Transcript Community

The Community as Client:
Assessment and Diagnosis
Community health nurses work with clients at
several levels as:
•
Individuals
•
Families
•
Groups
•
Subpopulation
•
Populations
•
Communities
Although community health nurses work at all
six levels of practice, working with communities
is a primary mission for tow important reasons:
1. Community directly influences the health of individuals,
families, groups, subpopulation, and populations who are a
part of it.
•
For example, if a city fails to take aggressive action to stop air
population, the health of all its citizens will be adversely affected.
2. Provision of most health services occurs at the community
level.
• Community agencies help develop specific health programs and
disseminate health information to many types of groups and
populations.
 The community health nurse, then, must work
with community as the client.
The community as client refers to the concepts of
a community- wide group of people as the focus of
nursing service.

Understanding the concept of the community
as client is a prerequisite of effective service at
very level of community nursing practice.
Dimension of the community as client
Chapter 1 defined a community as having three features:
(1) Location,
(2) Population
(3) Social system.
This three – dimensional view is especially appropriate for
consideration of a local community, which can vary in location if the
geographic boundaries are expanded or constricted ( Fig. 18- 1)
It is useful to think of these three dimensions of every
community as providing a rough map that one can follow in
assessing needs or planning for services provision. Further
guidance in assessing the health of a community is provided in the
community Profile Inventory found Tables 18-2, 18-3, and 18-4.
In considering each dimension, one should pay particular
attention to the questions that must be asked to assess the health
of a community.
Location:
Every physical community carries out its daily existence in a
specific geographic location. The health of a community is
affected by location, because placement of health services,
Geographic features, climate, plants, animals and the human
made environment are intrinsic to geographic location. The
location of a community places it in an environment that offers
resources and also poses threats (Skelly, et al, 2002; Neuman &
Fawcett, 2001).
The healthy community is one that makes wise use of its
resources and is prepared to meet threats and dangers. In
assessing the health of any community, it is necessary to collect
information not only about variables specific to location but also
about relationships between the community and its location. Do
groups cooperate to identify threats? Does the community make
certain that its members are given available information about
resources and dangers? Table 18-2 describes the location
perspective of the community profile inventory, including the
six location variables: community boundaries, location of health
services, geographic features, climate, flora and fauna, and the
human-made environment
Population
When one considers the community as the
client, the second dimension to examine is
the total population of the community.
Population consists not of a specialized
aggregate but of all the diverse people
who live within the boundaries of the
community.
The health of any community is greatly
influenced by the attributes of its population.
Various features of the population suggest
ealth needs and provide a basis for health
planning (Oleske, 2001). A healthy
community has leaders who are aware of the
population's characteristics, know its various
needs, and respond to those needs.
Community health nurses can better
understand any community by knowing
about its population variables: size, density,
composition, rate of growth or decline,
cultural characteristics, social class structure,
and mobility. Table 18-3 presents the
population perspective section of the
community profile inventory.
Social system
In addition to location and population, every
community has a third dimension- asocial system.
The various parts of a community's social system
that interact and influence the system are called
social system variables. These variables include the
following systems: health, family, economic,
educational,
religious,
welfare,
political,
recreational, legal and communication.
Whether assessing a community's health,
developing new services for the mentally ill within
the community, or promoting the health of the
elderly, the community health nurse needs to
understand the community as a social system. A
community health nurse working in a tiny village
in Alaska needs to grasp the social system of that
village no less than a nurse working in New York
City. Table 18-4 guides the nurse in assessing a
community's social system variables.
The concept of a social system
A social system is an abstract concept and can be more
readily understood by first considering the people who
make up the community's population. Each person enacts
multiple roles, such as parent, spouse, employee, citizen,
church member, and political volunteer. People in certain
roles tend to interact more closely with others in related
roles, such as a supervisor with a staff nurse or a
customer with a sales clerk. The patterns and interactions
that emerge from these interactions among roles form the
basis of organizations. Some organizations are informal
(eg, an extended family group).
Other organizations, such as a city police department or a software
business, are more formal. However, all organizations are
constructed from roles that are enacted by individual citizens.
Organizations, in turn, interact with one another, forming linkages.
For example, a medical equipment company and a laboratory
establish contracts (linkages) with a home care agency. When a
group of organizations are linked and have similar functions, such
as all those providing social services, they form a community
system or sub system (Fig. 18-2). The various community systems
have a profound influence on one another. Because this interaction
among parts determines the health of the whole, it is the total
social system that concerns community health nurses.
The health care delivery system as part of the social system.
Although community health nurse must examine all the systems
in a community and must understand how they interact, the
health system is of particular importance. Studying the health
system in a community can be compared with assessing an
individual client. The latter involves a head-to-toe examination
looking for indications of wellness and illness in thee
respiratory, musculoskeletal, glandular, skin, and circulatory
systems, among others, Initial assessment of a community also
begins with a survey of its ten major social systems, before
asking how well the specific parts are functioning.
The major function of the health system is to promote the health
of the community. Community assessment asks not merely
whether, but also how well, the system is functioning. What is the
level of health promotion carried out by the health system of a
community? To answer this question, which can be applied to any
system, one needs a clear notion about the subsystems,
organizations, and roles that make up the system.
The components of the health system, described in figure 18-3,
include eight major subsystems, each with one or more
organizations. Although the community health nurse must be
aware of all the systems in a community, the health system is of
central importance.
Community Dynamics:
 The discussion to this point may have suggested that the
community is a rigid structure composed of a geographic
location, a population, and a social system. Yet every
community has a dynamic or changing quality.

Think of the diagram in Figure 18-2 as a wheel that
turns as the community changes. Three factors in
particular affect community dynamics:
1.
Citizen participation in community health programs.
The power and decision-making structure.
Collaborative efforts of the community (Lynd, 1939).
2.
3.
Citizen Participation:
 In some communities, citizens show little concern about
public health issues and rely on health officials to take the
entire responsibility.
ْ ِ‫)ا‬, community
apathy abounds( َ‫اض ت َ َزايَ َد‬
ََ َ‫ستَف‬
health nurses need to promote community education and
awareness.
 When such
 One goal of a community nurse when working with
families or groups is to encourage people to participate
and take responsibility for their own health care.
 Community self-care is community health nursing's goal.
Power and Decision-Making Structure:
 The second dynamic factors, the power and decision-
making structure of a community, is a central concern to
anyone who wishes to bring about change.
 The description of the community as a social system may
suggest that power and decision-making reside primarily
in the political system, but this is not the case.
Community Collaboration Efforts:
 The third component of a functioning community social
system is the degree to which the community collaborates.
 Community collaboration refers to the ability of the
community to work together as a team of citizens
professionals and lay people alike – to meet an identified
need in the community.
Types of Community Needs Assessment:
 After considering the importance of community dynamics,
the community health nurse is ready to determine the
community's needs.
 Assessment is the first step of the nursing process.
Assessment for nurses means collecting and evaluating
information about a community's health status to discover
existing or potential needs as a basis for planning future
action (Heinemann & Zeiss, 2002).
 Assessment involves tow major activities. The first is
collection of data and the second is analysis and
interpretation of data.
 Community needs assessment
is the process of
determining the real or perceived needs of a defined
community.
 The type of assessment depends on variables such as the
needs that exist, the goals to be achieved, and the
resources available for carrying out the study.
1. Familiarization or "Windshield Survey":
 Familiarization assessment involves studying data already
available on a community, and gathering a certain amount
of firsthand data, to gain a working knowledge of the
community. Such an approach, sometimes called
“windshield survey” is used by new staff members in
community health agencies.
 Nurses drive (or walk) around the community; find health,
social, and governmental services; obtain literature;
introduce themselves and explain that they are working in
the area; and generally become familiar with the
community.
 This type of assessment is needed whenever the
community health nurse works with families, groups,
organizations, or populations.
2. Problem-Oriented Assessment:
 A second type of community assessment, problem-
oriented assessment, begins with a single problem and
assesses the community in terms of that problem.
 The problem-oriented assessment is commonly used when
familiarization is not sufficient and a comprehensive
assessment is too expensive. This type of assessment is
responsive to a particular need. The data collected will be
useful in any kind of planning for a community response
to the problem.
3. Community Subsystem Assessment:
 In Community subsystem assessment, the community
health nurse focuses on a single dimension of community
life.
 For example, the nurse might decide to survey the
religious organizations to discover their roles in the
community.
 Community subsystem assessment can be a useful way for
a team to conduct a more thorough community
assessment. If five members of a nursing agency divide up
the ten systems in the community and each person does an
assessment of two systems, they could then share their
findings to create a more comprehensive picture of the
community and its needs.
4. Comprehensive Assessment:
 Comprehensive assessment seeds to discover all relevant
community health information. A survey compiles all the
demographic information on the population, such as its
size, density, and composition.
 Key informants are interviewed in every major system
education, health, religious, economic, and others. Then,
more detailed surveys and intensive interviews are
performed to yield information on organizations and the
various roles in each organization.
 A comprehensive assessment describes not only the
systems of a community but also how power is distributed
throughout the system, how decisions are made, and how
change occurs (Plescia, Koontx, & Laourent, 2001;
Williams & Yanoshik, 2001).
 Because comprehensive assessment is an expensive, time-
consuming process, and waste of resources, it is seldom
performed.
 Performing a more focused study based on prior
knowledge of needs is often a better strategy.
5. Community Assets Assessment:
 The final form of assessment presented here is assets
assessment, which focuses on the strengths and capacities
of a community rather than its problems.
 The previously mentioned methods are needs oriented and
deficit based – in other words, they are "pathology"
models, in which the assessment is performed in response
to needs, barriers, weaknesses, problems, or scarcity in the
community.
 This may result in a fragmented approach to solutions for
the community's problems rather than an approach
focused on the community's possibilities, strengths, and
assets.
 This approach requires that the assessor look for the
positive, or see the glass as "half full".
Community Assessment Methods:

Community health needs may be assessed by a variety of
methods. Four important methods are discussed here:
1. Surveys
2. Descriptive epidemiologic studies.
3. Community forums or town meetings.
4. Focus groups.
1. Survey:
 A survey is an assessment method in which a series of
questions is used to collect data for analysis of a specific
group or area.
1.1 Planning Phase:


Select survey method or instrument to be used (eg,
interviews, telephone calls, questionnaires).
Determine sampling size (eg, a percentage of the total
population in question).
1.2 Data Collection Phase.
1.3 Data Analysis and Presentation Phase
 Report results, including implications,
recommendations.
2. Descriptive Epidemiologic Studies:
A
second assessment method is a descriptive
epidemiologic study, which examines the amount and
distribution of a disease or health condition in a
population by person (who is affected?), by place (Where
does the condition occur?), and by time (When do the
cases occur?).
3. Community Forums or Town Hall
Meetings:
 The community or town hall meetings is a qualitative
assessment methods designed to obtain community
opinions. It takes place in the neighborhood of the people
involved, perhaps in a school gymnasium or an
auditorium.
 This method is used to elicit public opinion on a variety of
issues, including health care concerns, political views, and
feelings about issues in the public eye.
4. Focus Groups:
 This fourth assessment method, focus groups, is similar to
the community forum or town hall meeting in that it is
signed to obtain grassroots opinion. However, it has some
differences. First, there is only a small groups of
participants, usually 5 to 15 people.
 The members chosen for the group are homogeneous with
respect to specific demographic variables. For example, a
focus group may consist of female community health
nurses, young women in their first pregnancy, or retired
businessmen.
 Usually the group meets for 1 to 3 hours, and there be a
series of meetings.
Sources of Community Data
 There are many places the community health nurse can
look for data to enhance and complete a community
assessment.
 Data sources can be primary or secondary, and they can be
from international, national, state, or local sources. Web
sites for many primary and secondary data sources are
included at the end of this chapter.
What is a Healthy Community?
The following descriptors can serve as a guide for assessing
a healthy community. The healthy community:
1.
2.
Is one in which members have a high degree of awareness that "we
are a community".
Uses natural resources wisely while taking steps to conserve them
for future generations.
3. Openly recognizes the existence of subgroups and
welcomes their participation in community affairs.
4. Is prepared to meet crises.
5. Is a problem-solving community; it identifies, analyzes,
and organizes to meet its own needs.
6. Has open channels of communication that allow
7.
8.
9.
10.
information to flow among all subgroups of citizens in
all directions.
Seeks to make each of its systems' resources available to
all members of the community.
Has legitimate and effective ways to settle disputes that
arise within the community.
Encourages maximum citizen participation in decisionmaking
Promotes a high level of wellness among all its
members.