Advanced Practice Nursing in the Community


Carl O. Helvie R.N., Dr.P.H.

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    This book is dedicated to Wilfried Kunstmann, Dortmund, Germany, colleague, friend, teacher, thinker, and questioner, and to those students who also questioned and helped me clarify my thoughts.


    I am grateful to many individuals who offered assistance in the preparation of this text. To acknowledge them all would be impossible within the limits of this section and the memory of the author. Thus, I apologize for any oversights, which are unintentional.

    First, I acknowledge my graduate students in community health nursing who offered comments and stimulating questions over the past years as I taught the course on which this book is based. I am grateful to each of you. I am especially grateful to Chris Elnitsky, currently a doctoral student, and to James Hosack, a White House nurse, who stimulated me to refine the energy theory.

    Next, I thank each of the contributors for the case studies and for the chapter on rural nursing. Their experience in applying the concepts in practice has added greatly to the book. In addition, their promptness in submitting the materials facilitated the meeting of deadlines.

    I thank each of the reviewers of the original proposal for their comments and confidence in me and the reviewers of the completed manuscript for their valuable comments for refining the manuscript. These have strengthened the book. I thank my chair of nursing, Dr. Brenda S. Nichols, who reviewed and commented on the proposal and who approved a semester's leave from my teaching position for writing the book. Thanks also go to Dean Lindsay Rettie and Vice President for Academic Affairs JoAnn Gora, who also had confidence in me and who approved my leave for writing. I also thank my colleague, Dr. Laurel Garzon, who provided continued support and encouragement.

    I also thank members of the leadership group of community health nursing of the American Public Health Association for their encouragement. I am especially grateful to Dr. Caroline White, past chair, Community Health Nursing Section of APHA who provided support and continued encouragement.

    Last but not least, I acknowledge Christine S. Smedley, previous sponsoring editor, Sage Publications, for her confidence in offering a contract for the book. I also recognize Mr. Daniel Ruth, my current editor at Sage, for his support and help in obtaining reviews of the manuscript, providing contracts to contributors, and providing other assistance that facilitated the production process and enhanced the quality of the book.


    This book is written for beginning graduate students in community health nursing or for nurses who need a community or aggregate focus in practice. It is the result of needing to use large numbers of articles for teaching graduate students in community health nursing over several years because a text that focused on multiple aspects of the community, aggregates, or both was not available. The text is different from other community health nursing texts and the author's previous community health nursing texts because it has a narrow and in-depth focus on the community and aggregates rather than covering the total field of community health nursing.

    Part I presents a book overview and a review of community health nursing concepts. The review covers timely concepts such as generalist versus specialist, community-based and population-focused nursing, and community health nursing or public health nursing, roles, and models. This review is useful for the nurse who has not studied or practiced community health nursing recently.

    Part II discusses a theoretical framework for the book. The theory selected to view the community or aggregate is the Helvie energy theory, a systems theory developed around the concept of energy. Models for using this theory in practice are included.

    Part III explores community assessment. Chapters 3, 4, and 5 in this section discuss the influence of economic, environmental, and sociocultural forces on the health of the community. Concepts and models related to these topics are presented. Special social and cultural aggregates, such as the homeless and migrant populations and African American, Native American, Asian American, and Latino American populations, are included. In addition, two case studies by community health nursing leaders in practice using the concepts presented for economic and environmental forces influencing health and nursing are presented. Chapters 6 and 7 present concepts and models for community assessment and community analysis. These concepts are applied to a fictitious community, and a nursing leader applies the concepts of community assessment to an actual community.

    Part IV covers community planning and interventions. Chapter 8 discusses the planning of community interventions and includes the planning process, concepts of community organization, community change, multilevel models of planning interventions, and other related concepts and models. Chapter 9 explores the planning for diffusion of programs and the maintenance of program changes initiated in the community. A case study by a nursing leader who used diffusion theory in the community to maximize the effects of a program is included. Chapter 10 looks at the first two community- or aggregate-focused interventions and includes concepts and models related to using mass media and the political process to introduce change into a community. Case studies by nursing leaders for these two interventions are included. Chapter 11 presents empowerment, coalition building, and involving professionals and the lay community as community interventions. Models and concepts appropriate to these overall concepts and three case studies by nursing leaders are presented. Chapter 12 discusses concepts of nursing centers, mass immunization clinics, community partnerships, and school nursing as aggregate interventions. A case study by a nursing leader who has developed and implemented a nursing center is included. Chapter 13 discusses the application of these interventions in a rural setting.

    Part V introduces community evaluation and presents concepts of outcome variables for measuring community change, components of evaluation, study outcome variables, and other appropriate concepts.

    It is the desire of the author that the book will assist the nursing student or practitioner to view the community as the focus of practice. This should be the domain of community health nursing.

  • Appendix: Community Assessment Tool

    Economic Subsystem
    Employment Distribution
    Number in CommunityPercentage of Population
    Employed persons________________________________
    Wholesale and retail________________________________
    Local government________________________________
    Federal government________________________________
    Unemployed persons________________________________
    Leading Industries

    Name _________________________ Address _________________________

    Number of employees ___________ Manager _________________________

    Family Income

    Governmental Budget
    Community Total in DollarsPercentage of Total
    Educational Subsystem
    Number of Educational Facilities
    Junior high_____________________________________________
    Senior high_____________________________________________
    Junior college_____________________________________________
    Special schools_____________________________________________
    Health Coverage

    Education Level of Population
    Less than 5 years_________________________________
    High school graduate_________________________________
    Some college_________________________________
    College graduate_________________________________
    Median school completed_________________________________
    Health Manpower Facilities
    NumberNumber Graduated Yearly
    Medical schools____________________________________
    Nursing schools____________________________________
    Dental schools____________________________________
    Physical therapy____________________________________
    Social workers____________________________________
    Communications Subsystem
    Radio Stations
    NameAddressAudiences (number, kindyoung/old, black/white, social class)
    Television Stations
    Key Community Leaders/Decision Makers Influencing Subsystem

    If inadequate, list media as follows with deficits.


    If poor, list media below with deficits.


    Is there a speakers bureau for health subjects?


    List community organizations that have active health programs for the public.

    Health Materials in Schools

    Is health integrated into the school curriculum at all grades?


    If no, discuss deficits.__________________________________________



    Discuss areas of health covered by grade ___________________________



    Is the information adequately covered?

    Political Subsystem
    Political Parties and Leadership
    Major party ____________________________________________________
    Key leaders ____________________________________________________
    Minor party ____________________________________________________
    Key leaders ____________________________________________________
    Major Issues over Last 5 Years that Influence Health
    YesNoParty FavoringImplemented
    Health facilities______________________________________________
    Water, sewage______________________________________________
    Recreation Subsystem
    Number and Location
    Total NumberPublicPrivate
    Leadership Available During Recreation
    AreaType of Leadership
    Hazardous Situations


    Religious Subsystem
    Religious Distribution
    Community Total NumberPercentage of Total
    Key Leaders in Religion (List)
    NamesPhone Number or Address
    Transportation Subsystem
    Routes and Services

    Describe major transportation routes.______________________________________


    Services available on these routes (buses, trains)______________________________

    Future Plans



    Transportation and health services_________________________________________


    Are transportation routes adequate for population getting to health facilities?


    If no, discuss specific deficits. ___________________________________________


    Welfare Subsystem

    List agencies, location, area served, and service.




    Are these services adequate to meet population needs?


    If inadequate, discuss agency and inadequacies.




    Population Subsystem
    Population Characteristics

    Population at last census_________________________________________________

    Population density______________________________________________________

    Population changes over 10-year period_____________________________________

    Age distribution _______________________________________________________


    Sex and Race Distribution

    Vital Statistics
    CategoryCurrent No./Rate10 Years Ago No./RateNo./Rate
    Live birth__________________________________________
    Neonatal death__________________________________________
    Infant death__________________________________________
    Maternal death__________________________________________
    General death__________________________________________
    Social Problems
    ProblemNumberPercentage of Total
    Illegitimate births__________________________________________
    Venereal diseases__________________________________________
    Narcotic users__________________________________________
    Health problems__________________________________________
    Communicable Disease Incidence
    DiseaseCurrent Year5 Years Ago
    Infectious hepatitis__________________________________________
    Immunization Level for Acute Communicable Disease

    Leading Causes of Death

    Health Subsystem

    Health Personnel
    CategoryBudgeted PositionsPercentage Unfilled
    Social workers________________________________________
    Physical therapists________________________________________

    Services Provided

    Total number of clients seen in home______________________________________

    Percentage of these for home care_________________________________________

    Types of Services in Home
    CategoryNumber of CasesNumber of VisitsPercentage of Total
    Heart disease_____________________________________________
    Venereal disease_____________________________________________
    Other diseases_____________________________________________
    School age_____________________________________________
    Clinic Services
    TypeMonthly AttendancePurpose
    School Services
    TypeMonthly Visits to NursePurpose

    Exchanges With Nonhuman Environment

    Housing Condition

    Housing Complaints (Numbers)
    ProblemCurrentYear 5 Years Ago
    Air Contaminants that are Source of Complaints
    SmokeYes ___________No ____________Specify:_________
    GasesYes ___________No ____________Specify:_________
    OdorsYes ___________No ____________Specify:_________
    VaporsYes ___________No ____________Specify:_________
    PollensYes ___________No ____________Specify:_________
    OthersYes ___________No ____________Specify:_________
    Sources of Air Contaminants
    VehiclesYes _________No_________
    HomesYes _________No _________
    IncineratorsYes __________No _________
    Other (Specify)Yes_________No_________
    Water Supply
    SourceNumberPercentagePercentage With Adequate Treatment
    Sewage Disposal
    SourceNumberPercentagePercentage With Adequate Treatment
    Solid Waste Disposal
    Vector Control Program
    Other (Specify)______________________________________

    Food and milk

    Food sourceAdequateInadequate

    Exchanges Beyond the Community

    Health Threats

    If present, describe.____________________________________________________


    Programs to reduce threat _______________________________________________


    Health Resources

    List available sources.





    SOURCE: Community Health Nursing: Theory and Practice by Carl O. Helvie. Copyright 1991, by Springer Publishing Co. Used by permission.

    About the Author

    Carl O. Helvie is Professor of Nursing at Old Dominion University in Norfolk, Virginia, where he teaches community health nursing at the undergraduate and graduate levels. He also teaches an elective course on the homeless that is televised throughout Virginia. He began his nursing career more than 45 years ago in upstate New York at St. Lawrence State Hospital, School of Nursing. Later, he received a BS degree in nursing from New York University and an MS and post-master's degree in public health nursing from the University of California, San Francisco. After teaching at the University of California, he returned to school and obtained an MPH and DrPH with a major in mental health from Johns Hopkins University, School of Public Health. He has published numerous articles in nursing and health journals and has presented research papers nationally and internationally. Previous publications include two undergraduate community health nursing texts and a review book. He is currently under contract to coauthor a book on the homeless with his colleague Wilfried Kunstmann in Germany. He is also an associate editor for Alternative Health Practitioner and a manuscript reviewer for Public Health Nursing. He has been very active in professional organizations and has held numerous positions at local and state levels of the Virginia Nurses Association. He was also vice president of the Virginia League for Nursing and is currently Chair of Awards for Public Health Nursing of the American Public Health Association (APHA) and co-caucus representative to APHA from the Homeless Caucus.

    About the Contributors

    Jacqueline Agnew, PhD, is Associate Professor of Environmental Health Sciences and Director of the Occupational Health Nursing Program at the Johns Hopkins School of Hygiene and Public Health in Baltimore, Maryland. She is Deputy Director of the Johns Hopkins Educational Resource Center, funded by the National Institute for Occupational Safety and Health (NIOSH) to prepare occupational health professionals. Her research focuses on occupational stress, ergonomic factors in the workplace, and the interactive effects of work exposures and age on the health of older workers. She is a member of the NIOSH Board of Scientific Counselors and also serves on the Workers’ Family Protection Task Force.

    Janie Canty-Mitchell earned a diploma in nursing from Lincoln Hospital School of Nursing, Durham, North Carolina, a BSN degree from Florida State University, and MSN and PhD degrees from the University of Miami. She was awarded a 2-year postdoctoral research fellowship at Indiana University School of Nursing in 1994. Her work in community health nursing spans 17 years, including work as a public health nurse, supervisor of public health nursing, assistant community health nursing director, and community health nursing university professor. Her nursing research has centered on stress, caring, and hope in inner-city adolescents. She was awarded a grant from the Agency for Health Care Policy and Research to conduct her dissertation research. She is a member of Sigma Theta Tau Nursing Sorority, the American Public Health Association, and the Midwest Nursing Research Society. She has numerous experiences working with youth and voluntary agencies in inner cities.

    Barrie Carveth, RN, MSN, FNP, is former Instructor of Nursing at the University of Virginia and is case manager, Westhaven Nursing Clinic, Charlottesville, Virginia.

    Jeri W. Dunkin received her PhD in nursing at the University of Texas, Austin, in 1988. She spent several years with the University of North Dakota, where she was director of the graduate Rural Health Nursing Specialization in the College of Nursing. At the same time, she served as chair of the Nursing Research Division at the University of North Dakota Rural Health Research Center. She is currently the Coordinator for the Center of Nursing Research, Medical College of Georgia School Nursing.

    Christine Elnitsky is a doctoral student in urban health services at Old Dominion University in Norfolk, Virginia. She holds an MSN (community health nurse specialist) and a BSN from Old Dominion University. Her nursing education began with a vocational nursing program at Harris Hospital School of Nursing in Fort Worth, Texas. Her 20 years of nursing experience in community health and hospital nursing includes clinical, administration, teaching, and research activities. She participates in research and is published in the areas of health care delivery systems, outcomes, chronic illness, health policy, and older adults.

    Sandra L. Ferketich, PhD, RN, FAAN, currently Professor at the University of Arizona College of Nursing, received a BSN from the University of New Mexico, an MS from Indiana University, and a PhD from the University of Arizona. She recently completed a year of analyzing health policy as a Fellow with the Institute of Medicine. Her publications and research have been on research methods, instrumentation, maternal role attainment, family functioning, childbearing, and nursing interventions with homeless persons on preventive therapy for tuberculosis and rural communities in partnership with community health nurses and lay health workers.

    Sharon Garrett earned a BSN degree from the University of Wisconsin—Madison and is currently an MSN candidate at Indiana University School of Nursing—Indianapolis. She has been involved in diverse communities in a professional and volunteer capacity for more than 25 years. Her professional experience includes work as a staff nurse and head nurse at a major hospital, home health nurse, health services coordinator for a Head Start program, an instructor for a continuing education program, and a research and teaching assistant. Her accomplishments include developing a health curriculum for a Head Start program, coordinating a community bloodmobile, and cochairing a community television telethon that focused on alcohol and drug abuse. She received a good citizen award from a Wisconsin city for her community contributions. She has worked extensively with young adolescents and parents.

    Laurel S. Garzon, PhD, is Associate Professor in the Advanced Perinatal/Neonatal Graduate Program at Old Dominion University School of Nursing in Norfolk, Virginia. She has participated in community empowerment projects involving women's health and adolescent parents. She is a graduate of the University of North Carolina at Chapel Hill, the University of Virginia, and the Catholic University of America.

    Doris Glick, RN, PhD, is Associate Professor of Nursing and Director, Primary Care Nursing Center, the University of Virginia.

    Bethany Hall-Long, PhD, RNC, is Assistant Professor in the College of Nursing at the University of Delaware. Her areas of undergraduate and graduate didactic and clinical teaching are community health nursing, health policy, and nursing theory. She has worked as a nurse educator, manager, recruiter, and clinician in a variety of acute care and public health settings. Her areas of scholarship and clinical expertise arc community health nursing, community development, health policy, and multicultural women's health. She is a member of numerous professional and civic organizations.

    Clare Houseman, PhD, RN, CS, is the Health Services Concentration Area Director for the PhD in Urban Services Program at Old Dominion University. She is also a Certified Clinical Nurse Specialist in Adult Psychiatric and Mental Health Nursing and maintains a part-time psychotherapy practice. She was a member of the HB1024 task force and at one point chaired the group. She also served as a consultant to the Virginia State Board of Nursing regarding the credentialing of clinical nurse specialists in the state. She is editor and author of a text titled Psychiatric Certification Review Guide for the Generalist and Clinical Specialist in Adult, Child, and Adolescent Mental Health Nursing (1994).

    Kathleen M. May, DNSc, RN, currently Associate Professor at the University of Arizona College of Nursing, received a BSN from Saint John College of Cleveland, an MS from the University of Colorado, and a DNSc from the University of California, San Francisco. She has practiced nursing in hospital settings, home health, and public health. Her publications and research have been on community health nursing and nursing interventions with homeless persons on preventive therapy for tuberculosis, older rural elderly receiving health peer teaching on health promotion, and rural communities in partnership with community health nurses and lay health workers.

    Sonda Riedesel Oppewal, PhD, is Associate Professor in the College of Nursing at East Tennessee State University in Johnson City, Tennessee. She teaches community health nursing and is Project Director of a federally funded school-based health center located in a rural high school. Her current research interests include adolescent health, rural health, and the diffusion of innovations.

    Anna L. Pratt, RN, MSN, is currently Nursing Supervisor with the Virginia Beach Department of Public Health. A graduate of Hartwick College (1970, BSN) and the University of Rhode Island (1978, MSNEd), she has practiced community health nursing for 26 years. Her experience includes traditional home-based nursing care as well as various services provided in a public health clinic setting. Currently, she supervises a self-directed team of public health nurses and health educators whose focus is to provide health promotion and risk reduction education to residents in a wide variety of community settings. She also has adjunct faculty status with Old Dominion University's School of Nursing and is an active volunteer with the American Cancer Society in Virginia Beach, serving on its executive board of directors.

    Angela B. Savage, RN, BSN, is currently Nurse Manager with the Virginia Beach Department of Public Health. A graduate of the University of Virginia (1969, BSN), she has 27 years of experience in community health nursing. She has provided home-based nursing care as well as maternal and child health and communicable disease services in public health clinics. Her career in middle- and upper-level management in public health spans more than 20 years. She is on the board of directors of a private, community-based clinic that provides free primary care to indigent residents of the city.

    Sherry Weinstein, MN, CPNP, is former Instructor of Nursing at the University of Virginia and school nurse practitioner, Greene County (Virginia) School Health Cottage.

    Cynthia Westley, RN, MSN, ANP, is Instructor of Nursing at the University of Virginia and care manager, Crescent Hall Nursing Clinic, Charlottesville, Virgina.

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