Topics- Select one of the community nursing diagnosis in chapter 16 and develop at least one program goal and two related outcomes. Discuss the rationale for your selection of the priority problem
Nursing diagnoses for communities may be formulated regarding the following issues: (CHOOSE ONE OF THOSE)
•Inaccessible and unavailable services
•Mortality and morbidity rates
•Communicable disease rates
•Specific populations at risk for physical or emotional problems
•Health-promotion needs for specific populations •Community dysfunction
•Environmental hazards (ANA, 1986)
Chapter 16 Community
Diagnosis, Planning, and
Intervention
Sergio Osegueda Acuna MSN-FNP-BC
MRC
Nursing Process with communities
Population-focused health planning
• Health planning is a continuous social process by which data about
clients are collected and analyzed for the purpose of developing a
plan to generate new ideas, meet identified client needs, solve health
problems, and guide changes in health care delivery.
• To date, you have been responsible primarily for developing a plan of
care for the individual client.
History of U.S. Health Planning
• The history of health planning in the United States has alternated between
the federal and state governments.
• Before the 1960s, health planning occurred primarily at the state level.
• In the 1960s, health planning became a federal effort.
• In 1966, the Comprehensive Health Planning and Public Health Service
Amendment was passed to enable states and local communities to plan for
better health resources.
• In the 1980s, President Reagan aimed to reduce both the size of the federal
government and the influence the federal government had on states. His
administration eliminated the federal budget and planning requirements
while encouraging states to make their own planning decisions.
History of U.S. Health Planning
• In 1980, the Omnibus Budget Reconciliation Act encouraged the use
of noninstitutional services, such as home health care, to fight
escalating costs.
• In 1983 the Prospective Payment System drastically changed hospital
reimbursement, resulted in shorter hospital stays for patients, shifted
care into the community, and placed greater responsibilities for care
of relatives on family members
• The federal Patient Protection and Affordable Care Act (Affordable
Care Act) of 2010 requires access to health care for most Americans.
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
• 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.
• Nurses spend a greater amount of time in direct contact with their
clients than do any other health care professionals.
Nursing Role in Program Planning
• Planning for change at the community level is more complex than at
the individual level.
• Components to the client system have been increased, and more
people and more complex organizations are involved.
• Baccalaureate-prepared community/public nurses are expected to
apply the nursing process with subpopulations or aggregates with
limited supervision (American Association of Colleges of Nursing,
1986; ANA, 2007)
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
organization process with regard to a specific health need or problem
must work with the community members.
Community Organization Models
• Rothman (1978, 2008) identifies three community organization
models designed to facilitate change in a community: community
development (now called empowerment), social planning, and social
action.
• Social planning was the model most used by community health
nurses and other public health care practitioners between the 1970s
and the early 1990s.
• Community organization approaches used by Lillian Wald and others
during the nineteenth century, as well as during the 1960s, are
reemerging as models for community empowerment.
Models
• Community empowerment model is an approach designed to create
conditions of economic and social progress for the whole community
and involves the community in active participation.
• Social planning approach emphasizes a process of rational, deliberate
problem solving to bring about controlled change for social problems.
This method is an expert approach in which knowledgeable people
(experts) take responsibility for solving problems.
• Social action approach is a process in which a direct, often
confrontational, action mode seeks redistribution of power,
resources, or decision making in the community or a change in the
basic policies of formal organizations, or both.
Change Theory
• Each of the community organization models involves change.
• Change can be threatening and stressful or it can be exciting and
rewarding.
• Understanding some theory about planned change will provide a
guide to use in the planning process
• Lewin (cited in Dever, 1991) describes change as being a three-stage
process: unfreezing, moving, and refreezing.
Steps of program planning
1.
2.
3.
4.
5.
Assessment
Diagnosis
Validation
Prioritization of needs
Identification of the target
population
6. Identification of the planning
group
7. Establishment of the program
goal
o8.Identification of possible
solutions
o9.Matching solutions with at-risk
aggregates
o10.Identification of resources
o11.Selection of the best
intervention strategy
o12.Delineation of expected
outcomes
o13.Delineation of the intervention
work plan
o14.Planning for program evaluation
Analysis of Data
• A systematic analysis of the data collected is necessary to identify the
problems, needs, strengths, and trends in the community.
• Categorizing the data first is always helpful to identify the inferences
that are descriptive of actual or potential health problems.
• In addition to illustrating the community’s strengths and weaknesses,
an analysis will provide information about demographic and personal
characteristics, which are important to consider when planning and
implementing health programs.
• Data Gaps:Assessment sometimes reveals areas in which all the
information is not available. This lack of information is called a data
gap.
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
• Health-promotion needs for specific populations
• Community dysfunction
• Environmental hazards
Diagnoses
• 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.
• 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).
Validation
• Validating data and nursing diagnoses with the community is
important. Do community members really see this as a problem? If
so, do they desire a solution? Have they adjusted to the problem and
therefore may be resistant to change?
• Many programs have failed because the professionals planned care
based on their own values and perceptions of the problem and did
not validate clients’ perceptions of the problem and their desire for
change.
Prioritization of Needs
• The APHA (1961) identified the first five of the following six factors to
consider when determining priority of health needs at the community
level:
1. Degree of community concern
2. Extent of existing resources for dealing with the problem (e.g., time, money,
equipment, supplies, facilities, human resources)
3. Solubility of the problem
4. Need for special education or training measures
5. Extent of additional resources and policies needed
6. Degree to which community/public health nursing can contribute to the
planning process
Identification of the Target Population
• Target population: the identified group or aggregate in which change
is desired as the result of a program or intervention.
• Intervention can also target one segment of the population. For
example, city X has a high rate of gonorrhea.
• Can the target population and the community ever be one and the
same? Even though they are listed separately in the previously
mentioned examples, the community and the target population may
be one and the same.
Establishment of the Program Goal
• The program goal is a comprehensive statement of intent or purpose.
A difference exists between the program goal and the desired
outcomes (objectives). The goal is stated in general terms and gives
no indication of possible means of achieving the desirable outcome
(McKenzie et al., 2009).
• Objectives are stated in terms of a specific outcome that contributes
in some way to the achievement of the goal.
• The following are two examples of program goals:
• To improve health knowledge regarding HIV/AIDS
• To decrease infant mortality rate
Identification of Resources
• Discussing the possible solutions in relation to the identified
resources is an important part of planning.
• The nurse should identify the resources within the community, as well
as outside the community, that can be used to help solve the
problem.
• These sources include both human and nonhuman resources.
• Human resources can provide expertise and people.
• Nonhuman resources include funding, facilities, supplies, and
equipment
Selection of the Best Intervention Strategy
• The nurse should select the best strategy for the population within
the context of resources and time available.
• A problem can almost always be solved in more than one way.
• The key in this step of the planning process is selecting the best
strategy for the population within the context of available resources.
• The best intervention strategies are culturally appropriate and
personalized to the preferences of the target population.
Work Plan
• A good plan will have the following questions answered before any
intervention:
• WHAT actions are to be done?
• HOW are the actions to be accomplished?
• WHAT resources (equipment, space, money) are needed?
• WHO is responsible for the accomplishment of each action?
• WHEN will each action occur?
• HOW MUCH TIME will be required to accomplish the action?
• WHERE will the actions take place? This question includes obtaining the place
and determining how much space is needed.
Planning for Program Evaluation
• Although evaluation is the last step of the nursing process, evaluation
planning should begin as soon as goals are established.
• All too often, evaluation is not even considered until the end.
However, plans must also be made for evaluation.
• Evaluation is needed throughout the program to measure progress, as
well as at the end to measure the overall value, adequacy, efficiency,
outcomes, and effectiveness.
• Evaluation is a continuous feedback process that provides the
stimulus for changes in the system.
Tools Used to Present and
Monitor Program
Progress
Program Evaluation and Review Technique
(PERT)
• PERT involves the following three steps
• 1.Identifying specific program activities
• 2.Identifying resources to accomplish these activities
• 3.Determining the sequence of activities for accomplishment
Planning, Programming, and Budgeting
System (PPBS)
• The three components of the PPBS are as follows:
• 1.Planning: formulation of objectives and identification of alternatives and
methods for accomplishing the objectives
• 2.Programming: delineation of resources for each identified alternative
• 3.Budgeting: assignment of dollar values to the resources required for the
program implementation
• Although designed by the U.S. Department of Defense to plan broadscale programs, the PPBS can be used as a framework to plan
programs for smaller organizations and population groups.
Implementation
• Implementation is the action portion of the plan; in other words, the plan
states what will occur in the implementation.
• Mobilizing people and resources to activate the plan of action is a
challenging task for the community/public health nurse.
• The role of the nurse during implementation varies based on the type of
program, the community, and the community organization methods used.
• Throughout the implementation phase, the nurse continues to collaborate,
coordinate, and consult with others.
• Implementation results in change that can be stressful and threatening.
Resistance to change is natural and inevitable, because every system
attempts to maintain dynamic equilibrium.
Types of Interventions
• Health education programs
• Screening programs
• Establishing services
• Policy setting and implementation
• Increasing community self-help and competence
• Increasing power among disenfranchised individuals
Strategies for Implementing Programs
• Single Action In the single-action approach, programs are
implemented one time for a specific purpose.
• Phasing Phasing in programs over a period is sometimes necessary or
advantageous.
• Collaboration and Networks Collaborative efforts between disciplines
and agencies can be effective and efficient when planning care at the
community level. A partnership between agencies and personnel
results in better use of resources and often a much stronger program.
• Coalitions A coalition is a temporary union for a common purpose.