1. Organizing Frameworks applied to Community Health Nursing

2. Community Assessment and Nursing Diagnosis, Data Collection, Analysis and Synthesis

3. By the end of this lecture you will be able to:
explain what is meant by a theory and a model of nursing
understand the main features of at least two models of nursing
understand how to critically review a model
Identify how the application of models to practice influences the activity of the nurse and the experience for the patient or client

4. Additional References………….
Models of nursing practice. McGee P. Stanley Thornes 1998
Conceptual bases of professional nursing. Leddy S. Pepper J. Lippincott 4th ed
Foundations of nursing practice. Hogston R & Simpson P. Macmillan (Ch 14)

5. Nature of theory: “represent a scientist’s best effort to describe and explain phenomena” Pollitt & Hungler 1997

6. Theory……
“…is a general statement that summarizes and organizes knowledge by proposing a general relationship between events - if it is a good one it will cover a large number of events and predict events that have not yet occurred or been observed” Robson C.

7. “an internally consistent group of relational statements (concepts, definitions & propositions) that present a systematic view about phenomenon and that is useful for description, explanation, prediction and control. A theory ….is the primary means of meeting the goals of the nursing profession concerned with a clearly defined body of knowledge” Walker & Avant 1996 (cited by Jasper M in Hogston & Simpson))

8. Purpose of theory
Support the development of knowledge through thesis and contestability
Explains and predicts outcomes
Supports decision making
Embeds goals and outcomes for the client and by implication for the nurse
Supports modeling of processes of nursing

9. Classifying theories Meta-theory (Theory building - values etc)
Grand theory (Broad conceptual frameworks - not testable e.g. Leininger theory of transcultural care)
Middle range theory (Narrower and testable e.g. Peplau)
Practice Theory (situational theory - focuses on the way in which nursing is practised e.g. Norton’s theory of nursing elderly people)

10. Typology:
Descriptive theory: Explains through describing relationships and patterns within the framework (e.g. Roper et al)
Predictive Theories: Address the consequences of interventions (e.g. Noddings theory of care)

11. The medical model Bio-reductionist
Differential diagnosis: signs & symptoms
Provision of treatment
Scientific theory - testable and not contestable
Goals - cure and therapy
Evaluation of treatment efficacy

12. Nursing models Located in social science Constructed
Contestable knowledge
Capable of change and development
Embed values and culture

13. What sort of theories would you use?
Tony Archer (18 years) underwent surgery to have a below knee amputation of his left leg
Peggy Mountford is 82 years old, lives alone with no family and is becoming increasingly confused and depressed

14. What sort of theories did you identify?
Physiology
Psychology
Sociological theory
Nursing theories
Descriptive theory
Predictive theory

15. Metaparadigm: constructs in all nursing theories
The person
the environment
health
nursing

16. Commonly used models Roper, Logan & Tierney (ADL)
Peplau (interpersonal communication)
Orem (Self-Care)
Roy (adaptation model)
Wolfensberger (social role valorisation)
Carper (personal explanations)

17. Roper, Logan & Tierney
Developmental model - emphasises growth & development
Person oriented
Focus on change
Sees process over time
Sees a range of activities of daily living changing with maturation
Supporting and enabling
Draws on Henderson’s work strongly

18. Callister Roy’s model Systems model - person is made up of systems
Systems interact with the environment
Health is equilibrium and managed systems
Nursing is supporting adaptation to environment
Is holist, purposeful and unifying
Adaptive modes: physiologic, self concept, role function, interdependence
Health is a process of responding positively to environmental changes

19. Model and Nursing Model
A conceptual model
A nursing model is a representation of nursing, not a reality.
A nursing model is an abstract of reality from the nursing perspective.
A conceptual model is the synthesis of a set of concepts and the statements that integrate those concepts into a whole.
A nursing model is a frame of reference, a way of looking at nursing, or an image of what nursing encompasses.
A nursing model is an abstract of reality from the nursing perspective.

20. The purpose of nursing model (1)
Provide a map for the nursing process
*Guide assessment (What do you assess?)
*Guides analysis
*Dictates nursing diagnoses
*Assists in planning
*Facilitates evaluation

21. The purpose of nursing model (2)
Provide a curriculum outline for education
Represents a framework for research
Provides a basis for development of theory
A model not only describe what is but also provides a framework for making decisions about what would be.

22. Community-as-partner model
Neuman’s model of a total-person approach
Community-as-client model: public health and nursing
Community-as-partner model: primary health care with two central factors
The first factor the focus on the community as partner represented by the community assessment wheel at the top.
The second factor is the use of nursing process.
Neuman’s model of a total-person approach
Community-as-client model: public health and nursing
Community-as-partner model: primary health care with two central factors. The first factor the focus on the community as partner represented by the community assessment wheel at the top. The second factor is the use of nursing process.

23. The core of assessment People who make up the community
*Demographic data
*Values, beliefs, and history
People who make up the community
*Demographic data
*Values, beliefs, and history
As residents of the community, the people are affected by and, in turn, influence the eight subsystems of the community.

24. Lines of defense
Normal line of defense: level of health of a community
Eight subsystems
Flexible line of defense: a buffer zone of a community
Normal line of defense or the level of health the community has reached over time. Some indicators of the level of health in a community include a high rate of immunity, low infant mortality, or middle-class income level. It also include usual patterns of coping, problem-solving capabilities.
Eight subsystems: physical environment, education, safety and transportation, politics and government, health and social services, communication, economics, and recreation.
Flexible line of defense is a buffer zone representing a dynamic level of health resulting from a temporary response to stressors. For example, the neighborhood mobilization against an environmental stressor such as flooding (桃芝颱風), The eight subsystems are divided by broken lines to remind us that they are not discrete and separate but influence (and are influenced by) one another. The principle of ecology is that everything is connected to everything. The eight subsystem provide the community health nurse with a framework for assessment.
Flexible line of defense

25. The selection of eight subsystem
Examining the selection of subsystems that have been identified. Can you think of any that have been omitted?

26. Line of resistance Line of resistance: community’s strength
Stressors: tension-producing stimuli
The degree of reaction: the amount of disequilibrium or disruption that results from stressors impinging on the community’s lines of defense.
Line of resistance: within the community are lines of resistance, internal mechanisms that act to defend against stressors. Example: an evening recreational program for young people implemented to decrease vandalism
A free-standing, no-fee health clinic to diagnose and treat sexually transmitted disease. Lines of resistance exist throughout each of the subsystems and represent the community’s 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 line of defense, resulting in disruption of the community. Inadequate, inaccessible, or unaffordable services are stressors on the health of the community.
The degree of reaction: the amount of disequilibrium or disruption that results from stressors impinging on the community’s lines of defense. The degree of reaction may be reflected in mortality and morbidity rates, unemployment, or crime statistics.

27. Analyze data
Compare and contrast your data with the neighbor areas and the national data.
Compare and contrast your data for 3 to 5 years.
Interpret your data

28. Nursing diagnosis
Stressors and degree of reaction become part of the community nursing/health diagnosis (health problem).
Example: the increased rate of respiratory illness (a degree of reaction) related to air pollution (a stressor)

29. Stressors leading to??
The outcome of a stressor impinging on a community is not always negative. Can you think of an example that stressors may lead to positive outcomes?

30. Community health diagnosis (1)
Comparing nursing diagnosis and community health diagnosis (see handout)
Community health diagnosis is preferred over community nursing diagnosis
Comparing nursing diagnosis and community health diagnosis (see handout)
Community health diagnosis is preferred over community nursing diagnosis for three reasons: it is holistic and does not imply that only a nurse can address the identified problem; it underscores or underlines that work in the community is by nature inter-and interdisciplinary (not even confined to health professions but incorporating many others); and it places the emphasis once again on the community, which is the focus of the community health nursing practice.

31. Community health diagnosis (2)
The community health diagnosis gives direction to both nursing goals and its interventions.
The goal is derived from the stressors
The goal may include
* the elimination or alleviation of the stressor
* strengthening of the community’s resistance
through strengthening the lines of defense.
The community health diagnosis gives direction to both nursing goals and its interventions.
The goal is derived from the stressors
The goal may include
* the elimination or alleviation of the stressor
* strengthening of the community’s resistance through strengthening the lines of defense.

32. Community health diagnosis (3)
The goal should state the degree of reaction
The goal should state the degree of reaction. The nurse than can plan interventions to strengthen the lines of resistance through one of the prevention modes.

33. Intervention
Three modes of prevention: primary prevention, secondary prevention, and tertiary prevention
Three modes of prevention: primary prevention, secondary prevention, and tertiary prevention.
Primary prevention is the nursing intervention that aims at strengthening the lines of defense so stressors cannot penetrate to cause a reaction or at interfering with a stressor by taking action against it. An example of primary prevention is the immunization of preschoolers to increase the percentage of immunized children in the community.
Secondary prevention is applied after a stressor has penetrated the community. Interventions support the lines of defense and resistance to minimize the degree of reaction to the stressor. For example, conducting a breast cancer screening (breast self-exam and mammography) and referral program are secondary prevention. Such a program and referral program is an example of secondary is aimed at early case findings to reduce the degree of reaction (such as the severity of the cancer when found).
Tertiary prevention is applied after the stressor penetrates and a degree of reaction has taken place. These has been system disequilibrium, and tertiary prevention is aimed at preventing additional disequilibrium and promoting equilibrium. For example, 九二一大地震 has occurred and a large number of children rare suffering from shock (physical and emotional). Teams of specialist (including community health nursing) are brought in to provide appropriate therapies and long-term follow-up as needed to re-established equilibrium in the community and prevent additional problems in the children.

34. Primary vs. tertiary prevention
In the case of 921 earthquake will you give an example of primary vs. tertiary prevention?

35. Evaluation Feedback from the community
Feedback from the community provides the basis for evaluation of the community health nursing intervention.
The parameters that were used for assessment are also used for evaluation. Interconnections, overlap, and interdisciplinary considerations are the rule.

36. Final note
Health may not be a primary goal of the community, It is, however, an important resource for the community to meet its goals.
The consequences intended in this model include a strengthened normal line of defense, increased resistance to stressors, and a diminished degree of reaction to stressors by the community.
Health may not be a primary goal of the community, It is, however, an important resource for the community to meet its goals. Realizing that we do not always share the same goals is important for anyone working in the community and must at least be considered as we plan, omplement, and evaluate the program aimed at improving health.