There are various methodologies available for use in delivering the services of a community health organization. These services are reflected in the goals of community health nursing as reported in the following comprehensive definition of community health nursing:
Community health nursing is a synthesis of nursing practice applied to promoting and preserving the health of populations. The nature of this is general and comprehensive. It is not limited to a particular age or diagnostic group. It is continuing, not episodic. The dominant responsibility is to the population as a whole. Therefore, nursing directed to individuals, families, or groups contributes to the health of the total population. Health promotion, health maintenance, health education, coordination and continuity of care are utilized in a holistic approach to the family, group, and community. The nurse's actions acknowledge the need for comprehensive health planning, recognize the influences of social and ecological issues, give attention to populations at risk, and utilize the dynamic focus which influence change (Missouri ANA, 1973, p. 2).
From this definition/description, the following goals are obtained: health promotion, health maintenance, health education, coordination of care, and continuity of care. If these are representative goals of community health nursing, then it follows that they should be the emphasis of a community health nursing class. Just as there are various methods used by a community health nurse, the same is true of the approach of teaching community health nursing at various nursing schools. The classroom/lecture portion of the course is relatively homogeneous, however, the lab session can differ substantially. The existence of various lab approaches is representative of Wilson's description of the difficulties encountered in obtaining the experiences student nurses need to round out their nurses training (Wilson, 1980).
The difficulties in obtaining "real-world" experiences in the area of community health nursing reflect the challenges actual practitioners face on a day-to-day basis. It is more convenient for students of a pediatrics class to go to a pediatrics wing of a hospital for clinical training, than for community health students to go where prospective clients are: directly into the client's home. In addition to the usual problems of locating and securing cooperation of a quality community health organization, community health educators must overcome other barriers that prevent students from obtaining good clinical experiences. For example, transportation costs for individual students to clients' homes aré fast becoming prohibitive. The racial tensions in black communities are high, thus inhibiting participation from a large section of low income groups. Also, students from white middle-class backgrounds tend to have difficulty in establishing significant rapport with black clients, which is necessary for therapeutic intervention. Lastly, lack of role models for students. Often, instructors are unable to make constructive evaluations of students' home visits in an ongoing way, because they can only be in one place at a time.
This paper describes an experimental program of a community health class of a four-year nursing program. The community health educators' intent was to design a program that would provide opportunities for students to practice "textbook community health nursing," and at the same time overcome the immediate physical barriers of transportation costs. The goal was to provide health promotion and illness prevention services as well as limited health maintenance services to citizens in the following settings: day care centers, schools, senior neighbors housing units, and government subsidized housing communities.
One of the clinical experiences selected for students were three government subsidized housing communities, under the supervision of three nursing professors. These areas were selected because of the high concentration of people, the probable common health problems of residents in the area, and the enthusiasm of officials/ management of the housing units.
The emphasis of the program was contacting clients in their natural environment, their homes. In the traditional single-dwelling communities this would be more difficult due to transportation and supervisory difficulties. The concentration of families in a relatively small geographical area facilitated mass (vans) transportation of students and ease of supervision (one nursing professor per housing unit).
The nursing administrators worked with local tenant associations in planning and introducing the program to residents. The tenant associations were composed of members of the community. This group provided vital links to grass roots leaders whose consultation was very helpful. The most crucial activity was determining what the residents wanted as far as their health was concerned. To determine this, a survey was employed. The grass roots leaders were consulted when composing the survey form, and their suggestions as to the best way to conduct the survey were obtained.
As mentioned earlier, the program was designed as part of the clinical laboratory section of an eight-hour community health course. Teams of two students were assigned up to three to five families to be visited on a weekly basis throughout the semester. The students' objectives and/or activities consisted of:
1. Introducing the program and explaining what the individual could receive from it;
2. Establishing rapport;
3. Assessing immediate needs and planning;
4. Intervening accordingiy and making referrals; and
5. Health promotion and illness prevention activities (in the form of health education mi ni talks and audio-visual programs for groups, etc.).
These activities serve as reinforcements to complementary material covered during lecture sessions.
The initial stage was devoted to cultivating the interest of community residents. Various methods had to be employed to obtain initial clients. At one site, clients were signed up for participation in the program through door-to-door solicitation by the community leaders; at another site, residents returned "request for home visit blanks" (designed to advertise the program), which were passed out by maintenance men working in that community. A total of 1 1 7 clients participated in the program.
Every program, especially one undertaken for the first time, needs to be critically evaluated. It is recognized that evaluations should be as objective as possible, but present situations dictate a relative subjective analysis by the administrators of the program. Due to this limitation, the critique will largely center on administrative areas of concern that were present.
One of the major areas of concern in administering the program centered around time constraints. It appeared that everyone involved with the program faced severe time constraints. Besides the home visiting requirement at the housing developments, each student was required to participate in two scoliosis screenings, two rural senior neighbors screenings, two senior citizens' health education programs, and 14 mental health/supportive therapy visits to one client.
These requirements, though legitimate for an eighthour course, were too varied and left little time for students to prepare adequately for such activités. The instructors were under coordination pressures as well as time pressures. Making sure everyone understood where they were to be and how things were to be done was a formidable task.
Also, sociological barriers hampered the program. Some students were hesitant about working in the localities selected, and these feelings were expressed in criticisms of the course and its requirements.
To provide some information on the reaction of the clients to the program, a questionnaire was administered to a representative sample (41) of participants. The questioning was done by interview, using a structured questionnaire. The questionnaire consisted of 15 statements concerning reactions to various aspects of the program. All 41 participants were questioned during a three-week span by an interviewer not associated with the school which conducted the program. The results of the survey are presented in the Table.
Various topics of interest could have been included on the questionnaire, but for this small scale study only 15 were included. There were general opinion questions such as perception of health states, health concerns, visitation of family physician, information derived from physician, and sharing of such information. The responses indicated a large percentage (61%) had a positive perception of their health. However, the residents still had health concerns. Possible responses listed on the questionnaire for health concerns included high blood pressure, diabetes, anemia, and an other category. Thirty-seven percent of the respondents cited blood pressure as their biggest health concern, however, a high proportion (66%) responded in the other category. A large portion of this 66% cited arthritis as their major concern. Respondents reported weekly and yearly visits as the most common at 37% and 34%, respectively. The type of information desired most from the physician was reported as information on medication (46%) and information about exercising (61%). Sixty-three percent reported that they did not share this information with anyone.
Ten of the 15 questions specifically addressed the community health project. An overwhelming 90% were in favor of visitation programs. The most effective mode of creating awareness of the program was a knock on the door, a verbal announcement. The services perceived most helpful or remembered were personal conversation, blood pressure screening, and counseling on healthful cooking at 39%, 34%, and 32%, respectively. Very few reported sharing this information with others.
SUMMARY OF OPINIONS OF CLIENTS
SUMMARY OF OPINIONS OF CLIENTS
Attendance at the health fairs appeared to be very weak. Only 29% of those responding attended the health fair, and they had became aware of it mostly through tenant association leaders (20%). Twenty-four percent reported a lack of awareness of the fair. Of those attending the health fairs, the most remembered features were the films. The most common reason for not attending was lack of awareness (44%), followed by not interested in topics (22%), and 20% felt the time was inconvenient. Attendance of children and teen-agers at various programs designed for them was reported as very weak at 12% and 2%.
The survey represented an attempt to assemble information on the perceptions the clients had of the community health program and the efforts of the students. Hopefully, such information would provide a conjecture of the effectiveness of these efforts. Due to time and monetary constraints, a very small sample from each involved locality was taken. This prevents drawing any general implications.
In summary, the residents/clients were very receptive to the idea of home visitations. This is not to conclude that everyone was enthused by the program, but those participating generally had positive attitudes toward it. This is not a disturbing finding in that the program cannot and should not be designed to reach everyone. A program of this nature should be directed at those who are receptive. The questionnaire indicated that the best method to discover the interested parties is by door-todoor visitation.
Information obtained concerning health concerns support existing health knowledge. Residents/ clients were mainly interested in assistance with blood pressure maintenance and control of arthritis. This concern is reflected in their positive attitude toward the student nurses in the taking of blood pressure and counseling on cooking. Both of these activities are directly related to the care for high blood pressure clients.
Of primary importance in any relationship is qualitative communication. It appears that residents/clients were decidedly satisfied with conversing with the student nurses. This is probably reflective of the social conditions of the clients. A vast majority of the clients were elderly, and the opportunity to talk with someone was a pleasurable experience. However, this conversing can be a negative factor if the clients are allowed to amble on in no specific direction. Possibly, students should receive more training in guiding and directing social conversation to elicit significant information that can bring to the surface areas of health concerns.
The attendance at the health fairs presents an interesting quandary. Attendance at the fairs was very weak; many clients reported that they were not aware of them. Before each of the fairs, handbills describing the event in an attractive way were placed in the door of every resident's dwelling. Posters were put up, and at one site large banners were placed in front of the community center where the fair was located. Students contacted their clients by phone or in personal visits. After these efforts, adult attendance was weak but attendance by the younger age groups was extremely high. Health fairs were indicated from the survey as a significant "want" of the residential heads of households, however, their attendance contradicts this finding.
Of those who did attend, the films were the most remembered activity. This further substantiates the ability of audio-visual communication to attract attention. More effort should be directed toward follow-up to see that this attention turns into action on information gained.
The children and teen-age programs were reported by the adults as being sparsely attended. This reveals that parents are unaware of their children's activities because administrative records indicate heavy attendance at these events. A gap exists between the children and their parents that possibly results in the loss of valuable information. The information received by the children needs to be supported/supplemented by parent action to produce desired behavior. The attendance of both parent and child at these programs, or separate programs covering similar subjects, would be ideal. However, such is not realistic, taking into account the discussion presented above on adult attendance at health fairs. One factor needs to be emphasized in this discussion; the children did attend and were an eager curious audience. This shows that more attention should be given to this impressionable age group. If the adults do not act on health promotion activities as readily as children do, then work with the children. After all, today's children are tomorrow's America. And, who knows, perhaps some of it will rub off on the adults.
The program implemented by the community health class was a bold and aggressive undertaking. It represented an effort to provide students with experiences of practical benefit, rather than just exposing them to an academic exercise. The problems faced were momentous but were successfully coped with, and an enriching educational experience was given the students and valuable assistance was given to many people.
- Standards-Community Health Nursing Practice. Kansas City, Missouri: American Nurses' Association, 1973.
- Wilson, M. Negotiating group process experiences. Nursing Outlook, June 1980, pp. 360-364.
SUMMARY OF OPINIONS OF CLIENTS
SUMMARY OF OPINIONS OF CLIENTS