theoretical basis of

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THEORETICAL BASIS OFCOMMUNITY HEALTH

NURSING

Ns. Setyoadi, M.Kep., Sp.Kom


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Community health nursing is a specialty in which

the unit of care is a specific community or

aggregate, and the nurse has responsibility to

promote group health.

The goal of this specialty is health improvement

of the community. The skills required for

excellence in community health nursing practiceinclude epidemiology, research, teaching,

community organizing, and interpersonal

relational care, as well as many others.


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Community-Oriented, Population-

Focused Care

a community is a group ofpeople who havesome characteristics in common, arebounded by time, interact with one another,and feel a connection to one another.

Community orientation is a process that isactivelyshaped by the unique experiences,

knowledge, concerns, values, beliefs, andculture of a given community.


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THEORIES AND MODELS FOR COMMUNITY

HEALTH NURSING PRACTICE

A theory is a set of systematicallyinterrelated concepts or hypotheses thatseek to explain or predict phenomena.

These early theories, also termedgrandtheories orconceptual models, provided abasis for building nursing knowledge.

One feature separating nursing theory fromother professional theories is the use of thenursing metaparadigm concepts: nursing,client/patient, health, and environment.


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To more fully understand the elementsinherent in a nursing theory, a pictorialrepresentation, or model, is often used.

These models provide a visual means tounderstand the relationships between, forinstance, the nurse and the environment, the

nurse and the client, or the stress factorsexperienced by the client.


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Both theories and models have beendeveloped to describe, clarify, and guidenursing practice. Theories and models thathave particular relevance to the practice ofcommunity health nursing are describedhere.


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Nightingales Theory of

Environment

Florence Nightingales environmental theory hasgreat significance to nursing in general and tocommunity health nursing specifically, because it

focuses on preventive care for populations. Crime WarHer observations suggested that

disease was more prevalent in poor environments,and that health could be promoted by providingadequate ventilation, pure water, quiet, warmth,light, and cleanliness.

The crux of her theory was that poor environmentalconditions are bad for health and that goodenvironmental conditions reduce disease.


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Orems Self-Care Model

Dorothy Orem, a nurse administrator andeducator, focused on the concept ofself-carelearned, goal-oriented actions topreserve and promote life, health, and well-being. She described people who neednursing care as those who lack ability in self-

care


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The goal of nursing action is to help peoplerecognize their selfcare demands andlimitations and increase their self-care ability.Nursing care also functions to meet clientsself-care needs until they are able to care forthemselves.


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Orem further described three types of

requirements that influence peoples self-care

abilities:

Universal requirements, common to all human beings,are self-care activities essential to meet physiologicand psychosocial needs.

Developmental requirements are activities necessary

to help people progress developmentally.

Health-deviation requirements are activities neededto help people deal with a diminished level ofwellness.


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Although Orems model focused primarily on individuals, itcan be applied to community health nursing.

Populations and communities can be considered to have acollective set of actions and requirements that affect the

well-being of the total group. If an aggregates demands for self-care exceed its ability,

the aggregate experiences a self-care deficit, andcommunity health nursing intervention is indicated.

According to this interpretation, the goal of community

health nursing is to promote a communitys collectiveindependence and selfcare ability.


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Neumans Health Care Systems

Model

In this model, people are seen as open systems thatconstantly and reciprocally interact with theirenvironments.

Each system is greater than the sum of its parts, and

wellness exists when the parts of the system interact inharmony with each other and with the systemsenvironment.

Four sets of variables, or influences, make up each systemswhole. These are physiologic, psychological,sociocultural, and developmental variables.

Given these variables, each system has a unique responseto stressors and to those tension-producing stimuli thatmay cause disequilibrium or illness.


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A systems response to stressors may be envisioned as aseries of concentric circles. In the center is a core of basicsurvival abilities, such as a communitys ability to make thebest use of its natural resources.

Surrounding this core are three boundaries. The innermostboundary is a flexible line of resistance that encompassesinternal defenses, such as a communitys collective sense ofresponsibility for raising healthy children.

The second boundary is the systems normal line ofdefense, such as a communitys police force or voluntaryfire brigade.

The third boundary is a dynamic, flexible line of defense, abuffer that prevents stressors from invading the systemsnormal line of defense.


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Rogers Model of the Science

of Unitary Beings

Rogers is responsible for modern nursingsemphasis on the whole person

she developed a nursing conceptual modelbased on systems theory. Her modelemphasized that the whole is greater thanthe sum of its parts


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Rogers also incorporated developmental theory into hermodel by describing the development of unitary personsor systems according to three principles: (1) life proceeds inone direction along a rhythmic spiral, (2) energy fieldsfollow a certain wave pattern and organization, and (3)human and environmental energy fields interactsimultaneously and mutually, leading to completeness andunity.

Using this model, the community health nurse can focus oncommunityenvironment interaction; the community

functions interdependently with others and with theenvironment.

The goal of community health nursing is to promote holisticand healthful communityenvironment interaction.


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INTERACTION BETWEEN

HUMAN AND ENVIRONMENT18

Environment

Energy Field

Human Being

Energy Field


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Penders Health Promotion

Model Pender defined health promotion as actions thatare directed toward increasing the level of well-being and self-actualization in individuals or

groups Penders health promotion model seeks to explain

this proactive behavior.

The model, based on social learning theory,

stresses cognitive processes that help regulatebehavior such as perceptions people have thatdirectly influence their motivation to begin orcontinue health-promoting behaviors.


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Five types of modifying factors influencepeoples perceptions about pursuing health-promoting behaviors:

Demographic factors, such as age and race Biologic characteristics, such as height and weight

Interpersonal influences, such as the expectationsof others

Situational factors, such as availability ofhealthfulfoods

Behavioral factors, such as stress-coping patterns


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Community-as-Partner Model

Based on Neumans model of a total-personapproach to viewing patient problems, thecommunity-as-client model was developed bythe authors to illustrate the definition of publichealth nursing as the synthesis of publichealth and nursing.

The model has been renamed the community-as-partner model to emphasize the underlyingphilosophy of primary health care.


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Systems have a common purpose,interrelated parts, and boundaries.

The whole system is considered greater than

the sum of its parts, and there is emphasis onthe interaction of those parts to make up thewhole.

An individual, group, or community can beconsidered an open system in that there isconstant interaction with the environmentthrough boundaries.


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There are two central factors in this model: afocus on the community as partner(represented by the communityassessmentwheel at the top, which incorporates thecommunitys people as the core) and the useof the nursing process.

The model is described in some detail to assistyou in understanding its parts; this will guideyour practice in the community.


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The core of the assessment wheel represents thepeople who make up the community.

Included in the core are the demographics of thepopulation as well as their values, beliefs, andhistory.

As residents of the community, the people areaffected by and, in turn, influence the eightsubsystems of the community.

These subsystems are physical environment,education, safety and transportation, politics andgovernment, health and social services,communication, economics, and recreation.


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The solid line surrounding the community

represents its normal line of defense, or the level

of health the community has reached over time.

The normal line of defense may include

characteristics such as a high rate of immunity,

low infant mortality,or middle-income level.

The normal line of defense also includes usualpatterns of coping, along with problem-solving

capabilities; it represents the health of thecommunity.


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Theflexible line of defense, depicted as abroken line around the community anditsnormal line of defense, is a buffer zonerepresenting a dynamic level of healthresulting from a temporary response tostressors.


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Within the community are lines of resistance,internal mechanisms that act to defendagainst stressors.

Lines of resistance exist throughout each ofthe subsystems and represent thecommunitys strengths.


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Stressors are tension-producing stimuli that havethe potential of causing disequilibrium in thesystem.

They may originate outside the community (e.g.,air pollution from a nearby industry) or inside thecommunity (e.g., the closing of a clinic).

Stressors penetrate the flexible and normal lines

of defense, resulting in disruption of thecommunity. Inadequate, inaccessible, orunaffordable services are stressors on the healthof the community.


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Stressors and lines of resistance (strengths)

together become part of the community nursing

diagnosis by giving rise to the degree of reaction.

The degree of reaction is the amount ofdisequilibrium or disruption that results from

stressors impinging on the communitys lines ofdefense.

The degree of reaction may be reflected in

mortality and morbidity rates, unemployment,

or crime statistics, to name a few.


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PRINCIPLES OF PUBLIC HEALTH

NURSING

Principle 1: Focus on the Community

Principle 2: Give Priority to Community Needs

Principle 3: Work in Partnership With the People

Principle 4: Focus on Primary Prevention

Principle 5: Promote a Healthful Environment

Principle 6: Target All Who Might Benefit

Principle 7: Promote Optimum Allocation ofResources

Principle 8: Collaborate with Others in theCommunity


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SOCIETAL INFLUENCES ON COMMUNITY

ORIENTED,

POPULATION-FOCUSED NURSING Communication Technology

In addition, Internet technology has made it possible toaccess local, state, national, and international data forcommunity assessment, planning, and evaluation.

Nurses who require data for a new intervention strategy,for example, can search the Internet for information fromconsumer groups, researchers, and other expertsworldwide.

To keep apprised of emerging issues and trends in publichealth, the nurse can join numerous Internet-based

electronic discussion groups or listservs (electronicdiscussions distributed by way of email).

The challenge to the nurse is to manage the volume ofinformation and to weigh its worth.


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Genetics, Genomics, and GeneticEngineering

Genetics, the science of heredity andgenomics, the study of the entire genome,are terms that have gained increasedattention from nurses over the past decade.

An outgrowth of this knowledge is geneticengineering, which can be defined as genemanipulation in a laboratory setting.


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In addition to increasing understanding of the contributionof genetic material to health and disease, genetic researchhas created new opportunities for early identification,prevention, and treatment of people at risk for disease.

For example, techniques for DNA screening of newbornsallows early detection of risk for certain diseases anddisabilities, thereby permitting early intervention. Geneticcounseling, previously only available to a limitedpopulation, is being used increasingly by women in thepreconception and prenatal periods.

In dealing with these concerns, it is the community healthnurses responsibility to be aware of the latest scientificinformation when educating communities, so that thedecisions made best fit the communitys value system.


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Global Economy A global economy also permits rich countries in need

of skilled workers to recruit them from developingcountries, causing a shortage of skilled labor in thosecountries that need it most.

In countries able to recruit labor, the presence of newimmigrant groups may be seen as a threat to the localculture or economy, causing an increase in ethnic,

racial, and religious tensions. Even people with jobs that pay well may react

negatively because they see their world changing andtheir own future as more uncertain.


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The economic trends of the late 20thcenturyhave contributed to greater worldwidedisparities in wealth, health, and relative poverty,a measurement of an individuals income againstthe average for the society in which thatindividual lives.

Community health nurses have an obligation toread the latest research, so that they can better

understand the relationship of poverty to health. At the same time, they need to advocate

forpolicies that will reduce adverse effects ofpoverty and income disparities.


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Migration Migration is the act of moving from one region or country to

another, either temporarily, seasonally, or permanently. The health care needs of migrants and migrant refugees are

enormous. Environmental factors are a primary reason for compromised

health, and include inadequate waste disposal, crowded andoften unsanitary living conditions, lack of access to healthfulfoods, and air pollution from an increased concentration ofvehicles used for moving refugees.

The potential detriments to health associated with migration

require that community health nurses ensure that surveillancesystems able to detect emerging health problems are in place;programs to prevent health problems and treat existingconditions also need to be developed.


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Terrorism and Bioterrorism

Terrorism is one way in which a small number ofpeople who perceive that they have been unfairly

treated can exert influence on a larger group or nation. Bioterrorism is the use of living organisms, such as

bacteria, viruses, or other organic materials, to harmor intimidate others, in order to achieve political ends.

Some of the possible biologic agents used includeBacillus anthracis, smallpox virus, Brucella, andbotulinum toxin


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Perhaps more importantly, community healthnurses need to be involved in primaryprevention of bioterrorism throughadvocating for the elimination of biologicweapons and addressing the root causes ofterrorism, such as poverty, hunger, poor

housing, limited educational opportunities,lack of clean water, and inadequate or nohealth care.


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Climate Changes Climate changes can be considered societal changes because

they may be influenced by economics. Since the Industrial Revolution, increased amounts of carbon dioxide, methane, and

nitrous oxide created by manufacturing industries, automobile

emissions, and consumer products have been introduced into theearths atmosphere.

These increases have contributed to climate changes that areexpected to affect sea level; the production of food, fiber, andmedicines; and the spread of infectious diseases. Conversely,significant

Population focused nurses need to educate the public about thepotential dangers of continuing to contaminate the environmentand to advocate for changes in public policy that reduce air andwater contaminants.

Daftar Pustaka


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Daftar Pustaka

Anderson, E.T., and McFarlane, J.(2011).

Community as partner:Theory and practice innursing, 3rd.ed, Philadelpia: Lippincott

Allender, J.A., and Spradley, B.W.(2010).

Community health nursing : Concepts andpractice, 4th.ed, Philadelpia: Lippincott

theoretical basis of

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