Brockton, Massachusetts: Use of the Adaptation Model,

Brockton, Massachusetts: Use of the Adaptation Model, Nursing Process and Guidelines for a Comprehensive Community Assessment

This work in writing will utilize the Adaptation Model, nursing process and guidelines to complete a community assessment, analyze gathered data for implications for health care, formulate a nursing diagnosis for the community, and incorporate findings into the nursing process and formulate a care plan for a specific community problem.

According to the Public Health Nursing: Leadership Guide and Resource Manual" published by the Massachusetts Association of Public Health Nurses (2005) nurses employed in public health nursing are constantly conducting assessments of the community's needs and resources both those available to the individual and groups. Public health nurses are focused on organization and working with a diverse network in promoting ensuring and strengthening the well-being and health in the community with goals for high standards of health care for the population. Public health is the systematic approach in the preservation, protection and improvement of the entire population's health enabled by "prevention and control of communicable disease, injury and prevention of disability" while promoting health status excellence for everyone in the community. This is inclusive of the prevention of epidemics and disease spread while protecting against hazards that are environmental in nature as well as response to disaster and community recovery inclusive of health care services access combined with promotion of healthy lifestyles.

Adaptation Model

The Adaptation model is a conceptual framework with a focus on the patient as "an adaptive system, one in which nursing intervention is required when a deficit develops in the patient's ability to cope with the internal and external demands of the environment." (Mosby's Medical Dictionary, 8th edition, 2009) These demands have been divided into four categories including those of:

(1) physiologic needs;

(2) the need for a positive self-concept,

(3) the need to perform social roles and (4) the need to balance dependence and independence." (Mosby's Medical Dictionary, 8th edition, 2009)

The maladaptive response of the patient is assessed by the nurse and utilizes this response to identify the type of demand creating the conflict. Nursing care is then planned around promotion of adaptive responses for successful coping with the effect that present stress places on the well-being of the patient. This is a model that was proposed by Sister Callista Roy.

A changing environment requires that the patient respond successfully and it was proposed by Sister Callista Roy that the environment must be considered in terms of the internal and external stimuli that affect the group or individual. Environmental stimuli is reported to be inclusive of "the conditions, circumstances, and influences that surround and affect the development and behavior of an individual or group.' (Mosby's Medical Dictionary, 8th edition, 2009)

Health is described as "a state being and a process of becoming an integrated and whole person. " (Mosby's Medical Dictionary, 8th edition, 2009)

Adaptive behavior takes place in four modes:

(1) physiological;

(2) self-concept;

(3) role function; and (4) interdependence. (Mosby's Medical Dictionary, 8th edition, 2009)

All of these four modes are collectively termed as 'wellness'. (Mosby's Medical Dictionary, 8th Edition, 2009)

The adaptation model is conceptualized as shown in the following illustration.

Figure 1

Adaptation Model

Illness is reported to be "ineffective adaptation in one or more of these modes. Nursing is a theoretical system of knowledge that prescribes a systematic process related to the care of the ill or potentially ill person." (Mosby's Medical Dictionary, 8th edition, 2009) Stated as the goal of nursing is the promotion of all four adaptive modes during wellness and illness." (Mosby's Medical Dictionary, 8th edition, 2009)

Six Steps in Nursing Process of Adaptation Model

There are six steps in the nursing process of the adaptation model including the following:

(1) assessment of behaviors, data regarding the client's physiological, self-concept, role function, and interdependence behaviors are collected. Once the data have been collected, the nurse must judge whether the behaviors are adaptive or ineffective. Thus the primary question is: To what extent is the person adapting to environmental stimuli?

(2) assessment of influencing factors, priorities are set for further assessment and identification of the environmental stimuli that influence the client's behavior and so contribute to the adaptive or ineffective responses.

(3) nursing diagnosis, involves a behavioral description of the client's adaptive or ineffective responses and identification of the most relevant influencing factors, as well as establishment of a hierarchy of importance for the nursing diagnoses.

(4) goal setting, the goals for nursing care are formulated. These goals are stated as behaviors expected as the outcome of nursing intervention.

(5) intervention, involves management of environmental stimuli, which takes the form of an increase, decrease, modification, maintenance, or removal of internal or external stimuli. The intervention with the highest probability of reaching the desired goal is selected.

(6) evaluation, the effectiveness of the nursing intervention is judged. The criterion for effectiveness is whether the desired behavioral goal was attained. The outcome of this step is updating of the nursing care plan. (Mosby's Medical Dictionary, 8th edition, 2009)

Brockton - Demographics

Brockton is a mid-sized southeastern Massachusetts city and racially and ethnically diverse. Brockton was once alive with manufacturing and was known well for the shoe industry however, presently the service sector is the primary employment for residents in the Brockton area. The population of Brockton is approximately 60% white, 18% Black, 8% Hispanic, 1% Asian and 19% other race. Nearly 12% of the current population is Sub-Saharan African with many being Cape Verdean.

Reports stated that the per capita income in Brockton is "$17,163, with 15% of the population living below 100% of poverty level, 33% living below 200% of poverty level and almost 20% of children living below the poverty line.

Nearly 16% of the population are Medicaid recipients and almost 7% are unemployed. Income levels in Brockton are lower than Massachusetts' averages and rates of people living in poverty are approximately one and a half times the state averages. " (AHEC, 2009)

Health Status

Reports state that mortality rates in Brockton "with age-adjusted rates per 100,000 persons shows that "a number of significant differences from state rates emerge as follows:

(1) First, both White men and women have high mortality rates for HIV / AIDS as compared to White men and women in other parts of Massachusetts, twice and eight times the rates respectively.

(2) White women also have almost twice the mortality rate of respiratory disease as White women in the rest of the state.

(3) Black men in Brockton have high cancer mortality rates. They have more than two and a half times the rate of colorectal cancer and more than twice the rate of prostate cancer as Black men in the state as a whole. Interestingly though, their rate for lung cancer is significantly lower than the rate for Black men in the rest of the state (one-sixth the rate).

(4) Black men also have three times the mortality rate of diabetes as the Massachusetts average for Black men.

(5) Black women in Brockton have more than one and a half times the mortality rate of diabetes as the Massachusetts average for Black women.

(6) Hispanic men also fare worse than their counterparts in the state as a whole. They are more than three times as likely to die of lung cancer, almost four times as likely to die of diabetes and more than one and a half times as likely to die of respiratory diseases. However, they are only one-fourth as likely to die of circulatory disease as Hispanic men in other parts of Needs Assessment .

(7) Hispanic women in Brockton are almost three times as likely to die from breast cancer as Hispanic women in the state as a whole.

(8) Morbidity rates in Brockton show that White men and women have almost twice the rates of hospitalization for alcohol and other drugs as Whites in the rest of the state.

(9) White men and women in Brockton also have roughly four times the rate of hospitalization for HIV / AIDS related health issues compared to their rates in the rest of the state (3.6 and 4.4 times respectively).

(10) White men also have almost twice the rates of hospitalization related to obesity as White men in the rest of the state.

(11) Black women in Brockton also have almost twice the rate of hospitalization for HIV / AIDS related health issues compared to Black women in the rest of the state.

(12) Hispanic men in Brockton are more than one and a half times more likely to have alcohol and other drug related hospitalizations, almost twice as likely to be hospitalized related to circulatory disease and more than twice as likely to be hospitalized for diabetes related complications as Hispanic men in the rest of the state.

(13) Hispanic women in Brockton are almost three times as likely to be hospitalized for system circulatory diseases, more than twice as likely to be hospitalized for diabetes related complications and more than twice as likely to be hospitalized for respiratory disease as Hispanic women in the rest of the state.

(14) Asian/PI men in Brockton are more than twice as likely to be hospitalized for respiratory disease as Asian/PI men in the rest of the state and Asian/PI women are almost four times as likely to be hospitalized for circulatory system disease as Asian/PI women in the rest of the state.

(15) When examining other health indicators, Brockton has more than one and a half times the rate of newly diagnosed AIDS cases, sixty-seven times the rate of Syphilis, almost twice the rate of Chlamydia and more than one and a half times the rate of Gonorrhea as compared to the statewide rates.

(16) Brockton also has more than one and a half times the statewide rate of admission to DPH-funded substance abuse facilities.

(17) Pregnant women in Brockton are almost twice as likely not to receive prenatal care in the first trimester of pregnancy compared to women. (AHEC, 2009)

It is reported that challenges include "re-emergence of previously controlled diseases and the emergence of new diseases, new and re-emerging social problems and the changing definition of health and health status." (AHEC, 2009) It is additionally reported that public health "in the Commonwealth of Massachusetts is unique to that found elsewhere in the United States. Generally, the home for public health is at the county and state health department level. In Massachusetts, each of the 351 cities and towns in the Commonwealth maintain and administer their own local health departments. These departments or boards of health may be comprised of either elected or appointed membership, generally serving limited terms of office. The membership of the boards is derived from civic-minded community members, who have varied knowledge of health and sanitation regulations or public health needs prior to their election or appointment. This results in a rapid turnover of board members with agencies in a frequent state of flux and struggling to properly address the community's public health needs." (AHEC, 2009)

Research in this study resulted in the emergence of consistent themes in relation to access barriers and need for specific services that were unmet as well as provider capacity limitations.

Barriers to Access of Health Care Services in Brockton

Barriers to access of health care services included the following:

(1) inadequate transportation and child care resources,

(2) insufficient interpreter resources to respond to the multiplicity of spoken languages, and (3) lack of access to safety net providers such as Community Health Centers in key pockets of the region, namely the Taunton and Plymouth service areas. (AHEC, 2009)

Service Gaps in Health Care Services in Brockton

Service gaps are reported to include "Unmet need for services" in the areas as follows:

(1) mental health care,

(2) substance abuse treatment,

(3) oral health care and (4) insufficient time to provide adequate case management services.

(5) The importance of coordination of care was emphasized, including the need for stronger linkages between case managers and health care providers.

(6) Respondents emphasized the lack of bilingual/bicultural providers as a significant factor impacting on the quality of care provided to the region's diverse communities as well as the need for more local, accessible specialty care. (AHEC, 2009)

It is reported that the Centers for Disease Control and Prevention (CDC) in 1995 in collaboration with "an extensive group of health care organizations promulgated a detailed list of ten essential services that more explicitly defined the role of public health. " (AHEC, 2009)

Services Required to Implement Core Functions

These are services that must be achieved if core functions are to be implemented. Included in these services are the following:

(1) Monitor health status to identify community health problems;

(2) Diagnose and investigate health problems and health hazards in the community

(3) Inform, educate, and empower people about health issues

(4) Mobilize community partnerships to identify and solve health problems

(5) Develop policies and plans that support individual and community health efforts

(6) Enforce laws and regulations that protect health and ensure safety

(7) Link people to needed personal health services and assure the provision of health care when otherwise unavailable

(8) Assure a competent public health and personal health care workforce

(9) Evaluate effectiveness, accessibility, and quality of personal and population-based health services; and (10) Research for new insights and innovative solutions to health problems. (AHEC, 2009)

The overall health of the community of Brockton is characterized by health behavioral risks and most specifically at focus in this study is the rate of newly diagnosed AIDS cases, Syphilis and Chlamydia as well as Gonorrhea which is reported to be more than one and half times, sixty-seven times, twice and more than one and half times the statewide rates, respectively. In addition, Brockton is found to have more than one and a half times the statewide rate of admission to DPH-funded substance abuse facilities. It is these two areas that will be addressed in this particular study. This study has already identified barriers to accessing health care and unmet needs for services including substance abuse treatment and coordination of care.

AHEC (2009) reports a study in which focus group discussions revealed that "chronic disease, substance abuse, mental health and infectious diseases (including HIV, STDs and Hepatitis) were found to be "consistent themes across groups. Chronic diseases that were mentioned included: diabetes, hypertension, and cardiovascular disease. Groups were also concerned about the health consequences of obesity and tobacco use. Several respondents shared their impression that many immigrants become more prone to chronic illnesses upon coming to the U.S." (AHEC, 2009) HIV / AIDS is a problem in pediatric patients and in correctional facilities. There were concer5ns expressed about "the correlation between living conditions for immigrant men and increased risk for HIV. According to one health care provider, many immigrants share housing and in some cases prostitutes, engage in high-risk sexual behaviors and thus increase their risk of HIV infection." (AHEC, 2009) There was a need expressed for local specialists to make provision of care and treatment for Hispanics with Hepatitis C