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MODULE 4
The Community Nursing Process
&
Community Assessment
By: Dr Peter Tylee
On successful completion of this module you will be able to:
In this module we will focus on the nursing process and introductory community assessment issues. A quite traditional perspective will be maintained which will be extended in the next module.
2.0 The Nursing Process and Professional Care
2.1 Components in the nursing process.
Let’s begin with a short test. By now you would be very familiar with the nursing process. You know that it is commonly referred to as being either a four or five step (or phase or stage) process, though some suggest seven or more steps are involved. As a reasonable starting point, let’s document the traditional five step nursing process.
Activity 4.2.1
| Write the five steps of the nursing process in correct logical order in the box below. |
Hopefully you found this very easy and you got them all right. Before we focus on our community adaptation it may be helpful to confirm that this is indeed a correct view of the nursing process. Lindberg, Hunter and Kruszewski (1990) state that:
| The nursing process is a series of scientific steps that
assist the nurse in using theoretical knowledge to diagnose strengths and nursing care
needs of persons and to implement therapeutic actions for the purpose of attaining,
maintaining, and promoting optimal biopsychosocial functioning. The nursing process proceeds logically through this series of scientific steps or phases from data collection to evaluation of care. Most nurse scholars suggest that five distinct phases – assessment, diagnosing, planning, implementing, and evaluating – compose the nursing process. (Lindberg et al 1990, 208) |
2.2 Just what is the nursing process?
It may be helpful to recall just what the nursing process is. It is sometimes perceived as ‘just a lot of paperwork’ by those who associate it negatively with nursing care plans. To others it is ‘just words’. In fact it is merely a way of describing or interpreting what nurses do when they are doing nursing. The interpretation is in terms of the rationalist problem solving process, of which the nursing process is just another example, along with the teaching process, the research process, the management process, and so on. This provides, or makes explicit, a framework for practice that helps nurses focus on, or become aware of, the need for and availability of sound theory upon which to base practice.
Some people say that the nursing process never ends. This may refer to the somewhat quaint idea that one can always provide more care, or perhaps it refers to the idea that there will always be more clients or patients. It should NOT be taken to mean, as some people think, that the process simply goes on ad infinitum. The nursing process is like an algorithim (a statement of steps leading to a solution of an identified problem) in any setting and must be conceptualised as having an end. One hopes that it will end in solution of the problem or problems it was instituted to address. After all, if we understand that the nursing process is a form of problem solving, doesn't it make sense that it should end?
Having said that, it is true that it is rarely the case that one can simply begin with an assessment, follow each step in turn and wave goodbye to another satisfied client. In practice the process is iterative (ie, has parts which repeat over and over) to the extent required in the circumstances. Assessment, for example, tends to be ongoing. It certainly belongs as the first step from which one proceeds to the other steps, but caring is dynamic and new data is always presenting itself (or being actively uncovered). With new data we sometimes need to amend our diagnoses or problem lists and then perhaps to update care planning. This may happen many times of course.
2.3 How does the nursing process differ in the community?
Nursing practice in the community can also be understood in terms of the nursing process. However, the process is adapted or extended for PHC (community) practice, exhibiting the following features.
2.3.1 It starts with negotiated access and requires ongoing interaction and communication.
This is necessary since one aim is to practice where people live, work and play. Access cannot be taken for granted as it so often is in institutional settings. Access may be initiated by the nurse, as in case finding for example, or by the client. For access to continue, some agreement must be reached, ensuring adequate communication between nurse and client.
2.3.2 It operates at multiple levels, including:
We will address the notion of ‘community as client’ in a later module. Remember that families, groups and communities are not just collections of individuals.
2.3.3 Assessment is complex and data must be validated carefully as it can be easy for subjective data and sampling biases, for example, to undermine its usefulness.
Diagram 4.2.1
(Spradley & Allender 1996, 246)
As we can see in Spradley’s model above, data collection should be based on a variety of techniques, rendering both qualitative and quantitative information. Careful and detailed analysis and inferential reasoning is then necessary to derive valid conclusions. These conclusions may take the traditional form of nursing diagnoses, although as we shall consider in a moment, there are problems with this approach. More commonly a needs statement will be the outcome and this should also be validated by the client, whether all of a group’s members perhaps or key informants in a community.
2.3.4 Diagnosis is problematic due to variation:
Remember that diagnoses are framed in relatively confined and standard terms. This is necessary since the point of using diagnoses is to provide a succinct statement (a type of ‘shorthand’) of assessment findings that can enable rapid and efficient communication amongst colleagues and others who share the language employed (for instance, medical diagnoses are for communicating within the medical profession but are also understood by nurses and other health professionals).
Given the significant variations highlighted by Muecke above, many problems confront anyone seeking to develop a conceptual schema that will enable a suitable set of diagnostic categories to be developed. Imagine the complexity given the various ways ‘health’ can be understood, across levels ranging from individuals to populations, with differences in perspective concerning what is a legitimate goal, all within a wide range of possible community types, some geographic but many not! Hence, needs statements are generally more appropriate.
2.3.5 Planning includes setting goals and objectives AND:
There can frequently be many more needs identified than means to satisfy them. It is therefore very important to prioritise the needs to ensure that more important issues are dealt with before less important ones. Of course, this must be done with regard to the actual resources available, material and personnel. Sometimes, it will be sensible to use available resources to meet a lower priority need rather than to do nothing just because insufficient resources are to hand to meet a higher priority need. This is the essence of planning! Notice that we do not plan to ‘do to’ our client but to ‘do with’ our client in collaboration.
2.3.6 Implementation remains holistic in orientation.
The focus is on illness prevention and health promotion. This action phase requires:
Generally, these requirements extend the skill base of traditional institutional nursing practice.
The diagram below lists characteristics of the nursing process emphasised in community practice and indicates that a partnership approach is required to achieve community health.
Diagram 4.2.2
(Spradley & Allender 1996, 253)
2.3.7 Evaluation is vital and is no mere afterthought.
This is an expected part of quality assurance and as many projects are provided with programmatic funding, it may also be needed to justify:
The best time to determine methods and procedures for evaluation is during the planning stage. Too often it is neglected at that time and becomes something of an afterthought, if indeed it is performed at all. Addressing evaluation during the planning stage has two main advantages. Firstly, it enables a sense of completion at the conclusion of the planning stage and increases the probability that evaluation will actually be performed. Secondly, it enables a clearer sense of direction since it sharpens the planning focus on desired outcomes including how they will be measured.
2.4 A comparison: institutional & community based nursing process.
It may be argued that many of the above qualities of the community nursing process are just as important in an institutional setting. This is certainly true, though one can, for example, readily observe the approach made to hospitalised patients and realise that failure to emphasise the need for negotiated access has resulted in access being taken for granted in many cases. This may reflect the view that accepting hospitalisation itself implies a right of access by staff. In the community where people live, work and play this certainly is not the case and access must be negotiated and managed carefully.
A more detailed comparison of the influence of setting on the nursing process is provided in the following table.
Table 4.2.1 The Influence of Setting on Use of the Nursing Process
| Variable | Hospital Setting | Community Setting | Nursing Process in the Community |
| Client | Individual | Individual, family, community | Identify the client before proceeding through
process. Apply theory to the process based on client selection. Look for relationships between individual, family, and community clients. |
| Client health state | Acutely ill | Ranges from optimal wellness to severe
illness. Diverse chronic health conditions among clients. |
Draw upon broad knowledge of health and disease. |
| Client autonomy | Limited due to institutionalization. Consent to hospitalization implies consent to nursing services. | Retains autonomy. Client may not have asked for or consented to nursing service. | Obtain client consent to interact before beginning the process. |
| Goal of health care | Institutional goal is treatment and recovery of acute illness. Nursing care goals collaborate or compete with medical care goal of institution. Less client input into goal setting. | Goal of community health is prevention. Prevention ranges from health promotion to rehabilitation. Nursing care competes with non-health-related goals of clients and institutions. Client goal-setting imperative. | Recognize that the process competes with other client related interests. Tailor the content of the process to compete favorably with other interests by providing care the client wants. Use the process to personalize the reasons for and benefits of prevention, since the value of prevention is not always self-evident. The concept of prevention is addressed during each component of the process. |
| Nature of nursing care | Predictable client population segregated by disease entity and/or age. Responsibility for planning nursing care is rotated with nursing staff assignment. Care provided directly by nurse or delegated to auxiliary nursing personnel (i.e., social worker, chaplain, etc) and is facilitated by institutionalization. | Diverse client population. One nurse usually responsible for care planning because nursing staff assignments are not rotated. Care provided indirectly through others. Coordination of care via multiple institutions and resources. Work with health and nonhealth-related personnel. | Review references frequently and consult with resource people in order to apply theory to the process. Generalist practice requires broad theory base. Work with and through others. Identify client strengths. |
| Client outcomes | Nursing care results are more readily observable to client, nurse, and others. | Nursing care results are less apparent to client, family, and coworkers. | Involve the client in documenting goal achievement. Break long-term goals into small steps. Reinforce client progress by recognizing small steps toward goal. |
| Physician influence on nursing care delivery | Influence is direct (i.e., medical diagnosis and treatment orders provide the framework for many nursing activities). Hospital admissions (by physicians) dictate caseload. Physicians more readily available. Each patient has a physician. | Influence is less direct but remains substantial since clients may refuse nursing care because their physician did not recommend it. Nurse has more control over caseload. Physician is less available. Some clients do not have a physician. | Recognize that many clients view the physician as the decision-maker for any health related problem or concern for which they seek professional care. Use the state’s nurse practice act as a guide for deciding which services require physician collaboration. Decide who does and does not need nursing (admit to caseload) as a part of nursing diagnosis. Screening for disease and physician referral is a necessary part of the community nurse role. |
(Logan & Dawkins 1986, 158-159)
Activity 4.2.2
| Make a note to read Chapter 11 Using the
Nursing Process to Promote the Health of Aggregates, in Spradley & Allender. &/or In Stanhope & Lancaster, read the sections identified in the index under "Nursing process" (they are somewhat scattered). Be sure to include Chapter 16 Community as Client: Using the Nursing Process to Promote Health, as a minimum. |
3.1 Community assessment in general.
A community assessment may be performed for many different reasons, by many different people, including nurses, community development workers, various council officers such as engineers and environmental health officers, assorted researchers, and others. Our concern is with community assessment for nursing or health purposes but this does not simplify the situation very much. A profusion of purposes, methods and approaches remains.
3.1.1 The purpose may be to perform an assessment that is:
The time and effort involved in each of these may vary markedly. It is important to address purpose to ensure that appropriate resources are available for the assessment itself. Clearly, an assessment aimed at general familiarisation will not provide the rich data set of a comprehensive assessment, nor can a subsystem focussed assessment be expected to provide a general overview. However, to achieve more will cost more resources.
3.1.2 Many different methods are employed in assessments, including:
Whilst for the purpose of some assessments only one of the above may be utilised, it is common for multiple methods to be employed. Interaction is clearly an important method. It involves engaging client-members in some type of two-way communication and generally requires some form of community entry or access. Observation also generally requires entry but can to some extent be performed from the sideline and may be carried out over reasonable time periods.
Tool based measurement is also a significant method. This method can enable uniformity in the data set when more than one team member is involved in data collection. The tools you have been introduced to in this subject are examples of the ones used. Don’t be put off by the term ‘measurement’, in this context it simply means recording data collected using an instrument. Come to think of it, don’t be put off by the term ‘tool’ either. A tool is simply an instrument or device which makes work easier or more effective, whether referring to a shovel to dig a ditch for example, or your data collection documents.
The document review method is an important adjunct to any other method, or in some cases may suffice by itself. It has the virtue that much data can be collected by mail and analysed in a warm and dry office, which can be most welcome during inclement weather! Quite seriously, a great deal can be learned about various groups or geographic communities from what has been previously documented in a variety of sources and this can be very convenient. It is important to consume such data critically however, as it may not necessarily be entirely correct. There may be errors of fact, data may be outdated, particular biases may be apparent, and so forth.
Our American colleagues sometimes refer to ‘windshield surveys’, by which they refer to the practice of becoming acquainted with a particular geographic area by driving around in it and taking a look. We prefer to emphasise the looking rather than the transport and refer to this, just as colloquially, as the ‘eyeball test’. Notwithstanding the benefits of document reviews, there is nothing better than actually physically getting into the client community and taking a good look around to note its form, features and what can be observed of its function. Naturally, one needs to employ informed eyes.
3.1.3 Various approaches can also be discerned.
In this regard one should note:
3.2 Typical assessment details.
Notwithstanding the variety described above, of all the community assessments performed, the most common would certainly involve geographic communities. Accordingly it would seem appropriate to identify a generic set of common variables or characteristics that could be included in any geographic community assessment. The scope needs to cover population, location and social system variables as follows.
3.2.1 Population variables
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Just how many people are we dealing with? |
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How are they distributed (clustered/spread)? |
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Many very young or old would be significant. |
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What impact on planning? |
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For health patterns, practices, language, etc. |
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For health patterns and intervention approaches. |
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Significant mobility in these areas will have a major impact on planning. Consider attempts to raise community awareness of service availability in an area of high geographic mobility for instance. It may seem as though people leave the area as soon as you get them informed! Rapid upward or downward social mobility in an area can lead, for example, to social isolation for pockets of people. |
3.2.2 Location variables
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See just what you are dealing with (at a glance). |
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Is this adequate and equitably distributed? |
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Such things as rivers, lakes, ocean beaches, mountains, dense bushland, etc can all have health implications. |
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Extremes of heat or cold, levels of humidity, rainfall patterns, prevailing pollen types, etc can all have health implications. |
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Are there poisonous plants or venomous reptiles in the area for example? |
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Such things as major highways, airports, aluminium smelters, mines, high tension overhead power lines, radio frequency transmitters, munitions factories and stores, etc can all have health implications. |
3.2.3 Social system variables
On assessment of the identified geographic community one can document which elements within the community relate to each of the major social systems (or community subsystems, depending on your perspective). Then ask, for example, what is this system meant to do in this community? Does it perform well, satisfactorily or poorly? Why? What data supports your judgement? Can it be validated from within the community? (Remember, validated doesn't mean one cranky or super supportive person happens to agree with you!)
With some time and effort a valuable and very useful data set can be compiled upon which a sound assessment can be based. Such an assessment is an essential starting point for quality PHC practice.
Now complete the following self-test to conclude this module.
| Select the most correct
answer by clicking on the button corresponding to your choice. Note that in some browsers
a default choice is already shown but it is not active. You must click on the button
of your choice. 1. The nursing process: 2. The nursing process is conceptualised as having: 3. The nursing process in the community: 4. The use of diagnoses in nursing practice in PHC is problematic in community settings for all the following reasons EXCEPT: 5. Which one of the following is NOT true of community implementation of the nursing process? 6. Community assessment: 7. In a geographic community assessment, health services would: 8. Describing the influence of setting on the use of the nursing process, Logan and Dawkins: |
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