations
Formative: Throughout the nursing process; daily; allows modification
Summative: Effectiveness of care following interventions
Community Involvement
Document and validate outcomes directly with community members
Including stakeholders: Persons with expectations about care (contributors, volunteers)
Standards for Evaluation of Nursing Care with Communities
The employing agency is to provide supervision, consultation, & evaluation plans
Community members are to participate in evaluation
Nursing care is to be revised based on evaluation
Evaluation is to be documented & disseminated
Steps in Evaluation
Planning
Collecting data
Analyze/interpret data
Providing recommendations
Reporting results
Implementing recommendations
Questions Answered by Evaluation
Outcome Attainment: Effectiveness
Appropriateness of Care
Adequacy of Care
Resources & Results: Efficiency
Process
Possible Outcome Measures
Knowledge: Surveys, interviews
Behaviors and skills: Health records
Attitudes: Emotional or affective learning
Emotional well-being and empowerment
Health status: Epidemiological measures
Presence of health-related services
Satisfaction and acceptance of program interventions
Policy that allows, mandates, or funds
Altered relationships with environment
Evaluation
Appropriateness: How well do the planning and interventions fit the assessed need?
Goals and objectives are realistic
Interventions are evidence-based
Adequacy: Goals and interventions are sufficient to achieve the desired change
Efficiency: Measures the relationship of resources to outcomes
Process: How well the program is operating & linked to the plan
Criteria for Effectiveness
Goal-based: Random sampling or percentage of population; statistics
Individual/family: Legal records
Normative referencing: Compare population (county) to another population (U.S.)
Criterion-referenced: Measures objectives reached at desired level (Healthy People 2020)
Sources of evaluation data: Relevant outcome measures collected from target population: morbidity; mortality
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Test your knowledge
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1 Which nurse is practicing in the community but also has the community as the target of practice?
A The nurse who gave care to an active caseload of 50 families in the neighborhood
B The nurse who invited all the parents of asthmatic children in the school to meet together for mutual support
C The nurse who shared assessment findings and health goals with every community group that would listen
D The nurse who wrote articles for the local newspaper highlighting the various programs and services of the local health department
2 What will the nurse who wishes to assess the status of a community's health examine?
A Community awareness
B Health facilities
C Health care manpower
D Vital statistics
3 During the assessment phases, the nurse complies and interprets available data and draws conclusions as to the community's strengths and concerns. Why might the nurse go on to continue to observe and interview key informants?
A To ensure that others agree with the nurse's plans for interventions
B To confirm the nurse's initial findings and conclusions
C To encourage the community partners to feel they "own" the data
D To generate non-statistical data such as values, beliefs, and perceived needs
#1. Answer C:
Meeting with all interested community groups is the only way to keep the focus on the community rather than on individuals
#2. Answer D:
Health care manpower (nurses, physicians), and health facilities (hospitals, clinics) are measures of community health structure. Community awareness is a measure of the process.
#3. Answer D
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