While the focus of community health nursing should be on promoting and preserving the health of populations (American Nurses' Association, 1973), with an emphasis on planning for the community as a whole rather than solely on individual health care (American Public Health Association, 1980), we in nursing education do little to help students study community needs and plan for care of aggregates (Allor, 1983; Morgan, Hogan, & Burbank, 1984). Community health nursing, practiced in a setting that allows the nurse to work with population groups rather than individuals, focuses on disease prevention and health promotion (Humphrey, 1988). As health care becomes more complex, and nursing services move into the community in greater force, graduates of baccalaureate nursing programs must be prepared to plan for health care based on needs assessment within a "marketing environment" (Archer, 1983). Marketing is a strategy to provide information regarding services or products to consumers in order to entice potential consumers to use those services or products. The needs assessment may be the consumers' initial contact with the potential provider of the services. Through this recognition, consumers view the provider as truly interested in their needs and, therefore, provide significant input about the population that may not be known (Yoder Wise, 1981).
Kotier (1982) defines the market environment as those groups that an organization directly works with to accomplish its mission. Merely providing services does not guarantee consumers. Kotier states:
Marketing is the analysis, planning, implementation, and control of carefully formulated programs designed to bring about voluntary exchanges of values with target markets for the purpose of achieving organizational objectives. It relies heavily on designing the organization's offering in terms of the target markets' needs and desires, and on using effective pricing, communication, and distribution to inform, motivate, and service the markets (p. 6).
At the senior level in our nursing program, students are introduced to the concepts of leadership and collaboration in nursing practice. Participative leadership has significant implications for community health nursing practice and education. According to Hersey and Blanchard (cited in Spradley, 1985), participative leadership style is dynamic, adaptive, and relationship-oriented. The more students and staff nurses in community health adapt their style of leadership behavior to meet the needs of the community, the more effective they will be in reaching health-related goals (Spradley, 1985).
As faculty responsible for senior students' community health experience, we saw an opportunity to introduce the students to the concept of needs assessment as a marketing strategy to plan health care for and with the community. A community health nursing agency affiliated with our school of nursing wished to conduct a community needs assessment as part of its strategic plan. The idea of a marketing needs assessment as an option for the semester's community health project was presented to the students. The possibility of the project also was explored with the executive director of the agency. The students were challenged by the opportunity to conduct a project that focused on the community in aggregate. The objectives of the project were:
* to conduct a needs assessment utilizing the concepts of marketing in health planning, and
* to identify health needs of a community based on active participation by members of the community.
The students also were introduced to the advantages of conducting a community assessment as a group project. This project provided experiential learning for the students, and a mechanism to collaborate nursing education and nursing practice.
The first step in the marketing needs assessment was to collect demographic data about the service area of the agency - what Kotier (1982) refers to as part of the macroenvironment that shapes opportunities and poses threats to an agency. The community health agency where the needs assessment survey was conducted is located in the eastern portion of Connecticut. Its service area includes three small rural towns and one large suburban town, for a total population of 60,000. Ten percent of the population were over age 65 at the time of the survey and 23% were under age 15, providing a dependency ratio of 1:3.
After a review of the literature, students and faculty developed a community needs assessment questionnaire by using brainstorming techniques. Most of the questionnaire was devised in a multiple-choice format. The initial questions in the instrument were aimed at ascertaining the respondents' knowledge of the agency, and included such questions as: "How did you hear about our Agency?" and "Which services are you aware ofthat our Agency now provides?" Other questions explored any previous experience with home health care, such as: "How were you, or your family member, put in contact with the services?" and "Had you heard of the services provided prior to this experience?" Additional questions were asked to help guide future agency offerings and policies, such as: "Which services would you be interested in having offered?" and "Are you interested in health screening/counseling?" The final component of the questionnaire dealt with demographics such as age, marital status, educational level, number of dependent children, and town of residence.
A draft of the instrument was reviewed and approved by the agency before the survey was conducted. Each of the 10 students was responsible for mailing 20 questionnaires to randomly assigned households in the four-town service area. Using the needs assessment questionnaire, each student surveyed an additional 10 adult (over age 20) respondents either by telephone or by face-to-face interviews. The face-to-face interviews were conducted in various settings (shopping centers and senior citizen residential centers) to maximize the diversity of the sample population. Using a variety of methods to obtain the data gave students the added benefit of experiencing the advantages and disadvantages of each mode of conducting a survey.
While the sample (N = 300) was a small representation of the total population over age 20 (36,000), resources did not allow for a strictly scientific sampling of the adult population within the service area.
A total of 149 questionnaires were completed (50%). Forty-five percent (N = 67) of the respondents were between the ages of 20 and 40; 33% (N = 50) were between 41 and 65; and 17% (N = 5) of the respondents were over age 80.
The majority of the respondents (65%) were married. Twenty-two percent were divorced, separated, or widowed, and 13% were never married. The educational level of the respondents ranged from less than 12th grade (15%), to a master's degree or higher (5%), with the majority (31%) having at least a high school education. The majority of the respondents (51%) had no children; 46% had one to three children; and 2% had four or more children.
The significant results of the needs assessment survey included findings that 41% of the respondents were not familiar with the agency and the services it provided. In addition, 61% of those surveyed felt that residents in their towns were generally unaware of the services offered.
Those who were aware of the agency services (59%) reported that they became aware of the services through: hospital nurses (24%), friends (22%), physicians (20%), advertisements (16%), and family members (15%). Of those who had received services, most common were the traditional services of nursing care and home health aid.
When asked which services would be of interest to them, the respondents were not asked to make only one choice or to rank order their preferences. However, the services chosen in order of their frequency were:
* health screening and counseling (88),
* transportation to medical appointments (81),
* health education (69),
* meals-on-wheels (67),
* ill child day-care for working parents (64), and
* adult day-care (55).
In response to the question that dealt with scheduling preference for health screening and counseling, the majority (45%) of the respondents indicated that evenings would be most convenient, while 35% preferred the morning. The majority (53%) of respondents also preferred evenings for health education programs; 29% preferred mornings.
The students were able to identify several community health needs based on the data collected from the marketing needs assessment. These data also provided valuable information that the community health agency has integrated in its strategic planning.
Health planning for and with the community is recognized as an essential component of community health nursing practice by nurse educators (Archer & Fleshman, 1985; Spradley, 1985; Stanhope & Lee, 1984). Yet, involvement in the planning of health care services by nurses is a relatively new concept and has not been an integral part of baccalaureate education (Morgan, Hogan, & Burbank, 1984). If nurses are to provide stewardship of society's resources, they must have the tools to make the requisite strategic responses. Nursing has a vested interest in the future growth and direction of community-based nursing care, and the opportunities for growth in any of the community health market segments is great (Mershon & Wesolowski, 1985). The growth of community-based nursing care indicates an increased demand for nurses in this practice environment - nurses who understand and are comfortable with the concept of marketing (Archer, 1983; Morgan, Hogan, & Burbank, 1984).
A marketing orientation holds that the main task of community health nurses is to determine the needs and wants of their target markets and to satisfy them through the design, communication, pricing, and delivery of appropriate and competitively viable products and services (Kotier, 1982). With potential wants and needs of the market environment (the clients who will seek nursing services) delineated, community health nurses are then in the position to determine what services and products are necessary to serve that market.
Marketing, as a concept and a set of activities, has been overlooked in community health. As we approach the 21st century, community health organizations are recognizing that they face marketing problems (Archer, 1983; Freitag, 1988). If nurses are expected to participate in strategic planning and marketing, they must be knowledgeable about the process and comfortable with the concept of marketing applied to nursing services; that is, ". . . human activity directed at satisfying needs and wants through exchange processes" (Kotier, 1980, p. 19). Therefore, this underlying philosophical premise must be an integral part of nursing education just as health planning must be an integral part of the undergraduate curriculum. Students must learn not only the marketing planning process, but also the opportunities for community involvement at many levels (Morgan, Hogan, & Burbank, 1984).
Historically, the community has been involved passively in activities conceived and carried out by health professionals. However, from a marketing point of view, this approach is often ineffective (Archer, 1983). Times are changing rapidly and community health nursing agencies must do a great deal more marketing if they are to survive (Archer, 1983). Goeppinger (1984) defines partnership for community health as active participation by the community or its representatives in health planning. However, health professionals, including community health nurses, have challenged the notion of partnership. "In community and clinical practices, compliance is preferred rather than collaboration" (Goeppinger, 1984, p. 387). If we in nursing education are to integrate the partnership-in-decisionmaking principle into learning experiences, we must offer our students the opportunity to participate in health planning for and with the community through needs assessment marketing strategies.
Hopefully, the experience described in this article will enable students to appreciate the need to include clients in health care planning.
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