THEORIES AND MODELS FOR COMMUNITY/PUBLIC HEALTH NURSING
DISPLAY 14.2 EXAMPLES OF PHYSICAL DETERMINANTS OF HEALTH
Natural environment, such as green space (e.g., trees and grass) or weather (e.g., climate change)
Built environment, such as buildings, sidewalks, bike lanes, and roads Worksites, schools, and recreational settings
Housing and community design
Exposure to toxic substances and other physical hazards Physical barriers, especially for people with disabilities Aesthetic elements (e.g., good lighting, trees, and benches)
From U.S. Department of Health and Human Services. (2016). Healthy People 2020: Social determinants of health. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=39
Why these services were created?
Who benefits from the services?
Who pays for the services?
What is the cost to the people using the services?
What is the public perception of the services?
For example, if ventilation in a city’s homeless shelter is inadequate, the public health nurse who plans to advocate for capital improvements to the shelter needs to consider who pays for the shelter as well as the public’s perception of the shelter.
One contemporary example of the utility of Nightingale’s theory is the work done by public health nurses in Cook County, Illinois. These nurses used geographic information system (GIS) technology to create maps that indicated the level of walkability in low- income neighborhoods. Features that were identified included availability of sidewalks and accessibility to grocery stores and health services (DeGuzman & Kulbok, 2012). Using the evidence that demonstrates the link between environment and poor health, these nurses were able to advocate for changes to be built into those communities identified as having poor walkability. Nightingale’s influence on the way nurses approach health issues that impact the communities of today remains a powerful force, as noted by Zborowsky (2014) in a study about the influence of Nightingale’s theory on nursing research.
Orem’s Self-Care Model
Dorothy Orem (1914–2007), a nurse administrator and educator, focused on the concept of self-care—learned, goal-oriented actions to preserve and promote life, health, and well- being. She described people who need nursing care as those who lack ability in self-care and discussed three systems of self-care: fully compensatory system where the nurse needs to provide care as the patient is unable to do any self-care, partially compensatory system where both the patient and the nurse work together in care provision, and the supportive–
educative system where the nurse reinforces the patient’s self-care efforts (Johnson &
Webber, 2015; Orem, 2001). If a demand for self-care exceeds the client’s ability, the client experiences a self-care deficit, and nursing intervention becomes appropriate. The goal of nursing action is to help people recognize their self-care demands and limitations and increase their self- care ability. Nursing care also functions to meet clients’ self-care needs until they are able to care for themselves. Orem further described three types of requirements that influence people’s self-care abilities:
Universal requirements are activities common to all human beings, which are essential to meet physiologic and psychosocial needs.
Developmental requirements are activities necessary to help people progress developmentally.
Health-deviation requirements are activities needed to help people deal with a diminished level of wellness.
Although Orem’s model focused primarily on individuals, it can be applied to public health nursing practice. Populations and communities can be considered to have a collective set of self-care actions and requirements that affect the well-being of the total group. If an aggregate’s demands for self-care exceed its ability, the aggregate experiences a self-care deficit, and public health nursing intervention is indicated. According to this interpretation, the goal of nursing is to promote a community’s collective independence and self-care ability. Kagan expanded on Orem’s interpretation of self to reflect a more unitary link between humans and their environment; considering human–environment as one entity. With this worldview, she emphasized that nurses “can learn new information, make ethical and political decisions, and act to take care of the environment including regulation of human interaction with, and impact on, the environment” (Kagan, 2011, p.
73).
Green (2013) described how Orem’s Self-Care Deficit Theory can be applied at the population level by school nurses who develop care plans for children with disabilities to help them meet their self-care requisites. Orem’s constructs of conditioning factors and universal self-care requisites correlate to the public health concepts of social determinants of health and the World Health Organization’s (2016) definition of health, not as the absence of disease, but as physical, mental, and social well-being. Orem’s basic conditioning factors can be related to the compounding effect that overlapping factors of inequality such as
access issues, discrimination, and racism present. This is known as intersectionality (Green, 2013). Children with disabilities are an example of a vulnerable population because of accessibility challenges, discrimination, and their young age, which is further compounded by health risks related to their preexisting medical condition. Health outcomes are likely to differ between students even though they may have similar diagnoses. One child may be from a mainstream culture and have a stable, middle-income family, whereas another may be a minority, experiencing racism and living in poverty. To ensure optimal health for all, school nurses must be mindful that children may experience confounding factors beyond their physical disability that further threaten their self-care agency to ensure health (Green, 2013).
Neuman’s Health Care Systems Model
Betty Neuman, a leader in mental health nursing and nursing education, proposed a systems model first used in a graduate community mental health clinical specialist program (Neuman, 1982; Neuman & Fawcett, 2011) and can be adapted to view clients as aggregates. In this model, people are seen as open systems that constantly and reciprocally interact with their environments. Each system is greater than the sum of its parts, and wellness exists when the parts of the system interact in harmony with each other and with the system’s environment. Four sets of variables, or influences, make up each system’s
“whole.” These are physiologic, psychological, sociocultural, and developmental variables.
Given these variables, each system has a unique response to environmental stressors and to those tension-producing stimuli that may cause disequilibrium or illness (Alligood, 2014;
Johnson & Webber, 2015).
A system’s response to stressors may be envisioned as a series of concentric circles (Fig.
14–1). In the center is a core of basic survival abilities, such as a community’s ability to make the best use of its natural resources. Surrounding this core are three boundaries. The innermost boundary is a flexible line of resistance that encompasses internal defenses, such as a community’s collective sense of responsibility for raising healthy children. The second boundary is the system’s normal line of defense, such as a community’s police force or voluntary fire brigade. The third boundary is a dynamic, flexible line of defense, a buffer that prevents stressors from invading the system’s normal line of defense (Alligood, 2014;
Johnson & Webber, 2015). An example is regular maintenance of a community’s roads and bridges.
FIGURE 14–1 Neuman’s Health Care Systems Model applied to a rural county regarding traffic safety issues concerning the elderly by D. Block. (From Allender, J., & Spradley, B.
(2001). Community health nursing: Concepts and practice (5th ed.). Philadelphia, PA:
Lippincott, with permission.)
In Neuman’s model, stressors can originate from the internal environment or the external environment. Examples of internal stressors include a high proportion of low- income residents or an inadequate system of water purification. External stressors might include natural disasters, war, or a downturn in the global economy. The role of public health nursing, then, is to assist communities in remaining stable within their environments.
Olowokere and Okanlawon (2015) used the concepts from Neuman’s Healthcare Systems Model to guide population-level interventions for school children in Nigeria.
Neuman’s model is a good fit for population-level nursing interventions because it provides a systems perspective on the relationships between people, the environment, nursing care, and health. This intervention focused on addressing the psychosocial needs of children who had chronic illnesses such as HIV/AIDS, had one or both parents die, were victims of abuse or traumatized by conflict, or were in need of legal protection or alternative care. The nurses caring for the children had little time and no training to provide psychosocial support to these children. Neuman’s model provided the framework for public health nurses to help the students develop a line of resistance to prevent stress (primary prevention) or to help them cope with the stressors they faced (secondary prevention) to protect their inner core. Examples of resistance resources included participation in support groups and resilience training (Olowokere & Okanlawon, 2015). Public health nurses also helped develop protective resources within the family and the community by serving as case managers to help the children access needed resources. At the tertiary level, the nurse facilitated access to needed services such as counseling to prevent regression (Olowokere &
Okanlawon, 2015).
Rogers’ Model of the Science of Unitary Human Beings
Martha Rogers (1914–1994) created the Science of Unitary Human Beings Model. She had a strong public health nursing background. She worked as a public health nurse in 1937 to 1939 and was on staff as a home visiting nurse from 1940 to 1945 and established the first visiting nursing service in Arizona in the mid-1940 to 1951; it was one of the first in the nation (American Nurses Association [ANA], 2016; Tomasson, 1994). In 1954, she obtained a public health master’s degree from Johns Hopkins University (ANA, 2016). A nursing administrator and long-time nurse educator, Rogers is responsible for modern nursing’s emphasis on the whole person. In 1970, she developed a nursing conceptual model based on systems theory. Her model emphasized that the individual and environment should be viewed as one unit; that is, focusing on the individual without examining their environment, or examining parts of a community, such as its health care or housing, does not provide an adequate picture of its totality in relation to the person (Johnson & Webber, 2015).
Rogers also incorporated developmental theory into her model by describing the development of “unitary” persons or systems according to three principles: (1) life proceeds in one direction along a rhythmic spiral, (2) energy fields follow a certain wave pattern and organization, and (3) human and environmental energy fields interact simultaneously and mutually, leading to completeness and unity (Rogers, 1990). Not typically linked with community/public health nursing practice, this model can be useful for the public health nurse in promoting holistic and healthful community–environment interactions. Using this model, the public health nurse can focus on community–environment interaction; the community functions interdependently with others and with the environment. Utilizing Rogerian concepts, Jarrin (2012) described how environment affects both the nurse and the patient, explaining that caring in nursing is situated in “space, place, and time, shaped by the internal and external environments of both the nurse and the patient/client” (p. 15).
Jarrin further notes that nursing needs to provide evidence about our care environments to policymakers in order to effect meaningful changes.
Rogers’ work continues to influence nursing care decades after her death. Reis and Alligood (2014) used patterning concepts from Rogers’ theory in their study of 27 pregnant women from a public health prenatal clinic and a private practice who participated in a 6- week prenatal yoga class. They used baseline measures for optimism, power, and well-being, as defined by Rogers, and then retested participants at the end of the class. The 21 participants who completed the program had higher, statistically significant scores on all three measures at the conclusion of the yoga classes that were viewed by the researchers as a
“holistic practice” consistent with a “holistic Rogerian view” (p. 35).
Guided by Rogers’ concepts of human–environment and the effect of environmental stressors on human–environment energy field, Greene and Greene (2012) provided Internet-based guided imagery to a convenience sample of adults. Guided imagery uses
visual stimuli and a calming story or fantasy journey that encourages relaxation and may integrate “suggestion and affirmations” (p. 152). It has been found to be helpful with chemotherapy patients and those patients experiencing pain. This pilot study provided a 7- minute session that was available on demand to participants by accessing a specific Web site. No limits were set on the number of times a person could participate in the guided imagery session, and participants took a brief pretest as a baseline measure of stress and anxiety and then completed a posttest. Researchers found participants by sending email invitations to known subjects, who in turn forwarded the email invitations to others (e.g., a snowball sample). Results revealed a significant difference in pre- and posttest scores, indicating reduction in self-reported levels of stress. This research has implications for population health, especially for those living in remote areas.
King’s Theory of Goal Attainment
Imogene King (1923–2007), nursing scholar and educator, was one of the early nurse theorists to provide a conceptual model of nursing (Messmer & Palmer, 2008). Her groundbreaking work Toward a Theory for Nursing (1970) and the subsequent A Theory for Nursing: Systems, Concepts, Process (1981) were both designed to “promote conceptual learning in undergraduate and graduate nursing programs” (1981, p. vii) and can be utilized by the public health nurse to define the nurse–client relationship. From the original general systems model that demonstrated the interrelationship between social, interpersonal, and personal systems (Killeen & King, 2007), King formulated the Theory of Goal Attainment. The theory focuses on the personal and interpersonal systems of the conceptual model. The basis of the theory is that, in any nurse– client encounter, both the nurse and the client come to the situation with their own goals and expectations. Optimal success at goal achievement is only possible when the nurse and the client work together to set goals, thus recognizing the expectations of both parties rather than the preeminence of one over the other. For instance, a public health nurse may have planned to speak to a teen mother about birth control on a home visit. The teen, however, has nearly run out of formula and has exhausted all her cash. In this instance, the teen’s priorities are to locate formula or the resources to obtain formula, whereas the nurse may be concerned that the teen has resumed sexual activity and may become pregnant again. The immediate priority would clearly be the formula, but the nurse can also provide birth control information within that context after the teen is aware that a solution to the formula issue can be found.
King’s theory is a reminder of the importance of the reciprocal relationship between the nurse and the client. Negotiation is a skill inherent in the theory; only through recognition of the perceived needs and goals of the client can the public health nurse help maintain or improve the client’s health and well-being.
Another example is seen with Housing First programs where the primary focus is on housing those who experience chronic homelessness, rather than on enforcement of strict abstinence rules among those who struggle with addition (Collins et al., 2012). The traditional abstinence-only programs were found to not be in alignment with the needs of this population. Collins et al. (2012) sought to understand the barriers to abstinence and identified that chronic alcohol use served to hold off withdrawal symptoms, was used as self-medication for psychiatric conditions, and also served as a social convener. Through the program, instead of only recognizing total abstinence, any positive change was rewarded.
Ultimately, residents reported that having housing allowed them to have control over their own goals and most were able to reduce their substance use (Collins et al., 2012). The results of this program serve as a reminder of the importance of treating the client as an equal partner in their own goal setting.
Community engagement and empowerment are key concepts in international public health practices as well. An example of the importance of this approach can be seen during an Ebola outbreak where community participation can play a critical role in the control of
this disease (Shrivastava, Shrivastava, & Ramasamy, 2015). Fear and lack of information contribute to the rapid spread of this deadly disease. Culturally sensitive approaches are needed to counter misunderstandings about the disease, ineffective treatments through traditional healers, and exposures to reservoir species (e.g., bats). Community-based approaches where public health nurses and community members are working toward common goals can result in collaboration in contact investigations, improved cooking methods, and even changes in funeral practices (Shrivastava et al., 2015). These and many other examples demonstrate the utility of King’s work to current practice in public health.
Parse’s Theory of Human Becoming
Rosemarie Rizzo Parse developed her theory, initially called the “man-living-health” theory, in 1981. In 1992, she changed the name to Human Becoming Theory to better reflect all people. The theory posits quality of life from each person’s own perspective as the goal of nursing practice (Johnson & Webber, 2015). The theory is structured around three themes (Parse, 1981, 1998):
Meaning. People coparticipate in creating what is real for them through self-expression by living their values in their own chosen way.
Rhythmicity. The unity of life encompasses apparent opposites in rhythmic patterns of relating. While living moment to moment, one shows and does not show the self, creating both opportunities and limitations that emerge as moving with and moving apart from others.
Transcendence. Viewed as moving beyond the moment and forging a unique personal path for oneself in the midst of ambiguity and continuous change.
These three themes apply effectively to the community. The nurse must know what the community means to its inhabitants, identify and be aware of the rhythmicity of the people as attempts are made to create positive health changes in the community, and realize the transcendence that occurs when people work in the presence of ambiguity and continuous change, characteristics inherent in a community. Use of this theory as a guide enhances the ability of community members to work together to accomplish identified goals. Examples of the use of the theory most applicable to public health nursing practice include nursing’s engagement in health policy (Poirier, 2012), the act of being “present” in professional practice (Zyblock, 2010), and supporting caring– healing–sustainable nursing practices (Clark, 2012).
Building on her research, Parse has developed what she terms a Human Becoming Community Model (Parse, 2012). The model emphasizes the change concepts of moving–
initiating, anchoring–shifting, and pondering–shaping. She clarifies the significance of community such that “when people come together as a group, the individual communities bring their histories to the emerging now, and this creates an entity of coevolving histories, which confirms individual as community and group as community” (pp. 44–45). The work of Parse and others brings a unique and holistic perspective to community/public health nursing practice.
This theory can serve as a guide for nurses advocating for health care policy change.
Milton (2015) noted that the constructs of freedom and choice are often overridden when policies and protocols are implemented in health care settings. People often become labeled as noncompliant if they do not agree with set protocols. However, Parse’s theory described freedom and choice as woven into the fabric of being human (Milton, 2015). Milton called for nurses to honor the importance of freedom and choice when creating and implementing policies rather than dehumanize the health care process.