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Population Health for Nurses

16.3 The Nursing Process as a Framework

Population Health for Nurses16.3 The Nursing Process as a Framework

Learning Outcomes

By the end of this section, you should be able to:

  • 16.3.1 Explain how the nursing process serves as a framework to gain a holistic perspective of the community and population.
  • 16.3.2 Describe how the nursing process can serve as a framework to plan evidence-based nursing interventions.

Nurses use the nursing process to deliver care in a systematic and personalized way to individuals and communities through scientific reasoning, problem-solving, and critical thinking (Lotfi et al., 2020; Wagoro & Rakuom, 2015).

The nursing process has five stages:

  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation

These stages may appear familiar from foundational nursing courses where they would have been applied to physical assessment or care planning across client populations. Defining each stage and applying it to Elsa’s community provides a practical framework for understanding how nurses might organize community care in each stage.

Through an assessment, the nurse collects data about the community. As discussed, the nurse may collect data through a windshield survey, informant interviews, or publicly available data. Specific evidence collected could include community characteristics, health behaviors, and social determinants of health.

  • The population of Elsa’s community significantly decreases when the summer residents leave. The closure of stores, restaurants, health clinics, dental offices, and pharmacies during the offseason makes it difficult for year-round community members to access essential items and health services. Some community members feel isolated during the offseason, contributing to mental health concerns and increased substance use. The lack of an endocrinologist or clinic that can address Elsa’s diabetes requires them to travel long distances for appointments, and Elsa and their classmates do not have all-day, everyday access to a school nurse.

Through diagnosis, the nurse analyzes the data collected to identify areas of opportunity in the community in the context of health. The nurse identifies patterns, trends, or key problems in the data that point to a need for intervention in order to improve health.

  • The community health nurse determines that there is limited access to health care across the continuum for community members. There is also an increased risk of social isolation and mental health concerns, which peaks during the offseason but can impact health and well-being year-round. There is a specific lack of diabetes care. School students may not have access to chronic disease management and treatment of episodic concerns during the school day.

The planning stage involves determining goals or desired outcomes of community interventions and developing a plan to progress toward those goals. Community-based interventions could be as local as day-long health fairs or as broad as policy work that changes a population’s health care.

  • The community health nurse may plan to increase the availability of telehealth services to address the lack of health care access during the offseason. The nurse would collaborate with area physicians, nurse practitioners, and other clinicians to determine the feasibility of offering telehealth services. The community health nurse may also plan to explore possibilities for increased funding for school nurse positions so that the community’s students can access a qualified health care professional during the school day. The nurse would discuss the challenges of limited school nurse staffing with current nurses, teachers, students, and families and share the information with the local school board. The nurse may also plan to develop support networks and engaging events for community members facing isolation during the offseason. They would work with community members to identify events likely to draw a crowd and find space to host engaging events.

In the implementation phase, the nurse carries out a health program.

  • The community health nurse establishes a telehealth clinic at the community center, where every day of the week during the offseason, at least one of the summertime health care providers provides telehealth services to community members. The community health nurse advocates for school nurse support with local community decision-makers and the school committee and can secure funding to double the number of school nurse positions for the public schools. The nurse also organizes community events for different age groups throughout the month, including events for families with infants and young children, meetings for teens, and breakfast groups for seniors.

Finally, the nurse collects additional data to determine progress toward the identified goals and outcomes following a community program or intervention. This evaluation helps the nurse make evidence-based decisions regarding whether the program is meeting the community’s health needs or requires modification.

  • Tracking the number of residents who engage in a telehealth visit may be one method of evaluation. Additionally, due to the availability of primary and chronic care services via telemedicine, the community health nurse may determine whether visit volumes were any lower at urgent care centers and emergency departments. The community health nurse can track these same measures in relation to student health and the presence of a school nurse. The nurse could also track attendance at the new community events and survey attendees on their feelings of isolation and whether they are feeling down, depressed, or anxious.

Theory in Action

HI-5 Initiative

The nursing process steps and activities that support the health of the community and broader population health goals align with the CDC’s Health Impact in 5 Years (HI-5) initiative. This initiative aims to support community health interventions that have positive health impacts, demonstrate results within 5 years, are cost-effective, and offer cost savings. Interventions of this program have contributed to ameliorating a variety of pressing community health concerns.

Visit the website to review this initiative, select an HI-5 intervention that interests you most, and then respond to the following questions.

School-Based Programs to Increase Physical Activity

School-Based Violence Prevention

Safe Routes to School

Motorcycle Injury Prevention

Tobacco Control Interventions

Access to Clean Syringes

Pricing Strategies for Alcohol Products

Multi-Component Worksite Obesity Prevention

Early Childhood Education

Cleaner and Alternative Fuel Bus Fleets

Public Transportation System: Introduction or Expansion

Home Improvement Loans and Grants

Earned Income Tax Credits

Water Fluoridation

  1. How does the intervention you selected support the HI-5 initiative?
  2. How could a public/community health nurse carry out this program in another community or population? Would the intervention need modification to be successful in a different type of community, such as a rural area, a city with a large population of older adults, or a community with a large refugee population?
  3. Ideally, the programs will be sustainable beyond 5 years. What do you think is needed to sustain the program you read about?

Nursing practices that have the goal of healing the whole person are consistent with holistic nursing (Thornton, 2019). Holism is the concept that all parts of a whole are interconnected and do not exist or function without each other. This concept is easily applicable to community-based nursing, as a thorough understanding of the many barriers and facilitators of health in each community is needed to plan effective and appropriate interventions. Nurses can best address the needs of the community and partner with the community when a thorough assessment of the following has been performed:

  • Health services
  • Community priorities
  • Health risks
  • Local policies and practices
  • Other aspects of the dimensions of community health

In addition to guiding clinical care and use of evidence-based practices, the nursing process guides the work of nurses in the community. Using the nursing process to guide community practice supports a systematic approach to completing work in a holistic manner. Assessment of community needs, development of care plans specific to the community, and implementation of health-promoting interventions that address the community’s unique health resources, concerns, and needs are possible through the holistic approach that the nursing process facilitates.


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