I am a public health nurse, married to a Los Angeles–area police officer. His job with a juvenile diversion program for 13- to 18-year-old offenders (gang youth or those at risk of gang involvement) includes organizing a semester-long course to build confidence and self-esteem, as well as physical training and education in a classroom setting. Various officers teach the course, and they invite guest speakers. I ended up being a guest speaker for three 3-hour sessions and loved it! In order to prepare, I examined statistics and other assessment information about gangs as an aggregate. I noted that they have been found to have higher drug and alcohol use, earlier sexual initiation, and unsafe sexual practices with attendant higher rates of STIs (sexually transmitted infections).
Higher rates of mental disorders, drug-related crime, and violent victimization are also hallmarks of gang membership. Basically, they are more likely to engage in high-risk behaviors, and I wanted to try to reach this aggregate that often has little access to health care. I thought this was a great opportunity to reach a vulnerable population and generate a discussion with them on health-related issues. I wanted it to be interactive and used examples they could identify with; I also spoke with some of their slang terms. The first session addressed major causes of morbidity and mortality among their age group. I showed them a photograph of a car involved in a crash due to driver texting and discussed the dangers of racing cars, driving drunk, and driving while distracted (as this driver had done). I started a discussion with them about homicide statistics and asked how this has personally affected them. I also gave them information about suicide and hotline numbers.
At the second session, I wanted to focus on major health issues (e.g., obesity, drug use, mental and sexual health) and addressed each by highlighting the health consequences, behaviors that needed to change, and how they could prevent problems and access care when needed. We discussed obesity, and I brought examples of food nutrition labels, especially from fast food restaurants they frequented. They were amazed at the calories and fat levels, so we discussed healthier alternatives. At the last session, I focused on health promotion and risk prevention. I emphasized testicular and breast self-exams (yes, there were girls) and encouraged medical screening for STIs, with information on free clinics in their areas.
Although no formal evaluation of the program was done, I got great feedback from parents of the youth involved, who reported that their child’s attitudes improved. Also, a good number of graduates of the program came back to work as student volunteers with subsequent cohorts. I felt a sense of accomplishment, having reached this difficult yet vulnerable population. I think that my openness and frankness in answering their questions and comfortable use of their slang terms developed rapport with them and permitted me to reach them with health information that they really needed to hear. I would encourage you to look for opportunities to do the same!
Alisha, BSN
Adapted from Sanders, B., Schneiderman, J., Loken, A., Lankenau, S., & Bloom, J. (2009). Gang youth as a vulnerable population for nursing intervention. Public Health Nursing, 26(4), 346–352.
Types of Community Needs Assessment
After considering the importance of community partnerships and coalitions, the community health nurse is ready to determine the community’s health status, resources, and needs. Assessment is the key initial step of the nursing process. Assessment for nurses means collecting and evaluating information about a community’s health status to discover existing or potential needs and assets as a basis for planning future action (Anderson &
McFarlane, 2015). Assessments are also a critical requirement for public health department accreditation (Public Health Accreditation Board, 2013) and are now a requirement for nonprofit hospitals under the Affordable Care Act, or health care reform, a program supported by nurses (Rice et al., 2014; ANA, 2014).
Several models or frameworks can be used for assessment. Three such models are Mobilizing for Action through Planning and Partnerships (MAPP) and Protocol for Assessing Community Excellence in Environmental Health (PACE EH). These models have been developed through partnership with the Centers for Disease Control and Prevention (CDC) to improve community assessment in relation to Healthy People goals (CDC, 2015a). An earlier tool, the Planned Approach to Community Health (PATCH), was developed to assist communities in assessing health promotion and chronic disease prevention programs (NACCHO, 2012). The Healthy People 2020 website also provides planning tools and toolkits to assist local communities (see Internet Resources on thePoint).
These are all valuable resources that provide specific guidelines focusing on local-level strategies to improve the health of communities.
Assessment involves two major activities. The first is collection of pertinent data, and the second is analysis and interpretation of data. These actions overlap and are repeated constantly throughout the assessment phase of the nursing process. While assessing a community’s ability to enhance its health, the nurse may simultaneously collect data on community lifestyle behaviors and interpret previously collected data on morbidity and mortality.
Community health assessment is the process of determining the real or perceived needs of a defined community. In some situations, an extensive community study may be the first priority; in others, all that is needed is a study of one system or even one organization. At other times, community health nurses may need to perform a cursory examination or windshield survey to familiarize themselves with an entire community without going into any depth (Anderson & McFarlane, 2015).
Familiarization or Windshield Survey
A familiarization assessment is a common starting place in evaluation of a community.
Familiarization assessment involves studying data already available on a community and then gathering a certain amount of firsthand data in order to gain a working knowledge of the community. Such an approach may utilize a windshield survey—an activity often used
by nursing students in public health courses and by new staff members in community health agencies. Nurses drive (or walk) around the community of interest; find health, social, and governmental services; obtain literature; introduce themselves and explain that they are working in the area; and generally become familiar with the community and its residents. This type of assessment is needed whenever the community health nurse works with families, groups, organizations, or populations. The windshield survey provides knowledge of the context in which these aggregates live and may enable the nurse to better connect clients with community resources (Table 15–4). See an example in From the Case Files I.
Table 15–4 Community Familiarization (Windshield) Survey
Adapted from Anderson, E. T., & McFarlane, J. (2015). Community as partner: Theory and practice in nursing (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
From the Case Files I
The Angelo Family and a Familiarization Assessment
A community health nurse named Jean visited the Angelo family on the outskirts of Philadelphia. During the initial visit, she gathered information, learning that the family was Italian American and that there were four children, ranging in age from 15 to 3. The father had been out of work for 6 months; the mother worked on weekends as a maid in a motel; the oldest boy had been in trouble with the juvenile authorities; the 13-year-old girl was deaf; and their house appeared rundown. Jean assessed this family, trying to determine its coping ability and its level of health. Furthermore, because community health nursing is population focused, her concern was not only for the Angelo family but also for the population of families with similar problems that this family represented.
However, the nurse’s assessment was almost impossible without further knowledge of the community. Was theirs an Italian American neighborhood with specific cultural influences? What was the extent of unemployment in this city? What were the services for the deaf? Were all the houses in this part of town old and in need of repair? Once the nurse began working with the family, familiarity with the community became even more imperative. She discovered that, as a result of the Angelos’ low income, family conflicts were intense. The family members seldom got out; they made almost no use of the community’s recreational system. Before she could help them make use of it, however, the nurse had to find out what resources were available. As she familiarized herself with the community, she discovered Friends of the Deaf, which sponsored a group for parents of deaf children. The nurse could now help Mr. and Mrs. Angelo become part of that group. A quick survey of the religious system in the community revealed two job-transition support groups, one of which would welcome Mr. Angelo. In the meantime, the nurse chose to find out about the public assistance or welfare system and how this family and other similar families could benefit from its services. Even her own attitude changed as she studied the community. For instance, she discovered that a strike had closed down the plant where Mr. Angelo worked for 20 years and could view his and others’
unemployment from a broader perspective. Using a familiarization assessment helped this nurse to enhance her practice.
Whatever role nurses play in community health promotion, they will want to be making a continuous study, an ongoing assessment. Whether nurses become client advocates, work with the local government, or operate from a nursing agency serving
the elderly, a familiarization assessment is prerequisite for their work.
Windshield surveys are a quick way to become familiar with a new community and its residents.
Problem-Oriented Assessment
A second type of community assessment, problem-oriented assessment, begins with a single problem and assesses the community in terms of that problem. Suppose that Jean, the nurse who explored services available for the Angelo family’s deaf child in From the Case Files I, had discovered that there were none. Confronted with this problem—one family with one deaf child—she could make a problem-oriented community assessment.
Her first step would be to discover the incidence of childhood deafness, both in the community and in the state. Second, she might begin interviewing officials in the schools and health institutions to find out what had been done in the past to assist deaf children.
She could do an Internet search to locate available resources on the subject of deafness. Are there interpreters available for people who use sign language? How do hospitals and courts approach deafness? Are there any clubs or other organizations for deaf people? Are there school programs for the deaf, and if so, where are they located?
The problem-oriented assessment can be used when familiarization is not sufficient and a comprehensive assessment is not feasible. This type of assessment is responsive to a particular need and should also seek to describe contextual issues associated with the need.
The data collected can support community efforts to address specific problems. Data should address the magnitude of the problem to be studied (e.g., prevalence, incidence), the precursors of the problem, and information about population characteristics (e.g., community resources, strengths, and weaknesses), along with the attitudes and behaviors of the population being studied (Kirst-Ashman, 2014).
Community Subsystem Assessment
In community subsystem assessment, the community health nurse focuses on a single dimension of community life. For example, the nurse might decide to survey churches and religious organizations to discover their roles in the community. What kinds of needs do the leaders in these organizations believe exist? What services do these organizations offer?
To what extent are services coordinated within the religious system and between it and other systems in the community? For example, churches and other cultural leaders were instrumental in providing information to address a public health department’s concerns. A small county health department worked with the nearby university PHN clinical instructor and her students to determine why two specific racial/ethnic groups were not using the health department’s free women’s health clinics. One group of students led by a Black student met with local pastors from several Black churches, and the other group, who was led by a Hmong student, met with Hmong leaders. Students attended the local Black churches on a particular Sunday and met with the congregation after the services to ask them about their knowledge and use of the health department’s clinics. The students let
them know about the available health services and answered questions. The health department followed up with the pastors, and it was determined that most of the members of the congregations were unaware of the services provided through the county health department. PHNs and other staff made efforts to regularly meet with members of the congregations to encourage their attendance at various clinics. For the Hmong population, students met with a local clan leader and several members of the community to inquire about the lack of attendance at the women’s clinic. They were told that, with the Hmong culture, husbands generally accompanied their wives when getting prenatal care or family planning services. Also, they felt more comfortable with Hmong health care personnel than those from outside their group, and there happened to be a Hmong physician available to them in a larger neighboring county. The health department staff later met with members of the Hmong community to discuss their concerns, and it was determined that this population felt more comfortable not using health department services for women’s health but would participate in well-child and immunization clinics. Working with and through these subsystems facilitated this process.
Community subsystem assessment can be a useful way for a team to conduct a more thorough community assessment. If five members of a nursing agency divide up the ten systems in the community and each person does an assessment of two systems, they could then share their findings to create a more comprehensive picture of the community and its needs.
Comprehensive Assessment
Comprehensive assessment seeks to discover all relevant community health information. It begins with a review of existing studies and all the data presently available on the community. A survey compiles all the demographic information on the population, such as its size, density, and composition. Key informants are interviewed in every major system—
education, health, religious, economic, and others. Key informants are experts in one particular area of the community or they may know the community as a whole. Examples of key informants would be a school nurse, a religious leader, key cultural leaders, the local police chief or fire captain, a mail carrier, or a local city council person. Then, more detailed surveys and intensive interviews are performed to yield information on organizations and the various roles in each organization. A comprehensive assessment describes the systems of a community and also how power is distributed throughout the system, how decisions are made, and how change occurs (Anderson & McFarlane, 2015;
LeBan, 2011).
Because comprehensive assessment is an expensive, time-consuming process, it is not often undertaken. Performing a more focused study, based on prior knowledge of needs, is often a better and less costly strategy. Nevertheless, knowing how to conduct a comprehensive assessment is an important skill when designing smaller, more focused assessments (see Perspectives: Public Health Nursing Instructor).