Chapter 16 Community Diagnosis, Planning, and Intervention
Sergio Osegueda Acuna MSN-FNP-BC
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.
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.
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
Prioritization of needs
Identification of the target population
Identification of the planning group
Establishment of the program goal
8.Identification of possible solutions
9.Matching solutions with at-risk aggregates
10.Identification of resources
11.Selection of the best intervention strategy
12.Delineation of expected outcomes
13.Delineation of the intervention work plan
14.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.
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
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).
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:
Degree of community concern
Extent of existing resources for dealing with the problem (e.g., time, money, equipment, supplies, facilities, human resources)
Solubility of the problem
Need for special education or training measures
Extent of additional resources and policies needed
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.
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 broad-scale programs, the PPBS can be used as a framework to plan programs for smaller organizations and population groups.
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
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.