Ns. Setyoadi, M.Kep., Sp.

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THEORETICAL BASIS OF COMMUNITY HEALTH NURSING

 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 practice include epidemiology, research, teaching, community organizing, and interpersonal relational care, as well as many others.

Community-Oriented, PopulationFocused Care

a community is a group of people who have

some characteristics in common, are bounded by time, interact with one another, and feel a connection to one another. Community orientation is a process that is actively shaped by the unique experiences, knowledge, concerns, values, beliefs, and culture of a given community.

 A population is any group of people who share

at least one characteristic, such as age, gender, race, a particular risk factor, or disease. A population focus implies that a nurse uses population based skills such as epidemiology, research in community assessment, and community organizing as the basis for interventions.

THEORIES AND MODELS FOR COMMUNITY HEALTH NURSING PRACTICE

A theory is a set of systematically

interrelated concepts or hypotheses that seek to explain or predict phenomena. These early theories, also termed grand theories or conceptual models, provided a basis for building nursing knowledge. One feature separating nursing theory from other professional theories is the use of the nursing metaparadigm concepts: nursing, client/patient, health, and environment.

 To more fully understand the elements

inherent in a nursing theory, a pictorial representation, or model, is often used. These models provide a visual means to understand the relationships between, for instance, the nurse and the environment, the nurse and the client, or the stress factors experienced by the client.

 Both theories and models have been

developed to describe, clarify, and guide nursing practice. Theories and models that have particular relevance to the practice of community health nursing are described here.

Nightingales Theory of Environment

Florence Nightingales environmental theory has

great significance to nursing in general and to community 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 providing adequate ventilation, pure water, quiet, warmth, light, and cleanliness. The crux of her theory was that poor environmental conditions are bad for health and that good environmental conditions reduce disease.

Orems Self-Care Model

Dorothy Orem, a nurse administrator and

educator, focused on the concept of selfcarelearned, goal-oriented actions to preserve and promote life, health, and wellbeing. She described people who need nursing care as those who lack ability in selfcare

 The goal of nursing action is to help people

recognize their selfcare demands and limitations and increase their self-care ability. Nursing care also functions to meet clients self-care needs until they are able to care for themselves.

 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 physiologic and psychosocial needs. Developmental requirements are activities necessary to help people progress developmentally. Health-deviation requirements are activities needed to help people deal with a diminished level of wellness.

 Although Orems model focused primarily on individuals, it

can be applied to community health nursing. Populations and communities can be considered to have a collective 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, and community health nursing intervention is indicated. According to this interpretation, the goal of community health nursing is to promote a communitys collective independence and selfcare ability.

Neumans Health Care Systems Model

In this model, people are seen as open systems that

constantly and reciprocally interact with their environments. Each system is greater than the sum of its parts, and wellness exists when the parts of the system interact in harmony with each other and with the systems environment. Four sets of variables, or influences, make up each systems whole. These are physiologic, psychological, sociocultural, and developmental variables. Given these variables, each system has a unique response to stressors and to those tension-producing stimuli that may cause disequilibrium or illness.

 A systems response to stressors may be envisioned as a

series of concentric circles. In the center is a core of basic survival abilities, such as a communitys ability to make the best use of its natural resources. Surrounding this core are three boundaries. The innermost boundary is a flexible line of resistance that encompasses internal defenses, such as a communitys collective sense of responsibility for raising healthy children. The second boundary is the systems normal line of defense, such as a communitys police force or voluntary fire brigade. The third boundary is a dynamic, flexible line of defense, a buffer that prevents stressors from invading the systems normal line of defense.

Rogers Model of the Science of Unitary Beings

Rogers is responsible for modern nursings

emphasis on the whole person she developed a nursing conceptual model based on systems theory. Her model emphasized that the whole is greater than the sum of its parts

 Rogers also incorporated developmental theory into her

model by describing the development of unitary persons or systems according to three principles: (1) life proceeds in one direction along a rhythmic spiral, (2) energy fields follow a certain wave pattern and organization, and (3) human and environmental energy fields interact simultaneously and mutually, leading to completeness and unity. Using this model, the community health nurse can focus on communityenvironment interaction; the community functions interdependently with others and with the environment. The goal of community health nursing is to promote holistic and healthful communityenvironment interaction.

INTERACTION BETWEEN HUMAN AND ENVIRONMENT

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Environment Energy Field

Human Being Energy Field

Penders Health Promotion Model

Pender defined health promotion as actions that are 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 regulate behavior such as perceptions people have that directly influence their motivation to begin or continue health-promoting behaviors.

 Five types of modifying factors influence

peoples perceptions about pursuing healthpromoting behaviors:

Demographic factors, such as age and race Biologic characteristics, such as height and weight Interpersonal influences, such as the expectations

of others Situational factors, such as availability of healthfulfoods Behavioral factors, such as stress-coping patterns

Community-as-Partner Model
Based on Neumans model of a total-person

approach to viewing patient problems, the community-as-client model was developed by the authors to illustrate the definition of public health nursing as the synthesis of public health and nursing. The model has been renamed the communityas-partner model to emphasize the underlying philosophy of primary health care.

 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 on the interaction of those parts to make up the whole. An individual, group, or community can be considered an open system in that there is constant interaction with the environment through boundaries.

 There are two central factors in this model: a

focus on the community as partner (represented by the community assessment wheel at the top, which incorporates the communitys people as the core) and the use of the nursing process. The model is described in some detail to assist you in understanding its parts; this will guide your practice in the community.

 The core of the assessment wheel represents the

people who make up the community. Included in the core are the demographics of the population as well as their values, beliefs, and history. As residents of the community, the people are affected by and, in turn, influence the eight subsystems of the community. These subsystems are physical environment, education, safety and transportation, politics and government, health and social services, communication, economics, and recreation.

 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 usual patterns of coping, along with problem-solving capabilities; it represents the health of the community.

 The flexible line of defense, depicted as a

broken line around the community and its normal line of defense, is a buffer zone representing a dynamic level of health resulting from a temporary response to stressors.

 Within the community are lines of resistance,

internal mechanisms that act to defend against stressors. Lines of resistance exist throughout each of the subsystems and represent the communitys strengths.

 Stressors are tension-producing stimuli that have the potential of causing disequilibrium in the

system. They may originate outside the community (e.g., air pollution from a nearby industry) or inside the community (e.g., the closing of a clinic). Stressors penetrate the flexible and normal lines of defense, resulting in disruption of the community. Inadequate, inaccessible, or unaffordable services are stressors on the health of the community.

 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 of disequilibrium or disruption that results from stressors impinging on the communitys lines of defense. The degree of reaction may be reflected in mortality and morbidity rates, unemployment, or crime statistics, to name a few.

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 of Resources Principle 8: Collaborate with Others in the Community

SOCIETAL INFLUENCES ON COMMUNITY ORIENTED, POPULATION-FOCUSED NURSING

Communication Technology
In addition, Internet technology has made it possible to

access local, state, national, and international data for community assessment, planning, and evaluation. Nurses who require data for a new intervention strategy, for example, can search the Internet for information from consumer groups, researchers, and other experts worldwide. To keep apprised of emerging issues and trends in public health, the nurse can join numerous Internet-based electronic discussion groups or listservs (electronic discussions distributed by way of email). The challenge to the nurse is to manage the volume of information and to weigh its worth.

 Genetics, Genomics, and Genetic

Engineering Genetics, the science of heredity and genomics, the study of the entire genome, are terms that have gained increased attention from nurses over the past decade. An outgrowth of this knowledge is genetic engineering, which can be defined as gene manipulation in a laboratory setting.

 In addition to increasing understanding of the contribution

of genetic material to health and disease, genetic research has created new opportunities for early identification, prevention, and treatment of people at risk for disease. For example, techniques for DNA screening of newborns allows early detection of risk for certain diseases and disabilities, thereby permitting early intervention. Genetic counseling, previously only available to a limited population, is being used increasingly by women in the preconception and prenatal periods. In dealing with these concerns, it is the community health nurses responsibility to be aware of the latest scientific information when educating communities, so that the decisions made best fit the communitys value system.

 Global Economy
A global economy also permits rich countries in need

of skilled workers to recruit them from developing countries, causing a shortage of skilled labor in those countries that need it most. In countries able to recruit labor, the presence of new immigrant groups may be seen as a threat to the local culture 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 and their own future as more uncertain.

 The economic trends of the late 20th centuryhave contributed to greater worldwide

disparities in wealth, health, and relative poverty, a measurement of an individuals income against the average for the society in which that individual lives. Community health nurses have an obligation to read 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 of poverty and income disparities.

 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 and often unsanitary living conditions, lack of access to healthful foods, and air pollution from an increased concentration of vehicles used for moving refugees. The potential detriments to health associated with migration require that community health nurses ensure that surveillance systems able to detect emerging health problems are in place; programs to prevent health problems and treat existing conditions also need to be developed.

 Terrorism and Bioterrorism

Terrorism is one way in which a small number of

people 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 harm or intimidate others, in order to achieve political ends. Some of the possible biologic agents used include Bacillus anthracis, smallpox virus, Brucella, and botulinum toxin

 Perhaps more importantly, community health

nurses need to be involved in primary prevention of bioterrorism through advocating for the elimination of biologic weapons and addressing the root causes of terrorism, such as poverty, hunger, poor housing, limited educational opportunities, lack of clean water, and inadequate or no health care.

 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 the earths atmosphere. These increases have contributed to climate changes that are expected to affect sea level; the production of food, fiber, and medicines; and the spread of infectious diseases. Conversely, significant Population focused nurses need to educate the public about the potential dangers of continuing to contaminate the environment and to advocate for changes in public policy that reduce air and water contaminants.

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

Community as partner:Theory and practice in nursing, 3rd.ed, Philadelpia: Lippincott Allender, J.A., and Spradley, B.W.(2010). Community health nursing : Concepts and practice, 4th.ed, Philadelpia: Lippincott