Allender & Spradley 6th Edition

Allender & Spradley 6th Edition
Planning, Intervention, and Evaluation of Health Care in Communities © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Introduction: Applying Nursing process is essential requirement for nursing students at any setting. In the previous chapter, we discuss the assessment and diagnosis and in this chapter will continue to planning, intervention, and evaluation. In this chapter, two other models for planning, intervention, and evaluation of health care delivered to aggregates are investigated. The models highlighted are the (Health Planning Process and the Omaha Classification System). © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Characteristics Support the Use of the Nursing Process in Community Health Nursing: First, the nursing process is a problem-solving process that addresses community health problems at every aggregate level with the goals of preventing illness and promoting public health. Second, it is a management process that requires situational analysis, decision-making, planning, organization, direction and control of services, and outcome evaluation. As a management tool, the nursing process addresses all aggregate levels. Third, it is a process for implementing changes that improve the function of various health-related systems and the ways that people behave within those systems. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Nursing Process Components Applied to Community as Client
Process, the moving element of this tool, means forward progression in an orderly fashion toward some desired result. Nursing theorists attach different labels to the components, but all agree on the basic sequence of actions: assessment, diagnosis, planning, implementation, and evaluation.

Interacting With the Community:
Allender & Spradley 6th Edition Interacting With the Community: All steps of the nursing process depend on interaction, reciprocal exchange and influence among people. Although nurse—client interaction is often an implied or assumed element in the process, it is an essential first consideration for community health nursing. Example of interaction: Listening to a group of elderly people, teaching a class of expectant mothers, lobbying in the legislature for the poor, working with parents to set up a dental screening program for children. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

A. Need for Communication Characteristic of Interaction:
Allender & Spradley 6th Edition A. Need for Communication Characteristic of Interaction: Interaction Requires Communication. When a community health nurse initially contacts with community a group of community leaders, for example, any information the nurse may have in advance can give only partial clues to that group’s needs and wants. Unless everyone involved talks and listens, the steps of the nursing process will go awry. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Cont… By open, honest sharing, the nurse will begin to develop trust and establish lines of effective communication. Example, The nurse encourages the group members to talk about themselves. Nurse and group members together discuss their relationship and clarify the desired nature of that alliance.

Cont… 2. Interaction Is Reciprocal. Sharing of information, ideas, feelings, concerns, and self goes both ways. Nurses must avoid the temptation either to do all the talking or merely to listen while group members monopolize the conversation. There is a dynamic exchange between two systems. The community health nurse (and other collaborating health professionals) represents one system and the client group represents the other. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Cont… The key elements of interaction are mutuality and cooperation.
Example: when community nurse allow the females students to determine the educational topics for presentation.

Cont… 3. Interaction Paves the Way for a Helping Relationship. As nurse and client interact, each is learning about the other. There is a period of testing before trust can be fully established. Example: when community health nurse want to assess teen age students she need to gain boys trust, respect, and after they liked the nurse, she can to determine their needs. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

B. Aggregate Application:
Allender & Spradley 6th Edition B. Aggregate Application: Interaction goes beyond the one-to-one approach of clinical nursing. The challenge that the community health nurse faces is a one-to-aggregate approach. Interaction is more complex with an aggregate than with an individual. Once community health nurses acquire an understanding of aggregate behavior, they can capitalize on the potential of group influence to make a far-reaching impact on the health of the total community. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

C. Forming Partnerships and Building Coalitions
Allender & Spradley 6th Edition C. Forming Partnerships and Building Coalitions The job of planning for the health of an entire community or a community subsystem requires that the nurse collaborate with other professionals. Partnerships are agreements between people (and agencies) that support a joint purpose. Partnership from (large partnership --- small partnership) Community-wide partnerships require more planning and coordination than do small partnerships. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Cont… A coalition is an alliance of individuals or groups that work together to influence outcomes of a specific problem. Coalitions are an effective means to achieve a collaborative and coordinated approach to solving community problems. Steps to coalition building include defining goals and objectives, conducting a community assessment, identifying key players or leaders, and identifying potential coalition members. The best way for leader to keep coalition active done by knowing and staying in touch with the them, running effective meetings, and keeping every participant involved. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

PLANNING TO MEET THE HEALTH NEEDS IN THE COMMUNITY
Allender & Spradley 6th Edition PLANNING TO MEET THE HEALTH NEEDS IN THE COMMUNITY Planning is the logical decision-making process used to design an orderly, detailed series of actions for accomplishing specific goals and objectives. Planning for community health is based on assessment of the community and the nursing diagnoses formulated. But assessment and diagnosis alone do not prescribe the specific actions necessary to meet clients’ needs. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Tools to Assist With Planning:
Allender & Spradley 6th Edition Tools to Assist With Planning: Planning for community health caregiving and programs can be enhanced by the use of a variety of tools, including operational definitions of objectives and activities, conceptual a frameworks, and models. Such tools help to: Identify target population characteristics, clarify program goals, specify nursing interventions, and anticipate client outcomes. 2. Enable the nurse to test ideas and adjust solutions before actual implementation. 3. Enhances the planning process and promotes effectiveness of services, as well as professional standards of practice. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Cont… A systematic approach to planning guides the community health nurse to: (1) list needs in order of priority. (2) establish goals and objectives. (3) record the plan.

The Health Planning Process:
Allender & Spradley 6th Edition The Health Planning Process: The health planning process is a four-stage system used to design new health-related programs or services in the community. It is used by: health educators when designing educational programs. by administrators in community health agencies when initiating new services. 3. and by other people who are not nurses when developing services. The nursing process is very similar to the health planning process. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

The Omaha System The Omaha System was developed in the 1970s by the Visiting Nursing Service of Omaha as a framework for caregiving. Omaha system includes three schemes: problem classification, intervention, and the problem rating scale for outcomes. Omaha system involves more than 40 client problems grouped into four domains: environmental, psychosocial, physiologic, and behavioral, a domain that includes health modifiers and signs and symptoms. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Cont… The focus is on quality measurement and improvement in the community. Although the Omaha system is a useful tool for assessment of individuals, families, and small groups, it is not adaptable to the care of populations (i.e., the primary focus of community health nursing). In contrast to NANDA focuses on diagnoses for ill individuals with limited opportunity to focus on wellness nursing diagnoses.

Planning to Meet the Health Needs in the Community: 1. Setting Priorities Setting priorities involves assigning rank or importance to clients’ needs to determine the order in which goals should be addressed. One way to order needs is to group them into three categories—immediate, intermediate, and long-range—and then prioritize those in each group. Immediate needs are more urgent but not necessarily more important. For example, a community health nurse and a group of senior citizens wanted a class on exercise techniques but did not have a place to meet. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

2. Establishing Goals and Objectives
Allender & Spradley 6th Edition 2. Establishing Goals and Objectives The diagnosis that identifies needs must be translated into goals to give focus and meaning to the nursing plan. Goals are broad statements of desired end results. Objectives are specific statements of desired outcomes, phrased in behavioral terms that can be measured; target dates for expected completion of each objective are also stated. Objectives are the stepping stones to help one reach the end results of the larger goal. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Cont… Example: For the elderly group concerned about crime in their neighborhood, the need, the goal, and the objectives were defined as follows: Diagnosis (Need): The group of elderly people has altered coping ability related to their fear of crime. Goal: Within 6 months, this group of elderly people will be free to walk the streets of their neighborhood without experiencing any incidents of criminal assault. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Cont… Objectives: 1. By the end of 1st month, a safety committee (composed of seniors, nurses, police, and other appropriate community members) will be established to study the crime patterns in the neighborhood. 2. The safety committee will develop strategies for crime reduction and elder protection, which will be presented to the city council for approval by the end of the third month. 3. Safety strategies such as increased police surveillance and escort services will be implemented by the end of the fifth month. 4. By the end of the sixth month, nursing assessment will determine that seniors feel free to walk the streets. 5. By the sixth month, there will be no reported incidents of criminal assault.

Cont… Some rules of thumb are helpful when writing objectives:
1. Each objective should state a single idea. 2. Each objective should describe one specific behavior that can be measured. 3. Writing measurable objectives makes a tremendous difference in the success of planning. Planning means thinking ahead. Making decisions is an important part of planning. To facilitate planning and decision-making, the community health nurse involves other people.

3. Recording the Plan: the planning phase has been a series of intellectual exercises done jointly with clients and perhaps with other health team members. One way to record the plan is to list items in columns with space for the nurse to record specifics. It is also helpful to share copies of the plan with clients. In many instances, having copies of the plan promotes a client’s sense of equal partnership in and responsibility for meeting goals. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Steps of Record Plan: 1. A database comprises all the subjective and objective information collected about clients—physical, psychological, social, and environmental. It includes background health information (past and present), aggregate health assessment, and group history or group systems review. 2. Aggregate needs are the specific areas related to clients’ health that have been identified for intervention. Preferably, they are areas that both clients and nurse agree require action. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Cont… 3. Objectives are the specific statements that describe in behavioral and measurable terms what the nurse and clients hope to accomplish. 4. Planned actions are the specific activities or methods of accomplishing the objectives or expected outcomes. Plans should include appropriate actions by the nurse, clients, and others. 5. Outcome measurement is judgment of the effectiveness of goal attainment. Progress notes are not the same as outcome measurements. Progress notes are useful periodic summaries that give a running account of what is occurring.

Implementing Plans For Promoting the Health of Aggregates in the Community: 1. Implementation Is putting the plan into action. In community health nursing, implementation includes not just nursing action or nursing intervention but collaboration with clients and perhaps other professionals. However, a primary goal in community health is to help people learn to help themselves in achieving their optimal level of health . Empowerment: is one of the essential concept that used in implementation phase. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Cont… When bringing about change in a community organization," implementation involves: 1. preparing a timeline for completion of each program objective, 2. obtaining the necessary funding, 3. collaborating with agencies outside the community as needed, 4. recruiting additional community volunteers needed for program implementation, 5. and actually putting into action the interventions designed during the planning phase” © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

The Community-Oriented Primary Care (COPC):
Allender & Spradley 6th Edition The Community-Oriented Primary Care (COPC): 1. Assessment 2. Prioritizing the problems. 3. Choose single problem 4. make details assessment for it. 5. Develop intervention plan. 6. Implement the plan. 7. Evaluate the intervention 8. Reassessment The cycle continue until solving all the problems. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

2. Preparation: The actual course of implementation, outlined in the plan, should be fairly easy to follow if goals, expected outcomes, and planned actions have been designed carefully. Professionals and clients should have a clear idea of the: Who will be involved in carrying out the plan? What are each person’s responsibilities? Why and how to do their parts? When and where activities will occur? As implementation begins, nurses should review these questions for themselves as well as clients. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

3. Activities or Actions:
Allender & Spradley 6th Edition 3. Activities or Actions: The process of implementation requires a series of nursing actions or activities: 1. The nurse applies appropriate theories, such as systems theory or change theory, to the actions being performed. 2. The nurse helps to facilitate an environment that is conducive to carrying out the plan. 3. The nurse and other health team members prepare clients to receive services by assessing their knowledge, understanding, and attitudes and by carefully interpreting the plan to clients. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Cont… 4. The plan is carried out, or modified and then carried out, by professionals and clients. 5. The nurse and the team monitor and document the progress of the implementation phase by process evaluation, which measures the ongoing achievement of planned actions.

Evaluating Implemented Aggregate Health Plans
Allender & Spradley 6th Edition Evaluating Implemented Aggregate Health Plans Evaluation refers to measuring and judging the effectiveness of goal attainment. The nursing process is not complete until evaluation takes place. Evaluation requires a stated purpose, specific standards and criteria by which to judge, and judgment skills. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

1. Purpose The ultimate purpose of evaluating an intervention in community health nursing is to determine whether the planned actions met the client’s needs. If so: How well were they met, and if not, why not? Were there any unexpected outcomes? Has the client’s competence increased?

2. Criteria: Sometimes, plans include individual goals and criteria as well as group goals and criteria. Goals are statements of desired outcomes, and criteria are the smaller increments or steps that must be taken to achieve the goals. For example, several diabetic women attending a clinic had a problem with obesity. A community health nurse working in the clinic helped them form a weight loss group. The women planned to meet their individual goals by identifying specific criteria such as daily calorie limits (eg, 1500 calories per day). © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Cont. Group Goal: The group will stay healthy while accomplishing 90% of member weight loss goals. Group Objectives: 1. By the end of 6 months, the group will lose at least 90% of the sum of the expected individual weight losses. 2. The group will have no diabetes-related infections during the 6 months. 3. All of the group members will be exercising at least once a week by the end of 3 months. 4. No more than 10% of the group will have had an illness that keeps them in bed longer than 1 day during the 6 months. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

3. Judgment Skills Evaluation requires judgment skills that the nurse uses to compare real outcomes with expected outcomes so that discrepancies may be identified. If goals are not met, the nurse needs to examine several possible explanations for the failure, which may include inadequate data collection, incorrect diagnosis, an unrealistic plan, ineffective implementation, or loss of enthusiasm. Circumstances or client motivation or both may have changed. There may not have been enough client participation in one or more parts of the process. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Types of Evaluations 1. Structure-Process Evaluation Structure-process evaluation has as its emphasis the formation and operation of a plan or program. Established performance standards are used to determine what is working and what is not working throughout the process. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Cont… - Structure criteria: refers to the tools and resources in the health care environment that are beyond individual control. They include the physical and organizational structure of the agency, as well as community resources that provide a foundation for health care services. Such resources as staff qualifications, caseload, licensing, certification, compliance with state regulations, and available funding are part of the structural component. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Cont… When conducting a structure-process evaluation, questions to be answered include the following: Are all professional staff members licensed? Do they hold the appropriate certifications? Does the facility meet state and local health department standards? Are there adequate and accessible resources in the community to meet client referral needs?

Cont… - Process criteria: Refer to how caregiving is performed. These criteria focus on the delivery of services designed to achieve community health care outcomes. Process evaluation questions include the following: Are agency policies and procedures being followed? Are caregivers skilled in the latest technologies or caregiving practices required by the client mix? Do the staff nurses have adequate time for documentation? Is documentation done appropriately? © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Cont… 2. Outcomes Evaluation: It has been used independently to measure the end results (quality) of service—the effect and the impact of services. The effect: Is the degree to which an outcome objective has been met, informs the agency or program leader of the program’s impact on clients’ health. Example, one manufacturing company had an 80% adherence rate for employees who were supposed to wear proper protective devices. Three months after the program, 95% of the employees were adhering to the safety regulations. This 15% increase was attributed to the effect of the safety program. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

The impact: b. The impact: the impact of a program determines how close it comes to attaining its goals. In the earlier example, the objective of the safety campaign was to increase safety equipment use, and use was significantly increased as a result of the program. Even though the objective of the program was met. The full impact of the program cannot be determined without additional data: Were there fewer injuries caused by accidents? Were there fewer days lost to injuries? Did the company save money as the direct result of employee safety adherence? © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

1. Deliberative: The nursing process is deliberative—purposefully, rationally, and carefully thought out. It requires the use of sound judgment that is based on adequate information. Community health nurses often practice in situations that demand the ability to think independently and make difficult decisions. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Cont… Furthermore, thoughtful, deliberative problem-solving is a skill needed for working with the community health team to address the needs and problems of aggregates in the community. The nursing process is a decision-making tool to facilitate these determinations.

2. Adaptable: Its dynamic nature enables the community health nurse to adjust appropriately to each situation and to be flexible in applying the process to aggregate health needs. Furthermore, its flexibility is a reminder to the nurse that each client group, each community situation is unique. The nursing process must be applied specifically to the individual situation and group of people. Based on assessment and sound planning. The nurse adapts and tailors services to meet the identified needs of each community client group. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

3. Cyclic: The nursing process is cyclic and is in constant progression. Steps are repeated over and over in the nurse–aggregate client relationship. The nurse engages in continual interaction, data collection, analysis, intervention, and evaluation. As interactions between nurse and client group continue, various steps in the process overlap with one another and are used simultaneously. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Cont… The cyclic nature of the nursing process enables the nurse to engage in a constant information feedback loop. That is, information gathered and lessons learned at each step of the process promote greater understanding of the group being served, the most effective way to provide quality services, and the best methods of raising this group’s level of health.

4. Client Focused: The nursing process is client focused; it is used for and with clients. Community health nurses use the nursing process for the express purpose of addressing the health of populations. They are helping aggregate clients, directly or indirectly, to achieve and maintain health. Clients as total systems— whether groups, populations, or communities—are the target of community health nursing’s use of the nursing process. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

5. Interactive: The nursing process is interactive in that nurse and clients are engaged in a process of ongoing interpersonal communication. Giving and receiving accurate information are necessary to promote understanding between nurse and clients and to foster effective use of the nursing process. Furthermore, because of the movement toward informed consumption of medical care, demands for clients’ rights and the concept of self-care have gained emphasis. Client groups and community health nurses have increasingly joined forces to assume responsibility for promoting community health. The nurse–aggregate client relationship can and should be a partnership, a shared experience by professionals (nurses and others) and client groups. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Need Oriented: The nursing process is need oriented. Long association with problem-solving has tended to limit the focus of the nursing process to the correction of existing problems. Although problem-solving is certainly an appropriate use of the nursing process, the community health nurse can also use the nursing process to anticipate client needs and prevent problems. The nurse should think of nursing diagnoses as ranging from health problem identification to primary prevention and health promotion opportunities. This focus is needed if the goals of community health—to protect, promote, and restore the people’s health—are to be realized. © 2005 by Lippincott Williams & Wilkins All Rights Reserved.

Allender & Spradley 6th Edition

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