What is the role of the community health nurse in health planning implementation and evaluation based on the chosen determinants of health?

Assessment

To establish a professional relationship with the chosen aggregate, a community health nurse must first gain entry into the group. Good communication skills are essential to make a positive first impression. The nurse should make an appointment with the group leaders to set up the first meeting.

The nurse must initially clarify his or her position, organizational affiliation, knowledge, and skills. The nurse should also clarify mutual expectations and available times. Once entry is established, the nurse continues negotiation to maintain a mutually beneficial relationship.

Meeting with the aggregate on a regular basis will allow the nurse to make an in-depth assessment. Determining sociodemographic characteristics (e.g., distribution of age, sex, and race) may help the nurse ascertain health needs and develop appropriate intervention methods. For example, adolescents need information regarding nutrition, abuse of drugs and alcohol, and relationships with the opposite sex. They usually do not enjoy lectures in a classroom environment, but the nurse must possess skills to initiate small-group involvement and participation. An adult group’s average educational level will affect the group’s knowledge base and its comfort with formal versus informal learning settings. The nurse may find it more difficult to coordinate time and energy commitments if an organization is the focus group, because the aggregate members may be more diverse.

The nurse may gather information about sociodemographic characteristics from a variety of sources. These sources include observing the aggregate, consulting with other aggregate workers (e.g., the factory or school nurse, a Head Start teacher, or the resident manager of a high-rise senior-citizen apartment building), reviewing available records or charts, interviewing members of the aggregate (i.e., verbally or via a short questionnaire), and interviewing a key informant. A key informant is a formal or informal leader in the community who provides data that is informed by his or her personal knowledge and experience with the community.

In assessing the aggregate’s health status, the nurse must consider both the positive and negative factors. Unemployment or the presence of disease may suggest specific health problems, but low rates of absenteeism at work or school may suggest a need to focus more on preventive interventions. The specific aggregate determines the appropriate health status measures. Immunization levels are an important index for children, but nurses rarely collect this information for adults. However, the nurse should consider the need for influenza and/or pneumonia vaccines with the elderly. Similarly, the nurse would expect a lower incidence of chronic disease among children, whereas the elderly have higher rates of long-term morbidity and mortality.

The aggregate’s suprasystem may facilitate or impede health status. Different organizations and communities provide various resources and services to their members. Some are obviously health related, such as the presence or absence of hospitals, clinics, private practitioners, emergency facilities, health centers, home health agencies, and health departments. Support services and facilities such as group meal sites or Meals on Wheels (MOW) for the elderly and recreational facilities and programs for children, adolescents, and adults are also important. Transportation availability, reimbursement mechanisms or sliding-scale fees, and community-based volunteer groups may determine the use of services. An assessment of these factors requires researching public records (e.g., town halls, telephone directories, and community services directories) and interviewing health professionals, volunteers, and key informants (i.e., someone who is familiar with the community) in the community. The nurse should augment existing resources or create a new service rather than duplicating what is already available to the aggregate.

A literature review is an important means of comparing the aggregate with the norm. For example, children in a Head Start setting, day care center, or elementary school may exhibit a high rate of upper respiratory tract infections during the winter. The nurse should review the pediatric literature and determine the normal incidence for this age range in group environments. Further, the nurse should research potential problems in an especially healthy aggregate (e.g., developmental stresses for adolescents or work or family stresses for adults) or determine whether a factory’s experience with work-related injury is within an average range. Comparing the foregoing assessment with research reports, statistics, and health information will help determine and prioritize the aggregate’s health problems and needs.

The last phase of the initial assessment is identifying and prioritizing the specific aggregate’s health problems and needs. This phase should relate directly to the assessment and the literature review and should include a comparative analysis of the two. Most important, this step should reflect the aggregate’s perceptions of need. Depending on the aggregate, the nurse may consult the aggregate members directly or interview others who work with the aggregate (e.g., a Head Start teacher). Interventions are seldom successful if the nurse omits or ignores the clients’ input.

During the needs assessment, four types of needs should be assessed. The first is the expressed need or the need expressed by the behavior. This is seen as the demand for services and the market behavior of the targeted population. The second need is normative, which is the lack, deficit, or inadequacy as determined by expert health professionals. The third type of need is the perceived need expressed by the audience. Perceived needs include the population’s wants and preferences. The final need is the relative need, which is the gap showing health disparities between the advantaged and disadvantaged populations (Issel, 2009).

Finally, the nurse must prioritize the identified problems and needs to create an effective plan. The nurse should consider the following factors when determining priorities:

In addition, the nurse may further refine the priorities by applying a framework such as Maslow’s (1968) hierarchy of needs (i.e., lower-level needs have priority over higher-level needs) or Leavell and Clark’s (1965) levels of prevention (i.e., primary prevention may take priority for children, whereas tertiary prevention may take higher priority for the elderly).

Assessment and data collection are ongoing throughout the nurse’s relationship with the aggregate. However, the nurse should proceed to the planning stage once the initial assessment is complete. It is particularly important to link the assessment stage with other stages at this step in the process. Planning should stem directly and logically from the assessment, and implementation should be realistic.

An essential component of health planning is to have a strong level of community involvement. The nurse is responsible for advocating for client empowerment throughout the assessment, planning, implementation, and evaluation phase of this process. Community organization reinforces one of the field’s underlying premises as outlined by Nyswander (1956): “Start where the people are.” Moreover, Labonte (1994) stated that the community is the engine of health promotion and a vehicle of empowerment. He describes five spheres of an empowerment model, that focus on the following levels of social organization: interpersonal (personal empowerment), intragroup (small-group development), intergroup (community collaboration), interorganizational (coalition building), and political action. Attention to collective efforts and support of community involvement and empowerment, rather than focusing on individual efforts, will help ensure that the outcomes reflect the needs of the community and truly make a difference in people’s lives.

Labonte’s (1994) multilevel empowerment model allows us to consider both macro-level and micro-level forces that combine to create both health and disease. Therefore, it seems that both micro and macro viewpoints on health education provide nurses with multiple opportunities for intervention across a broad continuum. In summary, health education activities that have an “upstream” focus examine the underlying causes of health inequalities through multilevel education and research. This allows nurses to be informed by critical perspectives from education, anthropology, and public health (Israel et al., 2005).

Successful health programs rely on empowering citizens to make decisions about individual and community health. Empowering citizens causes power to shift from health providers to community members in addressing health priorities. Collaboration and cooperation among community members, academicians, clinicians, health agencies, and businesses help ensure that scientific advances, community needs, sociopolitical needs, and environmental needs converge in a humanistic manner.