16.1 The Community as the Client

Community Attributes

Formal and informal communities exist within and across towns and cities. A community may comprise people who celebrate the same cultural holidays or people who are at risk for the same health condition.

Consider the many communities that may be present in a classroom of nursing students: a community of students, a clinical team, a study group, students with children, and perhaps students studying nursing as a new career. Elsa, from the chapter’s opening scenario, is a member of numerous communities, including residents of the town, people with type 1 diabetes mellitus, high school students who are gender nonconforming, the soccer team, and residents who get around on bikes, among others. Communities of nursing clients may consist of those who inhabit a specific geographic location, share specific characteristics, or access the same social systems. Communities may also form when groups cannot access select health services and social systems.

Individuals do not have to live within mapped boundaries to be part of a geographic community. People who work, worship, or play in an area where they do not live can be interested in that community’s health.

A key activity for geographic communities is civic engagement—involvement in issues of public concern through political and nonpolitical processes that increase community vitality, challenge injustices, and address social problems (Figure 16.2) (American Psychological Association, 2009; Wray-Lake & Abrams, 2020). Other geographically based communities include members of community centers, such as a Council on Aging or a Boys and Girls Club, and populations of school students, home caregivers, and teachers in a geographic community.

Figure 16.2 Protest is a form of civic engagement. Protests can inform members of the public of issues, mobilize voters and community members to act for change, and influence the policy process. Here, people are voicing their opinion on the need to address climate change during a climate strike rally in 2019. (credit: “#ClimateStrike Rally” by MN Senate DFL/Flickr, Public Domain)

People who share personal characteristics such as race, ethnicity, gender, age, or occupation may create a formal community for mutual support or to advance equitable practices across health care and other fields. Others who share such characteristics may not participate in a formal community but may informally associate with members of the community, remain knowledgeable of the shared successes and challenges the community faces, and advocate for change. Populations of individuals who share health risks may also constitute a community.

Social Media and Other Social Systems

Social media and other social systems provide avenues for the formation and definition of communities. Social and political networks may serve as a basis for uniting as a community for health change. Technology has dramatically enhanced opportunities to join a community, as many people use social networks to participate in civic engagement, learn about health, effect change through sharing stories and knowledge, and organize to advocate for policies and societal changes that advance health. Social media has increased the visibility of community health issues, as community members and advocates can quickly share information with people around the globe.

Advocacy in the context of community health refers to support for a specific health cause or recommendations for community and policy change. Advocacy is a significant health promotion strategy to inform voters and policymakers of pressing community health issues and the consequences of harmful policies or inaction (Jackson et al., 2021). Community members who share their own health experiences encourage the forming of community, as other members who identify with the experiences or want to support health change can join the conversation and become involved. Social media has provided a platform for community members, clinicians, organizations, charities, and others to connect and work together to improve the dimensions of community health in many areas. Health advocates have used social media to call attention to, and impact change for, many issues across the globe, such as alcohol use in the Netherlands, tobacco control in Australia, sexual harassment in Egypt, traffic accidents in Ireland, maternal mortality in the United States, and housing in New Zealand (Albalawi & Sixsmith, 2015; Behm et al., 2022; Bekkers et al., 2011; Chisholm & O’Sullivan, 2017; Hefler et al., 2013; Peuchaud, 2014). Advocating for Population Health covers nurse advocacy in more detail.

Community Assessments and Profiles

Assessment is the first and most important step of the nursing process. Nurses cannot address a problem if they do not know it exists, and they cannot support a health behavior or community effort if they do not realize it is occurring. Assessment begins with gathering data. Nurses may take several approaches to gathering data. First, they may conduct a windshield survey. In a windshield survey, nurses explore a community or neighborhood and observe on foot, from a bench or street corner, or through the windows of a vehicle (Centers for Disease Control and Prevention, 2010). Observations made using this type of survey can alert nurses to urgent or potential health risks in the community, as observers may notice the condition of sidewalks and public spaces, community noise levels, street access and activity, and the presence or absence of businesses and places of employment. See Appendix A for an example of a windshield survey template that nurses may use to conduct one of these assessments. Per the University of Kansas Center for Community Health and Development Community Tool Box (2023), during such a survey, nurses should observe:

• Housing: age and condition of homes in the neighborhood
• Other buildings: occupancy and accessibility of buildings
• Public spaces: availability of places to gather and their amenities, upkeep, and utilization
• Parks: utilization, times of use, activities facilitated
• Culture and entertainment: presence of museums, libraries, theaters, and sports venues and their accessibility and use by members representative of the full community
• Streetscape: condition of building facades and storefronts, presence of trees and sidewalks, cleanliness
• Street use: presence of people during various times of the day
• Commercial activity: types of businesses, storefront vacancies, stores that provide necessities like groceries
• Signs: languages, level of information
• Industry: types of industry, pollution
• Land use: open space compared to used land; distribution of residential, commercial, and industrial areas
• Infrastructure: condition of roads, bridges, and sidewalks; differences in condition across the community
• Public transportation: presence and use of system
• Traffic: level of traffic, vehicles in traffic
• Environmental quality: green space presence and distribution, air quality, water sources
• Race/ethnicity: characteristics of community, separation or cohesion of groups
• Faith communities: religious institution types and presence
• Health services: hospital and clinic presence and accessibility
• Community and public services: presence of mental health centers, food banks, and housing support and their distribution and accessibility by public transit
• Community safety: police and fire stations
• Public schools: presence of schools and their level of maintenance or upkeep
• Higher education: two- and four-year colleges, location, integration with community versus isolation
• Political activity: political signs (e.g., yard signs during elections), protests, demonstrations
• Community organizations: service clubs and other groups centered on community issues
• Media: local outlets, sponsorship/influence
• Differences among neighborhoods: states of maintenance, presence of community amenities across neighborhoods or sections
• The “feel” of the community: the observer’s overall impression of the community

Regardless of the method they use to conduct a windshield survey, nurses should conduct the survey in pairs or groups. First, it is unsafe to attempt to drive and note observations at the same time. Additionally, each nurse may have different observations, which can add to the richness of data collected. Nurses may also collect data from open sources in the community, such as publicly available reports, census data, and other public documents (Quinn et al., 2019). For example, department of health reports regarding the rates of communicable illnesses and chronic conditions can help elucidate a community’s health needs, and the posted minutes of a local select board meeting can illuminate health topics on the minds of local community partners and residents. See Assessment, Analysis, and Diagnosis for more information regarding community data sources. Finally, nurses should consult key community partners, policymakers, community leaders, and community members during a community assessment.

Including community members in community-based nursing work is essential and should start from the earliest stages of a community initiative. Involving community members’ perspectives and participation supports not only thorough assessments and meaningful change but also ethical practice. Meaningful partnerships with community members show respect for the community, build trust and relationships, minimize risk and burden, build legitimacy, and positively impact health (Adhikari et al., 2020; Haldane et al., 2019).

Community inclusion also helps nurses work against both the narrative and the reality that clinicians often tell people what to do without considering personal, contextual, social, or other factors. Such actions may be perceived as patronizing and marginalizing the community, or treating them as insignificant and making them feel powerless or unimportant. In nursing, decolonization refers to processes that systematically dismantle “western colonial ideologies of superiority, thought, approaches, and privilege” (Fontenot & McMurray, 2020, p. 272). Partnering with members of a community is in alignment with decolonization and can contribute to community interventions that are robust, respectful, culturally responsive, and inclusive (Lin et al., 2020; McCreedy et al., 2018).

Gordon’s functional health patterns provide a method of structuring a community assessment and organizing the resulting data (Gordon, 1982). Nurse theorist Marjory Gordon developed the functional health patterns to guide nurses through a thorough assessment of individual clients and families (Gordon, 1982). However, the functional health patterns can also be applied to a community assessment. Ten years after Gordon published her work, nurse scholars Nancy Kriegler and Marilyn Harton used it to develop the community health assessment tool (Kriegler & Harton, 1992). See Table 16.1 for descriptions of the 11 functional health patterns for use in community assessments and the items nurses may assess in each pattern.

A functional health pattern assessment can help the nurse to develop a community profile that includes identifying health problems, describing health risks, and determining health promotion activities. Recall the chapter’s opening scenario. What patterns does the description of Elsa’s community address? What questions would the community health nurse have for Elsa and other community members to develop a comprehensive community assessment?

The functional health pattern assessment applies to nursing assessment and practice and can be used during interprofessional community health endeavors. Other tools that may be used include the American Hospital Association’s Community Health Assessment Toolkit, the CDC’s action model, and the CDC’s Community Health Assessment and Group Evaluation (CHANGE) tool. Assessment, Analysis, and Diagnosis provides more information on community health assessment tools, models, and frameworks.