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Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Community Health Nursing and the AIDS Pandemic: Case Report of One Community's Response Paul L. Kuehnert Published online: 07 Jun 2010.
To cite this article: Paul L. Kuehnert (1991) Community Health Nursing and the AIDS Pandemic: Case Report of One Community's Response, Journal of Community Health Nursing, 8:3, 137-146, DOI: 10.1207/s15327655jchn0803_3 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0803_3
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNAL OF COMMUNITY HEALTH NURSING, 1991,8(3), 137-146 Copyright O 1991, Lawrence Erlbaum Associates, Inc.
Community Health Nursing and the AIDS Pandemic: Case Report of One Community's Response Paul L. Kuehnert, RN, BSN Downloaded by [York University Libraries] at 09:00 03 March 2015
University of Illinois at Chicago
The World Health Organization (WHO) currently projects that there may be a cumulative total of 30 million cases of Acquired Immune Deficiency Syndrome (AIDS) worldwide by the year 2000 ("WHO Predicts," 1991). Community health nurses (CHNs), particularly those employed by local and state health departments, have a major role to play in the worldwide public health effort being mounted in response to the AIDS pandemic. CHN roles may include: direct caregiver, advocate, case manager, health educator, program planner, program coordinator, and policy advocate. How CHNs contribute to the effort against AIDS in various CHN roles is illustrated through a case report of a Midwestern U.S. suburban community's response to AIDS. The community's response was fostered and an AIDS program developed and implemented by CHNs employed by the community's health department. In addition to enabling this community to respond to AIDS in a humane and caring manner, the CHN initiatives have resulted in positive community feelings about the health department, and enhanced the image of CHNs as innovators and facilitators of change.
AIDS has been identified as the number one public health problem facing the nation (Bowen, 1988) and the world (Mann, 1990; Samuels, Mann, & Koop, 1988). The impact of AIDS is felt in all sectors of society in terms of lost lives, lost years of productive work, emotional distress, fears, stigma, and discrimination related to those affected. As the AIDS pandemic enters its second decade, the causative viral infection with Human Immunodeficiency Virus (HIV) continues to spread throughout the globe and the impact of the pandemic will not be fully appreciated until early in the next century (Mann, 1990). The future course of the pandemic will be largely shaped by the nature of our response to it (Mann, 1990). In no sector is the challenge of responding to AIDS more keenly felt than in the state and local health departments charged with the responsibility of protecting and preserving the public's health. Since the beginning of the AIDS epidemic, CHNs employed by health departments have blended AIDSspecific content into existing community health nursing programs and created new Requests for reprints should be sent to Paul L. Kuehnert, RN, BSN, College of Nursing, Department of Public Health Nursing, University of Illinois at Chicago, M/C 802, 845 South Damen, Chicago, IL 60612.
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AIDS-specific programs (Brent, 1987; Flaskerud, 1988a, 1988b; Goff & McDonough, 1986; Jones, 1988; Lyne & Waller, 1990; Martin, 1986a, 1986b; Santopoalo, 1989; Sheehan, 1986; Thobaben, 1989). The distinguishing characteristic of community health nursing practice is the identification of the community as its client (American Nurses' Association [ANA], 1986; Anderson & McFarlane, 1988; Hanchett, 1988, 1990; Higgs & Gustafson, 1985; Rodgers, 1984; Storfjell & Cruise, 1984; Walgren, 1984; Watson, 1984; White, 1982). This unique client is understood as a geopolitical entity in which people reside; combine in families, social networks, and other groups; and interact in ways to enhance the common good (Beauchamp, 1985; Bellah, Madsen, Sullivan, Swidler, & Tipton, 1985; Schultz, 1987). Community health nursing interventions focus on (a) protecting and (b) promoting the health of the entire community (ANA, 1980, 1986; American Public Health Association [APHA], 1980). This scope of practice is operationalized by applying the nursing process to the community as a whole, to community aggregates defined by social characteristics and or health-related risks, and to families and individuals, as illustrated in Figure 1. This specialty area of nursing practice is carried out by CHNs practicing in both
Advocacy
Services
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Services
Focus
Diagnosis Assessment
Advocacy
Assessment
Intervention
Community Diagnosis
Evaluation
Focus Assessment
t
The Public Health Nursing Agency
Community as Client FIGURE 1 Community as client model for community health nursing.
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generalist and specialist roles. These roles are determined in part by the agency by which CHNs are employed and by the CHN's educational preparation. The focus of the CHN role may be either primarily on individuals and families in a community setting (generalist role) or on groups, organizations, social networks, and the community as a whole (specialist role) as the unit and target of nursing services and advocacy efforts (ANA, 1986). In the local health department, examples of generalist roles include direct caregiver in the clinic or as home visitor, family/individual advocate and case manager, communicable disease investigator, and health educator. Specialist roles include: program planner, program coordinator, program evaluator, nursing supervisor or director, and policy advocate (Anderson, 1983; Storfjell & Cruise, 1984). Taken as a whole, community health nursing provided by local health departments includes both health-related services and advocacy to, for, and with community members, groups, organizations, and population aggregates. Examples include: screening, case finding, case management, health education, needs/resources assessments, establishing or participating in social/health service networks, healthcare system advocacy, and ongoing program evaluations (Anderson, 1983; Archer & Fleshman, 1975; Kenyon et al., 1990; Storfjell & Cruise, 1980). The dynamic interaction of the community health nursing agency and the community in these myriad ways results, over time, in health preservation and health improvements for the entire community.
CASE STUDY THE RESPONSE TO AIDS IN A MIDWESTERN COMMUNITY The response to the AIDS epidemic in this case study community, the "Village," has been developed and implemented entirely by CHNs applying the nursing process. Both CHN generalist and specialist role functions are illustrated in the case study. A particular CHN role developed by this local health department, that of AIDS Program Coordinator, has combined aspects of the CHN generalist's role in providing direct client services with the CHN specialist's role in advocating, planning, developing, and implementing programs targeted to specific aggregates. In addition to fostering a community-based response to AIDS that has been humane and caring, the CHN initiatives taken have resulted in positive feelings about the health department in the community and have enhanced the image of CHNs as innovators and facilitators of change. The Village is a suburban community that directly borders a large Midwestern U.S. city. It is a community of 4%sq mi containing some 53,648 residents. The most recent census data indicated that the median age of residents was 31.4 years, but nearly one fifth of the residents are over 60 years of age. Seventy-four percent of the community residents were White, 18% were Black, 4% were Hispanic, and the remainder were of other races (U.S. Department of Commerce, 1988). The Village has a complete array of municipal services for its residents, including
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a local health department certified by the state in which the Village is located. Comprehensive health department services-environmental, nursing, and vital recordsare provided to Village residents by a staff of nearly 20, 6 of whom are CHNs. Since the late 1960s, the Village has been viewed as a regional suburban leader in commitment to fair housing practices as well as a more general commitment to racial and cultural diversity. One long-standing group within the diverse cultural mix of the Village has been homosexual men and women. A Village resident was first reported to the health department as diagnosed with AIDS in 1983. The epidemic's pattern and curve in the Village closely resembled that of the epidemic in the larger neighboring city with slow increases of numbers of reported cases through 1986 and more rapid increases from 1987 onward. By January 1, 1991, the Village had a cumulative incidence rate for AIDS of 70.8/100,000. This rate was lower than the neighboring city's rate, 122.2/100,000, ~ ( 1N , = 2, 837, 374) = 11.9, p < .001, but was more than four times greater than the rate of the sub, = 2, 321, 341) = 96.1, p < .001, and nearly urban county, 16.3/100,000, ~ ( 1 NZ twice that of the state, 42.9/100,000, ~ ( 1 NZ , = 11, 000, 000 = 9.1, p < .005, in which the Village is located (All data reported for the period of January 1, 1981 to December 3 1, 1990). Like the national epidemic, AIDS in the Village has been reported in the largest numbers among 30-to-39-year-old men (42%) whose most common reported transmission risk factor was homo- or bisexual sexual intercourse (84%). Ninety-seven percent of reported cases were men and cases have been distributed among racial groupings proportionally to the racial makeup of the Village. (All data reported for the period of January 1, 1981 to December 3 1, 1990.) Community health nursing activities during the period of 1983 through 1985 consisted of the health department's nursing supervisor monitoring the developing national, regional, and local developments in the AIDS epidemic. By 1985, the CHN staff nurse who provided followup and treatment interventions for residents with sexually transmitted diseases was assigned the responsibility for performing epidemiological investigations related to AIDS. As part of these epidemiological investigations, she assessed these resident's needs and provided health education, counseling, and referrals. Community Needs
By late 1987, it was recognized within the Village health department and discussed with the Board of Health that: 1. The Village had a higher than expected incidence of AIDS in comparison to neighboring suburbs. 2. There was a high level of denial and/or ignorance within the community regarding AIDS and its potential impact locally in all areas of community life and resources. 3. There was an increasing demand on the health department for formal AIDS-
Community Health Nursing and AIDS
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6.
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related health education and consultation from local public and private agencies. There was a need for directed health education and outreach to high-risk aggregates in the community, especially the homosexual community. There was an apparent underreporting and/or missing of AIDS cases by local health-care providers. There was a need to respond to state health department mandates for AIDSrelated prevention and education services. There was a need for concentrated attention to the rapidly changing developments in the area of AIDS in all its aspects in order to maintain staff knowledge and expertise.
These identified needs were the basis for health department planning. Planning
Needs identification led to a plan to designate a staff nurse as AIDS Coordinator with specialized training and responsibilities. The other CHN staff would continue to receive AIDS-related continuing education and integrate AIDS prevention into all aspects of their efforts. AIDS Coordinator duties were initially expected to take 50% of the designated nurse's time; this became a full-time position in August 1989.
The designated AIDS Coordinator assumed these duties in January 1988. His goals were (a) to provide individual client services for AIDS-diagnosed and/or HIVinfected residents; @) to increase general community awareness of AIDS and support for a nondiscriminatory, caring response; (c) to increase AIDS/HIV prevention and risk-reduction knowledge and practices among high-risk aggregates of homosexual men and youths; and (d) to address current and potential AIDS-related service gaps. Nursing Interventions
Nursing interventions have been carried out by the AIDS Coordinator with individuals, social networks, families, and the community as a whole. A number of examples of these are given to illustrate the dimensions of this role. Some interventions with community-wide impact are illustrated in a time line of AIDS in the Village in Figure 2. Client services for individual clients have included both in-home community health nursing visits and an office setting anonymous counseling and HIV-antibody testing program. Client in-home visiting services are initiated by the AIDS Coordinator if, during the communicable disease follow-up visit mandated by the state health department for reported cases of AIDS, the client expresses a desire to have ongoing community health nursing services. In-home services are based on comprehensive community health nursing assessment of the client and his or her needs and
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AlDS In The Village: Epidemic-Related Events 1983-1990 December 1983
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FIGURE 2 Time line of AIDS-related events in the Village, 1983 through 1990.
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usually include: physical assessment, counseling and emotional support, AIDSspecific health teaching, partner and/or family counseling and education, and social service/health systems advocacy. The other individual client-oriented services are delivered in an office setting. These services consist of comprehensive HIV-risk assessment and risk-reduction education and counseling, offered on a one-to-one basis to individuals who have selfidentified as being at risk for HIV, or have been referred by health or social service providers. Those who desire it receive anonymous HIV-antibody testing and individualized posttest counseling. Aggregate focused services consist of health education directed to two specific aggregates: homosexual men and young people. Educational services are delivered directly to members of the aggregates and to health, educational, and social service providers that serve aggregate members to better inform these providers regarding HIV-risk assessment and HIV-risk reduction and prevention. Examples of these activities included: inservice presentations to hospital and health maintenance organization (HMO) nursing and medical staffs, inservices for school nurses, in-classroom teaching for Grades 5 through 8, and developing a male homosexual-oriented educational/support group with the local mental health center. Community health nursing interventions with a community-wide impact have included generalized health education efforts, service development, and local policy advocacy activities. Examples of generalized community health education activities include: local newspaper articles regarding AIDS and AIDS services, cable TV interview and feature shows on the local cable access channel, and the organization of a community-wide AIDS awareness months in June 1989 and October 1990. In mid-1988, the Department's community health nursing supervisor and AIDS Coordinator initiated a series of meetings that led to the formation of the Village AIDS Network. This is a group of local social and health service providers brought together to examine the extent of service needs and gaps for residents with HIV infection and AIDS. During the initial 3 months of the Network, the AIDS Coordinator and another Network member conducted a Village AIDS needs assessment. A number of present and potential service gaps were identified including the absence of any accessible, community-based AIDS support and advocacy agencies that would provide specialized services such as support groups, volunteer chore services, companions, transportation, and housing or residential services to community members affected by AIDS and HIV. One community service gap, addressed soon after the needs assessment was completed, was the lack of a continuum of residential services for persons with AIDS, including home-based care, hospice, and nursing home care. As an advocate for the service needs of present and future clients, the AIDS Coordinator worked with a diverse group of local citizens that was in the process of forming a not-for-profit organization for persons with AIDS. This group incorporated and began delivering a full array of social services, including residential services, to community members affected by AIDS in 1989. By December 31, 1990 nearly 200 residents of the Village and nearby communities had received services from this organization.
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Policy advocacy efforts of the AIDS Coordinator have been supported by the nursing supervisor and the health director. The health director had been involved in local policy efforts since the epidemic began by advising the local school districts regarding appropriate policy governing AIDS-affected students and staff. Based on the AIDS Coordinator's review of current research and recommendations, AIDS/ HIV-related personnel policies were developed by the health and personnel directors and recommended to the Village Board of Trustees. The proposed policy protected government employees from HIV-related discrimination if they were to become infected. It also provided for mandatory attendance in AIDS/HIV prevention education sessions for all Village employees. These public policy efforts culminated in October 1988 when the Board of Trustees approved the personnel policy and the Village became the first municipality in the state to adopt AIDS/HIV-related personnel policies for its government employees. As the Village enters the second decade of AIDS, a formal means for the updating of Village AIDS-related service needs on an ongoing basis as well as a means for local AIDS-related policy advocacy was created in September 1989. The six local taxing bodies (Village Board, Park Board, two School Districts, Library Board, and Township Board) established an intergovernmental AIDS Task Force. Based on Task Force recommendations made in late 1990, a formal standing AIDS committee of the Village's Board of Health has been established to monitor the course of the AIDS epidemic in the Village and advocate for needed services and local policy. CONCLUSION A community case report has been used to demonstrate program development in response to the AIDS epidemic in a Midwestern U.S. community. These efforts were developed and implemented by CHNs employed by a local health department. The dynamic interplay of community health nursing activities with individuals, families, groups, and aggregates, as guided by the nursing process, has been reported and used to illustrate CHN roles in a local health department. In this community, CHN initiatives have helped to shape the response of the community to the local manifestation of the evolving AIDS pandemic. AIDS presents a profound challenge to the entire world community in all the realms of human relations and human activity. As CHNs, we are challenged to respond to AIDS from the depths of our tradition to nurse the community as a whole (Freeman, 1981). Our unique community focus enhances the worldwide effort against AIDS and can enable a humane and caring response. REFERENCES American Nurses' Association. (1980). A conceptual model of community health nursing. Kansas City: Author. American Nurses' Association. (1986). Standards of community health nursingpractice. Kansas City: Author.
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American Public Health Association, Public Health Nursing Section. (1980). The definition and role of public health nursing in the delivery of health care. Washington, DC: Author. Anderson, E. T. (1983). Community focus in public health nursing: Whose responsibility? Nursing Outlook, 31(1), 44-48. Anderson, E. T., & McFarlane, J. M. (1988). Community as client: Application of the nursing process. Philadelphia: Lippincott . Archer, S. E., & Fleshman, R. P. (1975). Community health nursing: A typology of practice. Nursing Outlook, 23(6), 358-364. Beauchamp, D. E. (1985, December). Community: The neglected tradition of public health. Hastings Center Report, pp. 28-36. Bellah, R. N., Madsen, R., Sullivan, W. M., Swidler, A., & Tipton, S. M. (1985). Habits of the heart. New York: Harper & Row. Bowen, 0. R. (1988). In pursuit of the number one public health problem. Public Health Reports, 103(3), 21 1-212. Brent, N. J. (1987). Acquired immune deficiency syndrome and the home health care nurse: Selected legal concerns. Home Health Nurse, 5(4), 6-8. Flaskerud, J. H. (1988a). Community health nurses' AIDS information needs. Journal of Community Health Nursing, 5, 149-1 57. Flaskerud, J. H. (1988b). Prevention of AIDS in Blacks and Hispanics: Nursing implications. Journal of Community Health Nursing, 5, 49-58. Freeman, R. (1981). Community health nursing practice (2nd ed.). Philadelphia: Saunders. Goff, W,, & McDonough, P. (1986). A community health approach to AIDS: Caring for the patient and educating the public. Journal of Community Health Nursing, 3, 191-200. Hanchett, E. S. (1988). Nursing frameworks and community as client. Norwalk, C T Appleton & Lange. Hanchett, E. S. (1990). Applications of systems theory in community health nursing. In S. J. Wold (Ed.), Community health nursing. Issues and topics u p . 1-11). Norwalk, CT: Appleton & Lange. Higgs, Z. R., & Gustafson, D. D. (1985). Community as client: Assessment and diagnosis. Philadelphia: Davis. Jones, L. H. (1988). AIDS, education, and the community health nurse. Journal of Community Health Nursing, 5, 159- 165. Kenyon, V., Smith, E., Hefty, L. V., Bell, M. L., McNeil, J., & Martaus, T. (1990). Clinical competencies for community health nursing. Public Health Nursing, 7(1), 33-39. Lyne, B. A., & Waller, P. R. (1990). The Denver nursing project in human caring: A model for AIDS nursing care and professional education. Family and Community Health, 13(2), 78-84. Mann, J. (1990, June). Global AIDS: Revolution, paradigm, and solidarity. Paper presented at the 6th International Conference on AIDS, San Francisco. Martin, J. P. (1986a). The AIDS home care and hospice program. A multidisciplinary approach to caring for persons with AIDS. American Journal of Hospice Care, 3(2), 35-37. Martin, J. P. (1986b, June). Challenges in caring for the person with AIDS at home. Caring, pp. 12-20. Rodgers, S. S. (1984). Community as client-A multivariate model for analysis of community and aggregate health risk. In B. W. Spradley (Ed.), Readings in community health nursing (3rd ed., pp. 146-156). Boston: Little, Brown. Samuels, M. E., Mann, J., & Koop, C. E. (1988). Containing the spread of HIV infection: A world health priority. Public Health Reports, 103(3), 221-223. Santopoalo, T. (1989). Mandatory testing for the AIDS antibody. Journal of Community Health Nursing, 6, 23 1-244. Schultz, P. R. (1987). When client means more than one: Extending the foundational concept of person. Advances in Nursing Science, 10(1), 71-86. Sheehan, C. J. (1986, June). Hospice, AIDS, and the community. Caring, pp. 35-37. Storfjell, J. L., & Cruise, P. A. (1984). A model of community-focused nursing. Public Health Nursing, 1(2), 85-96. Thobaben, M. (1989). Coping with fears of caring for HIV-positive patients. Home Health Nurse, 7(3), 49-50. U.S. Department of Commerce Bureau of Census. (1988). City and county data book. Washington, DC: U .S. Government Printing Office.
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Walgren, D. J. (1984). Conceptual framework: A basis for community health nursing practice. In J. A. Sullivan (Ed.), Directions in community health nursing (pp. 45-68). Boston: Blackwell. Watson, N. M. (1984). Community as client. In J. A. Sullivan Pd.), Directions in community health nursing (pp. 69-90). Boston: Blackwell. White, M. S. (1982). Construct for public health nursing. Nursing Outlook, 30, 527-530. WHO predicts up to 30 million world AIDS cases by year 2000. (1991, January). The Nation's Health,
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Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Community Health Nursing and the AIDS Pandemic: Case Report of One Community's Response Paul L. Kuehnert Published online: 07 Jun 2010.
To cite this article: Paul L. Kuehnert (1991) Community Health Nursing and the AIDS Pandemic: Case Report of One Community's Response, Journal of Community Health Nursing, 8:3, 137-146, DOI: 10.1207/s15327655jchn0803_3 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0803_3
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNAL OF COMMUNITY HEALTH NURSING, 1991,8(3), 137-146 Copyright O 1991, Lawrence Erlbaum Associates, Inc.
Community Health Nursing and the AIDS Pandemic: Case Report of One Community's Response Paul L. Kuehnert, RN, BSN Downloaded by [York University Libraries] at 09:00 03 March 2015
University of Illinois at Chicago
The World Health Organization (WHO) currently projects that there may be a cumulative total of 30 million cases of Acquired Immune Deficiency Syndrome (AIDS) worldwide by the year 2000 ("WHO Predicts," 1991). Community health nurses (CHNs), particularly those employed by local and state health departments, have a major role to play in the worldwide public health effort being mounted in response to the AIDS pandemic. CHN roles may include: direct caregiver, advocate, case manager, health educator, program planner, program coordinator, and policy advocate. How CHNs contribute to the effort against AIDS in various CHN roles is illustrated through a case report of a Midwestern U.S. suburban community's response to AIDS. The community's response was fostered and an AIDS program developed and implemented by CHNs employed by the community's health department. In addition to enabling this community to respond to AIDS in a humane and caring manner, the CHN initiatives have resulted in positive community feelings about the health department, and enhanced the image of CHNs as innovators and facilitators of change.
AIDS has been identified as the number one public health problem facing the nation (Bowen, 1988) and the world (Mann, 1990; Samuels, Mann, & Koop, 1988). The impact of AIDS is felt in all sectors of society in terms of lost lives, lost years of productive work, emotional distress, fears, stigma, and discrimination related to those affected. As the AIDS pandemic enters its second decade, the causative viral infection with Human Immunodeficiency Virus (HIV) continues to spread throughout the globe and the impact of the pandemic will not be fully appreciated until early in the next century (Mann, 1990). The future course of the pandemic will be largely shaped by the nature of our response to it (Mann, 1990). In no sector is the challenge of responding to AIDS more keenly felt than in the state and local health departments charged with the responsibility of protecting and preserving the public's health. Since the beginning of the AIDS epidemic, CHNs employed by health departments have blended AIDSspecific content into existing community health nursing programs and created new Requests for reprints should be sent to Paul L. Kuehnert, RN, BSN, College of Nursing, Department of Public Health Nursing, University of Illinois at Chicago, M/C 802, 845 South Damen, Chicago, IL 60612.
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AIDS-specific programs (Brent, 1987; Flaskerud, 1988a, 1988b; Goff & McDonough, 1986; Jones, 1988; Lyne & Waller, 1990; Martin, 1986a, 1986b; Santopoalo, 1989; Sheehan, 1986; Thobaben, 1989). The distinguishing characteristic of community health nursing practice is the identification of the community as its client (American Nurses' Association [ANA], 1986; Anderson & McFarlane, 1988; Hanchett, 1988, 1990; Higgs & Gustafson, 1985; Rodgers, 1984; Storfjell & Cruise, 1984; Walgren, 1984; Watson, 1984; White, 1982). This unique client is understood as a geopolitical entity in which people reside; combine in families, social networks, and other groups; and interact in ways to enhance the common good (Beauchamp, 1985; Bellah, Madsen, Sullivan, Swidler, & Tipton, 1985; Schultz, 1987). Community health nursing interventions focus on (a) protecting and (b) promoting the health of the entire community (ANA, 1980, 1986; American Public Health Association [APHA], 1980). This scope of practice is operationalized by applying the nursing process to the community as a whole, to community aggregates defined by social characteristics and or health-related risks, and to families and individuals, as illustrated in Figure 1. This specialty area of nursing practice is carried out by CHNs practicing in both
Advocacy
Services
-----------------
Services
Focus
Diagnosis Assessment
Advocacy
Assessment
Intervention
Community Diagnosis
Evaluation
Focus Assessment
t
The Public Health Nursing Agency
Community as Client FIGURE 1 Community as client model for community health nursing.
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generalist and specialist roles. These roles are determined in part by the agency by which CHNs are employed and by the CHN's educational preparation. The focus of the CHN role may be either primarily on individuals and families in a community setting (generalist role) or on groups, organizations, social networks, and the community as a whole (specialist role) as the unit and target of nursing services and advocacy efforts (ANA, 1986). In the local health department, examples of generalist roles include direct caregiver in the clinic or as home visitor, family/individual advocate and case manager, communicable disease investigator, and health educator. Specialist roles include: program planner, program coordinator, program evaluator, nursing supervisor or director, and policy advocate (Anderson, 1983; Storfjell & Cruise, 1984). Taken as a whole, community health nursing provided by local health departments includes both health-related services and advocacy to, for, and with community members, groups, organizations, and population aggregates. Examples include: screening, case finding, case management, health education, needs/resources assessments, establishing or participating in social/health service networks, healthcare system advocacy, and ongoing program evaluations (Anderson, 1983; Archer & Fleshman, 1975; Kenyon et al., 1990; Storfjell & Cruise, 1980). The dynamic interaction of the community health nursing agency and the community in these myriad ways results, over time, in health preservation and health improvements for the entire community.
CASE STUDY THE RESPONSE TO AIDS IN A MIDWESTERN COMMUNITY The response to the AIDS epidemic in this case study community, the "Village," has been developed and implemented entirely by CHNs applying the nursing process. Both CHN generalist and specialist role functions are illustrated in the case study. A particular CHN role developed by this local health department, that of AIDS Program Coordinator, has combined aspects of the CHN generalist's role in providing direct client services with the CHN specialist's role in advocating, planning, developing, and implementing programs targeted to specific aggregates. In addition to fostering a community-based response to AIDS that has been humane and caring, the CHN initiatives taken have resulted in positive feelings about the health department in the community and have enhanced the image of CHNs as innovators and facilitators of change. The Village is a suburban community that directly borders a large Midwestern U.S. city. It is a community of 4%sq mi containing some 53,648 residents. The most recent census data indicated that the median age of residents was 31.4 years, but nearly one fifth of the residents are over 60 years of age. Seventy-four percent of the community residents were White, 18% were Black, 4% were Hispanic, and the remainder were of other races (U.S. Department of Commerce, 1988). The Village has a complete array of municipal services for its residents, including
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a local health department certified by the state in which the Village is located. Comprehensive health department services-environmental, nursing, and vital recordsare provided to Village residents by a staff of nearly 20, 6 of whom are CHNs. Since the late 1960s, the Village has been viewed as a regional suburban leader in commitment to fair housing practices as well as a more general commitment to racial and cultural diversity. One long-standing group within the diverse cultural mix of the Village has been homosexual men and women. A Village resident was first reported to the health department as diagnosed with AIDS in 1983. The epidemic's pattern and curve in the Village closely resembled that of the epidemic in the larger neighboring city with slow increases of numbers of reported cases through 1986 and more rapid increases from 1987 onward. By January 1, 1991, the Village had a cumulative incidence rate for AIDS of 70.8/100,000. This rate was lower than the neighboring city's rate, 122.2/100,000, ~ ( 1N , = 2, 837, 374) = 11.9, p < .001, but was more than four times greater than the rate of the sub, = 2, 321, 341) = 96.1, p < .001, and nearly urban county, 16.3/100,000, ~ ( 1 NZ twice that of the state, 42.9/100,000, ~ ( 1 NZ , = 11, 000, 000 = 9.1, p < .005, in which the Village is located (All data reported for the period of January 1, 1981 to December 3 1, 1990). Like the national epidemic, AIDS in the Village has been reported in the largest numbers among 30-to-39-year-old men (42%) whose most common reported transmission risk factor was homo- or bisexual sexual intercourse (84%). Ninety-seven percent of reported cases were men and cases have been distributed among racial groupings proportionally to the racial makeup of the Village. (All data reported for the period of January 1, 1981 to December 3 1, 1990.) Community health nursing activities during the period of 1983 through 1985 consisted of the health department's nursing supervisor monitoring the developing national, regional, and local developments in the AIDS epidemic. By 1985, the CHN staff nurse who provided followup and treatment interventions for residents with sexually transmitted diseases was assigned the responsibility for performing epidemiological investigations related to AIDS. As part of these epidemiological investigations, she assessed these resident's needs and provided health education, counseling, and referrals. Community Needs
By late 1987, it was recognized within the Village health department and discussed with the Board of Health that: 1. The Village had a higher than expected incidence of AIDS in comparison to neighboring suburbs. 2. There was a high level of denial and/or ignorance within the community regarding AIDS and its potential impact locally in all areas of community life and resources. 3. There was an increasing demand on the health department for formal AIDS-
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related health education and consultation from local public and private agencies. There was a need for directed health education and outreach to high-risk aggregates in the community, especially the homosexual community. There was an apparent underreporting and/or missing of AIDS cases by local health-care providers. There was a need to respond to state health department mandates for AIDSrelated prevention and education services. There was a need for concentrated attention to the rapidly changing developments in the area of AIDS in all its aspects in order to maintain staff knowledge and expertise.
These identified needs were the basis for health department planning. Planning
Needs identification led to a plan to designate a staff nurse as AIDS Coordinator with specialized training and responsibilities. The other CHN staff would continue to receive AIDS-related continuing education and integrate AIDS prevention into all aspects of their efforts. AIDS Coordinator duties were initially expected to take 50% of the designated nurse's time; this became a full-time position in August 1989.
The designated AIDS Coordinator assumed these duties in January 1988. His goals were (a) to provide individual client services for AIDS-diagnosed and/or HIVinfected residents; @) to increase general community awareness of AIDS and support for a nondiscriminatory, caring response; (c) to increase AIDS/HIV prevention and risk-reduction knowledge and practices among high-risk aggregates of homosexual men and youths; and (d) to address current and potential AIDS-related service gaps. Nursing Interventions
Nursing interventions have been carried out by the AIDS Coordinator with individuals, social networks, families, and the community as a whole. A number of examples of these are given to illustrate the dimensions of this role. Some interventions with community-wide impact are illustrated in a time line of AIDS in the Village in Figure 2. Client services for individual clients have included both in-home community health nursing visits and an office setting anonymous counseling and HIV-antibody testing program. Client in-home visiting services are initiated by the AIDS Coordinator if, during the communicable disease follow-up visit mandated by the state health department for reported cases of AIDS, the client expresses a desire to have ongoing community health nursing services. In-home services are based on comprehensive community health nursing assessment of the client and his or her needs and
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AlDS In The Village: Epidemic-Related Events 1983-1990 December 1983
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FIGURE 2 Time line of AIDS-related events in the Village, 1983 through 1990.
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usually include: physical assessment, counseling and emotional support, AIDSspecific health teaching, partner and/or family counseling and education, and social service/health systems advocacy. The other individual client-oriented services are delivered in an office setting. These services consist of comprehensive HIV-risk assessment and risk-reduction education and counseling, offered on a one-to-one basis to individuals who have selfidentified as being at risk for HIV, or have been referred by health or social service providers. Those who desire it receive anonymous HIV-antibody testing and individualized posttest counseling. Aggregate focused services consist of health education directed to two specific aggregates: homosexual men and young people. Educational services are delivered directly to members of the aggregates and to health, educational, and social service providers that serve aggregate members to better inform these providers regarding HIV-risk assessment and HIV-risk reduction and prevention. Examples of these activities included: inservice presentations to hospital and health maintenance organization (HMO) nursing and medical staffs, inservices for school nurses, in-classroom teaching for Grades 5 through 8, and developing a male homosexual-oriented educational/support group with the local mental health center. Community health nursing interventions with a community-wide impact have included generalized health education efforts, service development, and local policy advocacy activities. Examples of generalized community health education activities include: local newspaper articles regarding AIDS and AIDS services, cable TV interview and feature shows on the local cable access channel, and the organization of a community-wide AIDS awareness months in June 1989 and October 1990. In mid-1988, the Department's community health nursing supervisor and AIDS Coordinator initiated a series of meetings that led to the formation of the Village AIDS Network. This is a group of local social and health service providers brought together to examine the extent of service needs and gaps for residents with HIV infection and AIDS. During the initial 3 months of the Network, the AIDS Coordinator and another Network member conducted a Village AIDS needs assessment. A number of present and potential service gaps were identified including the absence of any accessible, community-based AIDS support and advocacy agencies that would provide specialized services such as support groups, volunteer chore services, companions, transportation, and housing or residential services to community members affected by AIDS and HIV. One community service gap, addressed soon after the needs assessment was completed, was the lack of a continuum of residential services for persons with AIDS, including home-based care, hospice, and nursing home care. As an advocate for the service needs of present and future clients, the AIDS Coordinator worked with a diverse group of local citizens that was in the process of forming a not-for-profit organization for persons with AIDS. This group incorporated and began delivering a full array of social services, including residential services, to community members affected by AIDS in 1989. By December 31, 1990 nearly 200 residents of the Village and nearby communities had received services from this organization.
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Policy advocacy efforts of the AIDS Coordinator have been supported by the nursing supervisor and the health director. The health director had been involved in local policy efforts since the epidemic began by advising the local school districts regarding appropriate policy governing AIDS-affected students and staff. Based on the AIDS Coordinator's review of current research and recommendations, AIDS/ HIV-related personnel policies were developed by the health and personnel directors and recommended to the Village Board of Trustees. The proposed policy protected government employees from HIV-related discrimination if they were to become infected. It also provided for mandatory attendance in AIDS/HIV prevention education sessions for all Village employees. These public policy efforts culminated in October 1988 when the Board of Trustees approved the personnel policy and the Village became the first municipality in the state to adopt AIDS/HIV-related personnel policies for its government employees. As the Village enters the second decade of AIDS, a formal means for the updating of Village AIDS-related service needs on an ongoing basis as well as a means for local AIDS-related policy advocacy was created in September 1989. The six local taxing bodies (Village Board, Park Board, two School Districts, Library Board, and Township Board) established an intergovernmental AIDS Task Force. Based on Task Force recommendations made in late 1990, a formal standing AIDS committee of the Village's Board of Health has been established to monitor the course of the AIDS epidemic in the Village and advocate for needed services and local policy. CONCLUSION A community case report has been used to demonstrate program development in response to the AIDS epidemic in a Midwestern U.S. community. These efforts were developed and implemented by CHNs employed by a local health department. The dynamic interplay of community health nursing activities with individuals, families, groups, and aggregates, as guided by the nursing process, has been reported and used to illustrate CHN roles in a local health department. In this community, CHN initiatives have helped to shape the response of the community to the local manifestation of the evolving AIDS pandemic. AIDS presents a profound challenge to the entire world community in all the realms of human relations and human activity. As CHNs, we are challenged to respond to AIDS from the depths of our tradition to nurse the community as a whole (Freeman, 1981). Our unique community focus enhances the worldwide effort against AIDS and can enable a humane and caring response. REFERENCES American Nurses' Association. (1980). A conceptual model of community health nursing. Kansas City: Author. American Nurses' Association. (1986). Standards of community health nursingpractice. Kansas City: Author.
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