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Theories applied in
Community
Health Nursing
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Introduction
• The concept of community is defined as "a group of
people who share some important feature of their
lives and use some common agencies and
institutions."
• The concept of health is defined as "a balanced state
of well-being resulting from harmonious
interactions of body, mind, and spirit."
• The term community health is defined by meeting
the needs of a community by identifying problems
and managing interactions within the community
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Basic Elements
• The six basic elements of nursing practice
incorporated in community health programs and
services are:
• (1) promotion of healthful living
(2) prevention of health problems
(3) treatment of disorders
(4) rehabilitation
(5) evaluation and
(6) research.
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Major Roles
• The focus of nursing includes not only the
individual, but also the family and the community,
meeting these multiple needs requires multiple
roles. The seven major roles of a community
health nurse are:
• (1) care provider
(2) educator
(3) advocate
(4) manager
(5) collaborator
(6) leader, and
(7) researcher.
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Major Settings

Settings for community health nursing can be

grouped into six categories:
• (1) homes
(2) ambulatory care settings
(3) schools
(4) occupational health settings
(5) residential institutions, and
(6) the community at large.
Community health nursing practice is not limited to a
specific area, but can be practiced anywhere.
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Theories and Models for community

health nursing
• Nightingale’s theory of environment
• Orem’s Self care model
• Neuman’s health care system model
• Roger’s model of the science and unitary man
• Pender’s health promotion model
• Roy’s adaptation model
• Milio’s Framework of prevention
• Salmon White’s Construct for Public health nursing
• Block and Josten’s Ethical Theory of population
focused nursing
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BRISSO ARACKAL
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Theory of Florence Nightingale

• Born - 12 May 1820
• Founder of mordern nursing.
• The first nursing theorist.
• Also known as "The Lady with the Lamp"
• She explained her environmental theory in her famous book Notes
on Nursing: What it is, What it is not .
• She was the first to propose nursing required specific education and
training.
• Her contribution during Crimean war is well-known.
• She was a statistician, using bar and pie charts, highlighting key
points.
• International Nurses Day, May 12 is observed in respect to her
contribution to Nursing.
• Died - 13 August 1910
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Assumpations of Nightingale's Theory

• Natural laws
• Mankind can achieve perfection
• Nursing is a calling
• Nursing is an art and a science
• Nursing is achieved through environmental
alteration
• Nursing requires a specific educational base
• Nursing is distinct and separate from medicine
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Nightingale’s Canons: Major

Concepts
• Ventilation and warming
• Light, Noise
• Cleanliness of rooms/walls
• Health of houses
• Bed and bedding
• Personal cleanliness
• Variety
• Chattering hopes and advices
• Taking food. What food?
• Petty management/observation
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BRISSO ARACKAL
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Theory of Florence Nightingale

Nursing Paradigms
Nursing
•Nursing is different from medicine and the goal of
nursing is to place the patient in the best possible
condition for nature to act.
•Nursing is the "activities that promote health (as
outlined in canons) which occur in any caregiving
situation. They can be done by anyone."
Person
•People are multidimensional, composed of
biological, psychological, social and spiritual
components.
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Theory of Florence Nightingale

Nursing Paradigms
Health
•Health is “not only to be well, but to be able to use
well every power we have”.
•Disease is considered as dys-ease or the absence of
comfort.
Environment
•"Poor or difficult environments led to poor health
and disease".
•"Environment could be altered to improve
conditions so that the natural laws would allow
healing to occur."
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Dorothea Orem's Self-Care Theory

• Born 1914 in Baltimore, US
• Earned her diploma at Providence Hospital –
Washington, DC
• 1939 – BSN Ed., Catholic University of America
• 1945 – MSN Ed., Catholic University of America
• She worked as a staff nurse, private duty nurse, nurse
educator and administrator and nurse consultant.
• Received honorary Doctor of Science degree in 1976.
• Theory was first published in Nursing: Concepts of
Practice in 1971, second in 1980, in 1995, and 2001.
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BRISSO ARACKAL
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Dorothea Orem's Self-Care Theory

• People should be self-reliant and responsible for their
own care and others in their family needing care
• People are distinct individuals
• Nursing is a form of action – interaction between two or
more persons
• Successfully meeting universal and development self-
care requisites is an important component of primary
care prevention and ill health
• A person’s knowledge of potential health problems is
necessary for promoting self-care behaviors
• Self care and dependent care are behaviors learned
within a socio-cultural context
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DEFINITIONS OF DOMAIN CONCEPTS

Nursing – is art, a helping service, and a
technology
• Actions deliberately selected and performed by
nurses to help individuals or groups under their
care to maintain or change conditions in
themselves or their environments
• Encompasses the patient’s perspective of health
condition ,the physician’s perspective , and the
nursing perspective
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• Goal of nursing – to render the patient or

members of his family capable of meeting the
patient’s self care needs
• To maintain a state of health
• To regain normal or near normal state of health
in the event of disease or injury
• To stabilize ,control ,or minimize the effects of
chronic poor health or disability
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• Health – health and healthy are terms used to

describe living things …
• It is when they are structurally and functionally
whole or sound … wholeness or integrity.
.includes that which makes a person human,…
operating in conjunction with physiological
and psychophysiological
mechanisms and a material structure and in
relation to and interacting with other human
beings
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Environment
•environment components are environement factors,
environment elements, conditions, and developed
environment
Human being – has the capacity to reflect,
symbolize and use symbols
•Conceptualized as a total being with universal,
developmental needs and capable of continuous self
care
•A unity that can function biologically, symbolically
and socially
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Nursing client
•A human being who has "health related /health
derived limitations that render him incapable of
continuous self care or dependent care or
limitations that result in ineffective / incomplete
care.
•A human being is the focus of nursing only when
a self –care requisites exceeds self care
capabilities
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Nursing problem
•deficits in universal, developmental, and health
derived or health related conditions
Nursing process
•a system to determine (1)why a person is under
care (2)a plan for care ,(3)the implementation of
care
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OREM’S GENERAL THEORY

OF NURSING
• Orem’s general theory of nursing in three related
parts:-
• Theory of self care
• Theory of self care deficit
• Theory of nursing system
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A. Theory of Self Care

• This theory Includes:
• Self care – practice of activities that individual initiates and
perform on their own behalf in maintaining life ,health and well
being
• Self care agency – is a human ability which is "the ability for
engaging in self care" -conditioned by age developmental state, life
experience sociocultural orientation health and available resources
• Therapeutic self care demand – "totality of self care actions to
be performed for some duration in order to meet self care requisites
by using valid methods and related sets of operations and actions"
• Self care requisites - action directed towards provision of self
care. 3 categories of self care requisites are-
▫ Universal self care requisites
▫ Developmental self care requisites
▫ Health deviation self care requisites
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Theory of Self Care

• 1. Universal self care requisites Associated with
life processes and the maintenance of the integrity
of human structure and functioning
• Common to all , ADL
• Identifies these requisites as:
▫ Maintenance of sufficient intake of air ,water, food
▫ Provision of care assoc with elimination process
▫ Balance between activity and rest, between solitude
and social interaction
▫ Prevention of hazards to human life well being and
▫ Promotion of human functioning
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Theory of Self Care

2.Developmental self care requisites
•Associated with developmental processes/
derived from a condition…. Or associated with
an event
▫ E.g. adjusting to a new job
▫ adjusting to body changes
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Theory of Self Care

3.Health deviation self care
•Required in conditions of illness, injury, or disease
.these include:--
•Seeking and securing appropriate medical assistance
•Being aware of and attending to the effects and
results of pathologic conditions
•Effectively carrying out medically prescribed
measures
•Modifying self concepts in accepting oneself as being
in a particular state of health and in specific forms of
health care
•Learning to live with effects of pathologic conditions
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BRISSO ARACKAL
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B. Theory of self care deficit

• Specifies when nursing is needed

• Nursing is required when an adult (or in the case of a
dependent, the parent) is incapable or limited in the
provision of continuous effective self care. Orem identifies
5 methods of helping:
▫ Acting for and doing for others
▫ Guiding others
▫ Supporting another
▫ Providing an environment promoting personal development in
relation to meet future demands
▫ Teaching another
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C. Theory of Nursing Systems

• Describes how the patient’s self care needs will be met by
the nurse , the patient, or both

• Identifies 3 classifications of nursing system to meet the

self care requisites of the patient:-

• Wholly compensatory system

• Partly compensatory system

• Supportive – educative system

• Design and elements of nursing system define

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C. Theory of Nursing Systems

• Scope of nursing responsibility in health care

situations

• General and specific roles of nurses and patients

• Reasons for nurses’ relationship with patients and

• Orem recognized that specialized technologies are
usually developed by members of the health
profession
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Betty Neuman's System Model

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Betty Neuman's System Model

INTRODUCTION
•Theorist - Betty Neuman - born in 1924, in Lowel, Ohio.
•BS in nursing in 1957; MS in Mental Health Public health
consultation, from UCLA in 1966; Ph.D. in clinical
psychology
•Theory was publlished in:
▫ “A Model for Teaching Total Person Approach to Patient
Problems” in Nursing Research - 1972.
▫ "Conceptual Models for Nursing Practice", first edition in
1974, and second edition in 1980.
•Betty Neuman’s system model provides a comprehensive
flexible holistic and system based perspective for nursing.
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Betty Neuman's System Model

DEVELOPMENT OF THE MODEL
•Neuman’s model was influenced by:
•The philosophy writers deChardin and Cornu
(on wholeness in system).
•Von Bertalanfy, and Lazlo on general system
theory.
•Selye on stress theory.
•Lararus on stress and coping.
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Betty Neuman's System Model

MAJOR CONCEPTS (Neuman, 2002)
Content
•the variables of the person in interaction with
the internal and external environment comprise
the whole client system
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Betty Neuman's System Model

Basic structure/Central core
•The common client survival factors in unique
individual characteristics representing basic
system energy resources.
•The basis structure, or central core, is made up
of the basic survival factors which include:
normal temp. range, genetic structure.- response
pattern. organ strength or weakness, ego
structure.
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Betty Neuman's System Model

• Stability, occurs when the amount of energy that
is available exceeds that being used by the
system.

• A homeostatic body system is constantly in a

dynamic process of input, output, feedback, and
compensation, which leads to a state of balance
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Degree to reaction
•the amount of system instability resulting from
stressor invasion of the normal LOD( Line of
defence)
Entropy
•a process of energy depletion and
disorganization moving the system toward
illness or possible death.
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Flexible LOD
•a protective, accordion like mechanism that
surrounds and protects the normal LOD from
invasion by stressors.
Normal LOD
•It represents what the client has become over
time, or the usual state of wellness. It is
considered dynamic because it can expand or
contract over time.
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Line of Resistance-LOR
•The series of concentric circles that surrounds the
basic structure.
•Protection factors activated when stressors have
penetrated the normal LOD, causing a reaction
symptomatology. E.g. mobilization of WBC and
activation of immune system mechanism
Input- output
•The matter, energy, and information exchanged
between client and environment that is entering or
leaving the system at any point in time.
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Open system
•A system in which there is continuous flow of
input and process, output and feedback. It is a
system of organized complexity where all
elements are in interaction.
Prevention as intervention
•Interventions modes for nursing action and
determinants for entry of both client and nurse
in to health care system.
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Reconstitution
•The return and maintenance of system stability,
following treatment for stressor reaction, which
may result in a higher or lower level of wellness.
Stability
•A state of balance of harmony requiring energy
exchanges as the client adequately copes with
stressors to retain, attain, or maintain an optimal
level of health thus preserving system integrity.
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Stressors
•environmental factors, intra (emotion, feeling),
inter (role expectation), and extra personal (job
or finance pressure) in nature, that have potential
for disrupting system stability.
•A stressor is any phenomenon that might
penetrate both the F and N LOD, resulting either
a positive or negative outcome.
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Wellness/Illness
• Wellness is the condition in which all system
parts and subparts are in harmony with the
whole system of the client.
• Illness is a state of insufficiency with disrupting
needs unsatisfied (Neuman, 2002).
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• the primary nursing intervention.

• focuses on keeping stressors and the stress
response from having a detrimental effect on the
body.
• Primary Prevention
▫ occurs before the system reacts to a stressor.
▫ strengthens the person (primary the flexible LOD)
to enable him to better deal with stressors
▫ includes health promotion and maintenance of
wellness.
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• Secondary Prevention
▫ occurs after the system reacts to a stressor and is
provided in terms of existing system.
▫ focuses on preventing damage to the central core by
strengthening the internal lines of resistance and/or
removing the stressor.
• Tertiary Prevention
▫ occurs after the system has been treated through
secondary prevention strategies.
▫ offers support to the client and attempts to add energy
to the system or reduce energy needed in order to
facilitate reconstitution
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FOUR NURSING
PERSON PARADIGMS
•Human being is a total person as a client system and the
person is a layered multidimensional being.
•Each layer consists of five person variable or subsystems:
▫ Physiological - Refers of the physicochemical structure
and function of the body.
▫ Psychological - Refers to mental processes and
emotions.
▫ Socio-cultural - Refers to relationships and
social/cultural expectations and activities.
▫ Spiritual - Refers to the influence of spiritual beliefs.
▫ Developmental - Refers to those processes related to
development over the lifespan.
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ENVIRONMENT
•"the totality of the internal and external forces
(intrapersonal, interpersonal and extra-personal
stressors) which surround a person and with which
they interact at any given time."
•The internal environment exists within the
client system.
•The external environment exists outside the
client system.
•The created environment is an environment that
is created and developed unconsciously by the client
and is symbolic of system wholeness.
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HEALTH
•Health is equated with wellness.
•“the condition in which all parts and subparts
(variables) are in harmony with the whole of the
client (Neuman, 1995)”.
•The client system moves toward illness and
death when more energy is needed than is
available. The client system moved toward
wellness when more energy is available than is
needed
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NURSING
•a unique profession that is concerned with all of the variables
which influence the response a person might have to a stressor.
•person is seen as a whole, and it is the task of nursing to
address the whole person.
•Neuman defines nursing as “action which assist individuals,
families and groups to maintain a maximum level of wellness,
and the primary aim is stability of the patient/client system,
through nursing interventions to reduce stressors.’’
•The role of the nurse is seen in terms of degree of reaction to
stressors, and the use of primary, secondary and tertiary
interventions.
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NEUMAN'S MODEL &

CHRACTERISTICS
• interrelated concepts
• logically consistent.
• logical sequence
• fairly simple and straightforward in approach.
• easily identifiable definitions
• provided guidelines for nursing education and
practice
• applicable in the practice
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Salmon White’s construct for public

health nursing
• Mark Salmon White (1982) describes a public
health as an organized societal effort to protect,
promote and restore the health of people and
public health nursing as focused on achieving
and maintaining public health.
• He gave 3 practice priorities i.e.; prevention of
disease and poor health, protection against
disease and external agents and promotion of
health.
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Milio’s Framework of
prevention
• Nancy Milio a nurse and leader in public health
policy and public health education developed a
framework for prevention that includes concepts of
community-oriented, population focused care.
(1976,1981).
• The basic treatise is that behavioral patterns of
populations and individuals who make up
populations are a result of habitual selection from
limited choices.
• She challenged the common notion that a main
determinant for unhealthful behavioral choice is
lack of knowledge.
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Milio’s Framework of
• Governmentalprevention
and institutional policies, she said
set the range of options for personal choice
making.
• It neglected the role of community health
nursing, examining the determinants of
community health and attempting to influence
those determinants through public policy.
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Milio’s Framework of
prevention
• For these 3 general categories of nursing
intervention have also been put forward, they
are
• 1.education directed toward voluntary change in
the attitude and behaviour of the subjects
• 2.engineering directed at managing risk-related
variables
• 3.enforcement directed at mandatory regulation
to achieve better health.
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Block and Josten’s Ethical Theory

of population focused nursing
• Derryl Block and Lavohn Josten, public health
educators proposed this based on intersecting fields
of public health and nursing. They have given 3
essential elements of population focused nursing
that stem from these 2 fields:
• 1.an obligation to population
• 2.the primacy of prevention
• 3.centrality of relationship- based care
• the first two are from public health and the third
element from nursing. Hence it implies to nursing
that relation-based care is very important in
population focused care.