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Population Health for Nurses

17.4 Formulating a Nursing Community Diagnosis and Plan of Care

Population Health for Nurses17.4 Formulating a Nursing Community Diagnosis and Plan of Care

Learning Outcomes

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

  • 17.4.1 Utilize various approaches and assessment findings to identify and prioritize individual, family, community, system, and population health concerns.
  • 17.4.2 Appraise the level of nursing intervention to make the most impact.
  • 17.4.3 Integrate individual, family, community, system, and population experiences and perspectives in designing plans of care.
  • 17.4.4 Develop a nursing community diagnosis and plan of care tailored to community culture.

Formulating a nursing community diagnosis and plan of care is similar to individual nursing community diagnosis and care planning. First, the CHA team identifies and prioritizes community health concerns. Next, the team develops community nursing diagnoses. Finally, the team tailors a community health improvement plan to community culture.

Prioritize Health Concerns

The CHA team uses the identified problem list created during analysis to prioritize community problems based on:

  • Extent of the problem (percent of the population affected by the problem and perception of health needs)
  • Relevance of the problem (degree of risk and economic loss)
  • Estimated effect of the intervention (impact, improvement of health outcomes, and potential adverse effects)

Health priorities should be those for which intervention would make the most impact on the community as a whole or for a specific at-risk population. Health priorities are those that have the

  • highest community perception of need,
  • largest reach,
  • highest degree of risk if unaddressed,
  • greatest economic impact,
  • greatest opportunity for improvement in health outcomes,
  • opportunity to promote health equity and reduce health disparities, and
  • least adverse effect on the population.

The team should base priorities on community strengths and available resources to increase the possibility of successful implementation of programs targeting those priorities. Resources include current and potential partnerships and collaborations, human resources or capacity, and funding. Health concerns may also be prioritized because they align with state and federal priorities, allowing for benchmarking and comparison to state and local data. Additionally, monies are usually available to fund programs that align with state or federal priorities.

The method the CHA uses to prioritize health concerns is determined by the CHA model, framework, or tool it chose at the beginning of the process. For example, a CHA team using the MAPP framework will first rank identified problems individually and then use a consensus to choose priorities or strategic issues. MAPP offers several tools to guide this process (NACCHO, 2023). In contrast, a CHA team using the Community Health Assessment toolkit would first identify specific criteria for prioritization and then choose an approach, such as group vote with majority deciding, averaging individual rankings, or using a matrix to weigh and rank criteria according to several factors (baseline data, feasibility, availability of resources, etc.) (AHA, 2017).

PHAB (2022) requires at least two health priorities, but most community care plans or community health improvement plans include at least three priority topics. Choosing health priorities also includes picking at least one health outcome indicator to measure health problem changes and identify the priority population of focus. For example, a team may choose mental health and addiction as a health priority. The priority outcome of this focus should then align with data collected during the CHA. Examples of mental health and addiction topic priority outcomes are “decrease the percentage of the community with depression,” “decrease suicide deaths,” and “decrease drug overdose deaths.”

Develop the Community Nursing Diagnosis

The community nursing diagnosis includes only one identified priority and the aggregate (population) affected, and it provides a rationale. A community nursing diagnosis should be written for each selected priority and include these three parts:

  1. Risk of: Identifies a specific problem or health risk faced by the community
  2. Among: Identifies the specific community aggregate with whom the nurse will be working in relation to the identified problem or risk
  3. Related to: Describes characteristics of the community

The community problem must be observable and measurable at the aggregate level. It considers which aggregate the risk affects most and which intervention will have the biggest impact. The community’s characteristics may contribute to the identified problem and/or be strengths of the community that can be built upon.

Examples of appropriately written community nursing diagnoses are as follows:

  • Risk of drug overdose among Hardin County adults related to increased opioid usage, presence of fentanyl, lack of available naloxone, ineffective drug misuse prevention programs, and decreased access to drug rehabilitation programs
  • Risk of infant and child malnutrition among families in Richmond County related to lack of regular developmental screenings, knowledge deficit about infant-related and child-related nutrition, knowledge deficit about available community resources, and lack of access to healthy foods
  • Risk for cardiovascular disease among Bailey County adults related to sedentary lifestyles, lack of walking trails, lack of safe sidewalks, and lack of affordable exercise facilities

Unfolding Case Study

Part B: Conducting a CHA

Read the scenario, and then answer the questions that follow based on all the case information provided in the chapter thus far. This case study is a follow-up to Case Study Part A.

After selecting the PRECEDE-PROCEED model, Tia’s CHA team completed phases 1–3. During the assessment, the team collected the following data:

  • GIS data shows one neighborhood with a disproportionate number of drug overdoses. This area also has high poverty and unemployment rates and is located by an entrance/exit on the interstate.
  • EMS calls for overdoses have tripled since the last CHA.
  • Drug overdose deaths are higher than the national benchmark (Healthy People 2030).
  • Provider opioid prescriptions have decreased in the area.
  • Reported opioid use (attained by any method—legal or illegal) has increased. Heroin usage has increased by 10 percent.
  • Availability of heroin mixed with fentanyl has increased over the past 6 months.
  • Infection rates related to needle use have increased at the local hospital.
  • Local schools continue to educate on drug abstinence using the Drug Abuse Resistance Education (DARE) program.
  • Naloxone training is available from the public health department, but utilization goals have not been reached.
  • Local EMS staff are volunteers, and the station is not regularly staffed.
  • A drug rehabilitation center is located within the community but frequently has a waiting list for outpatient appointments and inpatient admission.

Although the PRECEDE-PROCEED model does not require a community nursing diagnosis, the team decided to create one in order to clearly identify the aggregate and characteristics of the community.

The team has started planning for program implementation and wants to begin by promoting and enhancing available community resources, such as education within the schools, community naloxone training, education for providers related to opioid prescriptions, and drug rehabilitation. According to the PRECEDE-PROCEED model, phase 4, administrative and policy diagnosis, the team focuses on administrative and organizational concerns that should be addressed prior to program implementation.

Which community nursing diagnosis is written appropriately, reflects the data gathered during assessment, and aligns with community perceptions and needs?
  1. Risk for overdose among opioid/heroin users related to increased availability of heroin mixed with fentanyl, inconsistent EMS staffing, lack of availability/access to drug rehabilitation resources, increased opioid usage in the community, lack of knowledge of consequences of opioid misuse, and lack of utilization of community naloxone training
  2. Opioid misuse among community members living next to the highway who are unemployed and lack financial resources
  3. Risk for infection related to heroin injection, lack of knowledge of aseptic technique for injection, and availability of clean needles
  4. Increased opioid use in the county related to availability of heroin
Using the data collected during assessment and tentative plans for the program, what administrative and organizational concerns must the team address before program implementation?
  1. Reduced rates of opioid prescriptions by providers in the area
  2. Availability of appointments at the local drug rehabilitation center
  3. Response times of local EMS to overdose calls
  4. Increased availability of heroin in the community

Develop the Community Health Improvement Plan

The CHA team uses the identified priorities and community nursing diagnoses to develop the community health improvement plan (CHIP), the care plan for the entire community. PHAB (2022) defines the CHIP as a long-term systematic plan to address issues identified in the CHA that describes how the health department and community will work together to improve population health. Frequently, the public health department holds a leadership role, collaborating with various diverse community organizations to create the CHIP. The members of the CHA team are also usually involved in the CHIP process. As stated previously, the team members are individuals who either work or live within the community, ensuring the CHIP represents the community culture and values. The plan outlines goals and strategies community organizations, coalitions, and members will use to address priority health problems.

The team considers potential interventions for each identified priority. First, the team discusses existing community programs that may meet the community health need. The team performs a gap analysis to determine where the community should expand its efforts to meet community health needs. A gap analysis identifies and addresses the disparity between what is desired and real-world conditions (Davis-Ajami et al., 2014). For example, access to primary health care is a desired community health outcome for all. In reality, all people do not have access to a primary health care provider. A gap analysis identifies the disparity and potential solutions to reduce it. The team brainstorms strategies to enhance current programming and identify potential new interventions to fill the gaps noted to promote health and prevent disease. The team searches for new interventions that meet community needs and are innovative, evidence-based, most impactful, and sustainable. The team should also consider new partnerships to assist with planning or implementation. Finally, the team may complete a SWOT analysis to identify strengths, weaknesses, opportunities, and threats that may influence health outcomes or may promote or hinder possible interventions. The Minnesota Department of Health provides more information on completing a SWOT analysis. Overall, the team should select the best intervention after considering the various factors discussed.

The CHIP is designed to immediately follow the CHA and is updated with the CHA. So if the CHA process occurs every 3 years, the CHIP should be written as a three-year plan. CHIP interventions must align with chosen priorities and include measures for evaluation related to the rationale identified within the corresponding community nursing diagnosis. Current community resources and strengths are considered and integrated into interventions. The CHIP development also considers currently available and potential resources (such as grants) and partnerships. Community interventions are chosen when they are impactful, have the largest reach, are feasible, are innovative, are evidence-based, and can be completed within the CHIP time frame.

CHIP development continues by detailing goals and objectives, action steps, timetables, priority target populations, indicators to measure strategy impact, and accountability. Objectives should be SMART (specific, measurable, achievable, relevant, and time-bound). Action steps are specific and are listed by year of implementation. The time to complete each action step, target population, health indicator to measure the strategy, and responsible individual or organization is determined. Other details of the interventions are further detailed by the responsible individual or organization during program planning. See Planning Health Promotion and Disease Prevention Interventions for more information on writing SMART objectives.

The CHA and CHIP provide community organizations and health care systems with a common plan for addressing community health issues. The community is a partner in planning for health promotion and disease prevention efforts with community perspectives and community engagement at the center of the process. A comprehensive CHA provides evidence for community health priorities and social determinants of health impacting community health outcomes. The CHIP utilizes established community resources to combat identified priorities and reduce health disparities caused by determinants of health.


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