Response to "Theory Development in Community Health Nursing: Issues and Recommendations"

Article excerpt

Despite its distinguished past, the present and future of community health nursing is threatened by the paucity of efforts to identify and organize knowledge relevant to its unique focus, the community client. The Hamilton and Bush article begins with this premise but adds an energizing counterpart: knowledge pertinent to community health nursing, especially to the community client, can originate from a variety of perspectives - research, practice, and theory - and from richly diverse sources: the experiences of community health nurses and their clients, past and present; the structure, process, and outcomes of community health nursing practice; the educational arenas for generalized and specialized nursing practice; conceptual analyses of "community;" and the replication, extension, and reexamination of prior research.

Each perspective, of course, has limitations. The authors imply, in fact, that community health nursing inquiry might most productively begin with a theoretical stance. They emphasize the utility of an organizing framework, to focus the relatively undisciplined research of the past and to expand upon practice currently constrained by health care reimbursement policies. The contributions of research and practice perspectives, however, are not slighted. The second premise is appealing precisely because it emphasizes a variety of facilitators of knowledge development in and for community health nursing. It moves our thinking beyond popular dialectics like quantitative or qualitative research methodologies, empiricism or phenomenology, and theory discovery or verification, to multiple foci of inquiry, ways of knowing, and fields of knowledge. Such eclecticism exists within the traditions of both public health and nursing, and the admonition to recall its usefulness is particularly appropriate today. I have responded by reconsidering the concept of community client, the goals and means of community-oriented nursing practice, and a collaborative approach to inquiry; I invite you to join me.

THE CLIENT OF COMMUNITY HEALTH NURSING

The unique focus of community health nursing, the community client, is readily accepted today as a basic orienting concept for community practice. Chapters and even entire textbooks are devoted to its explication and application (Anderson & McFarlane, 1988; Goeppinger & Shuster, 1988; Turner & Chavigry, 1988). Undergraduate and graduate classes are devoted to the topic, and field guides for assessing needs of the community client, planning and implementing intervention, and evaluating impact are utilized.

Conceptual analyses of the referents of "person" in community health nursing suggest that widespread acceptance of the term "community client" is not synonymous with conceptual clarity and shared meaning among educators, practitioners, and researchers (Schultz, 1987). The community client is considered variously as the public or ultimate beneficiary of practice, a unit of practice or intervention partner with whom the nurse interacts, a target of change, and a setting for practice (Goeppinger & Shuster, 1988). Hamilton (1983) herself has proposed another typology of the community client: the individual and family within the community, the individual and family influenced by the community, and the community as client.

I agree with Schultz that "community client" must refer to more than the arithmetic sum of individuals residing within a defined area or at risk of a particular disease, that is, an aggregate. It must also reflect "themes of development, interaction and interdependence" that specify the aggregate as an "interactional whole," a nursing client (Schultz, 1987, p. 77). These themes are characteristics of families, groups, organizations, communities, and of the systems created by the relationships between and among them. Such a conceptual orientation to interaction promises to focus the research and expand the practice of community health nursing. …