JOURNAL

Laffrey, Kulbok
OF HOLISTIC
/ COMMUNITY
NURSING
HEALTH
/ March
NURSING
1999

An Integrative Model for Holistic

Community Health Nursing

Shirley Cloutier Laffrey, R.N., Ph.D., M.P.H., C.S.

University of Texas at Austin
Pamela A. Kulbok, R.N., D.N.Sc.
University of Virginia

Health and nursing are shifting from acute care to community settings, causing con-
fusion for clients and professionals. Although the holistic nursing perspective has im-
proved care to human beings in interaction with their environment and has moved
nursing away from pathology-focused care, the community as the focus of care has not
been addressed. This article presents an integrated model of community health that
expands holistic nursing to the community as client. The model clarifies nursing care
for the individual, family, aggregate, and community. One can focus on any one level,
with the awareness that each is part of a unified whole. Holistic community nursing
completes the circle of care by moving beyond the particular part to focus on the great-
est health for the community. The intent is to help nurses describe their unique areas
of expertise within the complex community system and to establish a basis for collabo-
ration and partnership.

Recent changes in health care delivery have meant a shift in the focus
of health and nursing care from acute care to community settings.
This shift is causing confusion among clients and health care profes-
sionals alike. The confusion is compounded by conflicting definitions
of community health nursing as (a) nursing of individuals in the com-
munity, or (b) nursing the community as an entity. Inadequate defini-
tions and an unclear understanding of what constitutes community
health nursing results in nursing care to individual clients in the com-
munity being represented as community health nursing.
Holism, defined by Smuts (1926, p. 317) as the “ultimate, synthetic,
ordering, organizing, regulative activity in the universe which
JOURNAL OF HOLISTIC NURSING, Vol. 17 No. 1, March 1999 88-103
© 1999 American Holistic Nurses’ Association
88
Laffrey, Kulbok / COMMUNITY HEALTH NURSING 89

accounts for all the structural groupings and synthesis in it,” is one of
the most promising perspectives from which to conceptualize com-
munity health nursing. This tendency toward wholes (Smuts, 1926)
provides the organizing principle that moves from the smallest cell to
the evolving universal whole. Holistic nursing has been based on the
perspective of holism, but it is focused on individuals as the target of
care (Dossey, 1995; Dossey and Guzetta, 1995; Hoekstra, 1994; Kee-
gan, 1996; Stetson, 1997). This is not to say that a concern with the indi-
vidual in his or her wholeness is not important. However, a holistic
approach for community health requires moving beyond the individ-
ual to incorporate the wholeness of community. As health care is
increasingly delivered in community settings, a framework is needed
that can assist nurses to integrate the larger units of aggregates and
communities within the healing paradigm.
The idea of addressing health from a broader perspective than that
of individual clients—although consistent with both holism and com-
munity—is not new. In the late 1800s, Florence Nightingale noted that
nursing work has less to do with nursing disease than with removing
factors that interfere with health maintenance (in Nightingale,
1860/1969). Those factors exist not only in the individual, family, and
aggregate but also in the community. They require an orientation to
the underlying fabric of the community, such as the economic, socio-
political, and environmental characteristics and opportunities that
are fundamental to living conditions which, as such, can hamper or
facilitate efforts of the population to achieve better health.
The holistic perspective was offered as an antidote to reductionism
and as a way to understand that whole organisms and systems have
an identity that is greater than the sum of their individual parts
(Smuts, 1926). Holism is described by the American Holistic Nurses
Association (AHNA) as “the individual as an integrated whole inter-
acting with and being acted upon by both internal and external envi-
ronments” (in Dossey & Guzetta, 1995, p. 7). To be acted on implies
that human beings and environment are separate to some degree.
Therefore, this phrase may not be congruent with the notion of
human beings and environment existing as a unified whole (Kleffel,
1996; Moss, 1989; Rogers, 1970; Sarter, 1988). Rogers (1970) noted that
there is no boundary between the human and environmental field.
So-called boundaries placed on human energy are artificial and are
only applied by a person in an effort to focus on a part of the whole. If
one accepts the mutuality of the human and environmental field, then
it is important to address the nature of this larger whole.
90 JOURNAL OF HOLISTIC NURSING / March 1999

A basis for understanding community and the human/environ-

ment relationship was presented by Kleffel (1996) in her three per-
spectives of environment. The first and most prevalent within nurs-
ing is the egocentric perspective in which the individual is viewed as
central and as the focus of change. The environment is viewed “in
relation to the individual person rather than in terms of its own
essence and intrinsic value” (p. 3). Most nurses, including many holis-
tic nurses, use this perspective when providing interventions to pro-
mote healing and wholeness of the individual. This is also the prevail-
ing definition of community health nursing when care is provided to
individuals within the community. In these cases, the community
provides the environmental context for individual care. The commu-
nity is important because the conditions within the environment
facilitate or hinder the individual’s healing. The notion of
community-based nursing fits within the egocentric perspective
when care is provided to individuals in the community.
Kleffel’s (1996) second definition of environment is homocentric,
in which social justice prevails over individual rights. Human health
is ascribed to cultural and social factors, and the concern is with the
health of populations rather than that of individuals. Therefore,
improving health requires changes in the environment rather than in
the individual. Many community health nurses use the homocentric
perspective when they conduct health assessments of the commu-
nity. They identify aggregates with health problems as the focus of
care. The homocentric perspective is congruent with the definition of
community-as-client, in which the physical, psychological, economic,
recreation, government, geographic, transportation, and communi-
cation networks are of prime concern, and nursing interventions are
targeted to organizational and community leaders and legislative
bodies to promote healthier communities.
The third perspective is ecocentric, in which “human and non-
human are one within the same organic system” (Kleffel, 1996, p. 4).
The whole of environment is assigned intrinsic value and, therefore, it
cannot be broken into component parts. This view is most consistent
with holistic nursing’s concern with the whole. Within the ecocentric
perspective, nursing therapeutics go beyond individuals’ health and
healing to incorporate the wholeness of life. A focus on wholeness is
reflected in Moss’s (1989) description of the “person and humanity as
a whole toward a more inclusive, more unobstructed relatedness to
all that is emerging in the adventure of life” (p. 37). The ecocentric per-
spective provides insight for a framework that incorporates
Laffrey, Kulbok / COMMUNITY HEALTH NURSING 91

individuals, families, aggregates, and communities as the focus of

care. A conceptual framework from the ecocentric perspective can
provide a coherent direction for holistic community health nursing
practice during a time of fundamental change in health care. Without
such a framework, advocates of traditional caring, technological cur-
ing, holistic nursing, and community nursing pull—sometimes in
opposing directions—at the very fabric of nursing’s efforts to facili-
tate integration among people and their environments to promote
health.
The purpose of this article is to present an integrated model that is
designed to clarify the continuity of community nursing care at the
multiple levels of the individual, family, aggregate, and community.
The intent of the model is threefold. First, it can help nurses to see the
continuity of care at multiple levels. Second, the model can assist
nurses to describe their own areas of expertise within a complex com-
munity health system. Third, it can establish a basis for collaboration
and partnership among nurses, other health care providers, and the
population, each of whom is part of and brings expertise to the client
system.
The assumptions of the Integrative Model (see Figure 1) are as
follows:

• The newly emerging health care system requires greater integration of

care.
• The biological, psychological, sociological, and spiritual individual is an
inseparable part of the family, aggregate and community system.
• The foundation of the system is health potential, which is maximized by
health promotion interventions.
• Levels within the community health system can be identified as targets
of care, with the awareness that they are only parts of the whole system.
• Care directed to any part of the system must be provided with considera-
tion of its effects on the health of the whole system.
• Holistic community health care requires a team approach, with all mem-
bers of the team identifying what contributions they will be make to the
overall health of the system.

Integrative Model for Holistic Community Health Nursing

The Integrative Model depicts the continuity and complexity of
community health nursing. The model includes two interrelated and
continuous dimensions: focus of care and client system. The two are
92 JOURNAL OF HOLISTIC NURSING / March 1999

Figure 1: Model of integrative community nursing.

inseparable, although specific interventions can be identified that are

most relevant and appropriate for each focus of care and each level of
the client system.

Focus of Care
The three foci of care are: (a) health promotion, (b) illness, disease,
or disability prevention, and (c) illness care. Health promotion is at
the center of the model, signifying that all measures are aimed, either
directly or indirectly, at optimizing health potential in a way that is
realistic at each level of both health status and complexity of client
system. The community health nurse’s primary concern is promotion
of optimal health as it is defined with and by the client.
An important aspect of health promotion is that it also encom-
passes the other foci of care. Even when care is directed toward allevi-
ating or preventing illness or disability, it will still contribute to health
promotion. However, the defining characteristic of health promotion
is that it goes beyond the alleviation of a specific illness or risk to
maximize overall health. For example, providing symptom relief for
the individual with pain leads to better health relative to that specific
Laffrey, Kulbok / COMMUNITY HEALTH NURSING 93

problem, but may contribute little to other illnesses or risks. The use of
broader measures, such as regular meditation or relaxation, reduces
specific pain and also contributes to reducing risks of other condi-
tions, such as cardiovascular disease, and increases general well-
being over a longer term.
The second focus of care is illness or disease prevention. At times,
the client’s health may require protection because of an existing or
potential threat. Illness and disease prevention strategies are those
that aim to reduce the likelihood that an actual illness, disease, or
injury will occur. The strategies aimed at reducing the threat of a dis-
ease are usually specific to that disease. Examples of preventive care
include immunizing a child to prevent rubeola or diphtheria, or com-
municating information about risks of lead poisoning from old batter-
ies strewn about playgrounds.
The third focus of care is illness care, in which assessments and
interventions are provided for alleviating symptoms, illness, disease,
or injury. This care can be provided directly to a patient, and it
includes measures applied to the immediate environment, such as
removing sources of excess noise or disruptions that would interfere
with healing. Both direct and indirect measures are aimed at resolv-
ing an existing disease or illness.
The core of the model (see Figure 1) is health promotion. Although
resolving and preventing an illness or a disease are important aspects
of community health care, facilitating the client’s greatest health
potential completes the process. This attention to health promotion is
an important aspect of holistic community health nursing.

Client System
The first and most easily identified client is the individual. Indi-
vidually oriented care includes health promotion; illness, disease, or
disability prevention; and illness care for individual human beings in
the community, as noted above. In many cases, the presence of a
health risk in the community comes to the attention of health provid-
ers because of an individual who has an identified health problem.
When the client is an individual, the environment or context includes
the family, aggregate, and the community. The mutual human/envi-
ronment interaction affects the planning of care for the client either
directly or indirectly by intervening on the client’s behalf with one or
more aspects of the environment. For example, teaching a mother to
do postural drainage with a young child, or teaching family members
94 JOURNAL OF HOLISTIC NURSING / March 1999

to give injections to an elderly family member are indirect care meas-

ures. Although the client is the recipient of the care, the interventions
are typically conducted with someone within the context or environ-
ment of the client.
When the identified client is the family, it is seen to be greater than
the sum of its individual members. The family unit is assessed and the
appropriate care is provided. Community health nursing’s tradi-
tional concern with families has meant extending the focus from one
or several individuals to the health of the family as a whole. The con-
cern with families may be for those with an existing illness, such as a
pattern of family violence. Other foci of concern are those who are at
risk of illness or disease, such as a high level of stress related to isola-
tion or poverty, or those whose health is basically adequate but could
be further enhanced with teaching, support, and additional health
resources.
When the identified client is an aggregate—a group of persons
who may or may not know each other but have a health-related char-
acteristic in common (Schultz, 1987)—care becomes more complex.
The health characteristic shared by the aggregate may be an illness
such as diabetes, a threat of illness such as elderly caregivers at risk of
exhaustion or with stress-related problems, or a group of healthy pre-
schoolers whose health could be maximized by developing a health
promotion program.
The community health nursing concern related to the aggregate-
as-client ranges from identifying and assessing the health status of
particular aggregates, to developing, implementing, and evaluating
appropriate programs to meet identified health needs. An example
would be identifying high blood lead levels among children in a par-
ticular neighborhood, developing a program to provide treatment to
children who are affected, and then identifying and reducing the
sources of lead within the neighborhood.
At an even broader level, the client may be the community. Schus-
ter and Goeppinger (1995) define community as “a locally-based
entity, composed of systems of formal organizations reflecting socie-
tal institutions, informal groups, and aggregates.” These functions
are interdependent, and their purpose is to meet a wide variety of col-
lective needs (Bogan, Omar, Knobloch, Liburd, & O’Rourke, 1992).
The community is a designated area in which persons live, work,
study, and play. It is a place that the residents identify as a commu-
nity. The safety and adequacy of the community; employment, edu-
cational, transportation, and recreational opportunities; and the
Laffrey, Kulbok / COMMUNITY HEALTH NURSING 95

formal and informal organizations and communication patterns

within the community provide important areas for assessment of the
health of the community.
Participation with residents to plan and develop needed programs
is an important function of community health nurses. Another func-
tion is to assure that programs are developed to meet health needs,
and a third function is to assure that ongoing assessments are con-
ducted to monitor program effectiveness and identify new needs and
resources.
The concepts of the Integrative Model show clearly that one com-
munity health nurse cannot attend to all foci of care and client levels
within the system at the same time. As Hanchett (1979) has noted, one
cannot see the forest while focusing on one tree and, conversely, one
cannot see the individual tree when focusing on the whole forest.
Thus, it is important to view the levels of clients within the system as
parts of the whole, rather than to view the particular part with which
one is concerned as the whole system, or even as the center of the sys-
tem—which is the present tendency.
The Integrative Model is both conceptual and practical. In concept,
it provides a map to guide practice and knowledge development for
the various aspects of community health nursing. Although the indi-
vidual concepts in the model are not new, their conceptualization as
continuous and integrated furthers theoretical thinking in commu-
nity nursing. The client system is continuous from the individual-as-
client to the community-as-client. Also, illness care is continuous with
health promotion care. Thus, the levels in the client system provide
the basis for developing interventions that are interrelated and that
can treat illness and symptoms; prevent disease and illness; and pro-
mote health at the personal, family, aggregate, and community levels.
The integrative model expands holistic care. It redirects the focus on
an individual’s interactions with the environment by shaping his or
her health (McVicar & Clancy, 1996) to one which includes the family,
aggregate, and community as levels within the client system and as
important domains for nursing in their own right.

Application of the Model: A Case Study

To illustrate the practical application of the model, it is applied to a
Mexican American community. During the past several years, the
first author has had professional experience in student community
health clinical placements, research on exercise, and community
96 JOURNAL OF HOLISTIC NURSING / March 1999

service as a board member within several health facilities in this

community. Community leaders and health professionals have a
high level of interest in obtaining and providing services that can
have a positive health impact on the population. Many residents of
the community also participate in activist and health-related activities.
One recognized health problem of concern to the population in this
community was the high rate of noninsulin-dependent diabetes mel-
litus (NIDDM), especially among older women. The community
health nursing students found this to be a health problem during their
community assessment. NIDDM is also documented as a national
health problem among the Hispanic population, with an incidence
double that of the non-Hispanic White population (United States
Department of Health and Human Services [USDHHS], 1991). There-
fore, the experience in this community has relevance for other com-
munities as well.
In examining the case study with the Integrative Model, diabetes
mellitus can be conceptualized as (a) an individual’s inability to
metabolize carbohydrate; (b) a problem that affects the family’s life-
style; (c) a prevalent condition in the high-risk aggregate of older
Mexican American women; or (d) a community problem that requires
planning for disease screening, treatment, prevention, and health
promotion. The interrelationships among NIDDM, nutrition, and
physical activity are important at each of these levels. Examples of
care are described below for the client system (individual, family,
aggregate, community) and foci of care (illness care, illness preven-
tion, health promotion).

Individual Care
A Mexican American woman, age 63, who had been diagnosed
with NIDDM several years previously, was seen in the clinic for rou-
tine care. This woman was slightly overweight, had an elevated
serum glucose level, and stated that her lifestyle included caring for
her family (husband, grown widowed daughter, and two adolescent
granddaughters), her home, and her garden. She stated that she did
not follow her food plan because her family liked high-fat, high-sugar
foods, and it was too hard to avoid these foods when she had to pre-
pare them for the family. In addition, she said that money was scarce
and good foods were very expensive.
Illness care included assessing her perceptions about herself, her
diabetes, her strengths, and her health care needs as related to the
Laffrey, Kulbok / COMMUNITY HEALTH NURSING 97

diabetes. Nursing interventions included providing her with basic

information about her diabetes and its relationship with her eating
and activity patterns. They also helped her to develop self-regulation
techniques, such as monitoring her serum glucose and comparing
these levels with her feelings and well-being. The major focus of the
intervention was to assist the woman to manage her diabetes.
Prevention care included examining her feet and assessing her
knowledge of foot care. Although she had no specific complaints, she
was at risk for foot problems. Nursing interventions consisted of both
teaching and demonstrating foot care to prevent lesions. A preventive
intervention could also include a referral to a podiatry clinic for rou-
tine foot care.
Health promotion care, based on assessing her strengths and inter-
ests, centered on a discussion of a physical activity recreation pro-
gram that could assist her to increase her energy and vitality. This
recreation program could engage her in enjoyable and supportive
relationships with other women. The focus of health promotion
care was not directly related to her diabetes; rather, it was focused
on her interests and strengths. The aim was to enhance her overall
well-being.

Family Care
At the family level of the system, care showed the family unit that a
disease in one individual affects the entire family. An example of
illness-related care was to assess the level of stress and fear within the
family and the impact of the diabetes on the family’s lifestyle. The
family members were afraid of the diabetes and of the possibility that
the mother/grandmother might die. Interventions included teaching
about the diabetes and also teaching stress reduction measures and
communication skills. Interventions might also include a referral for
family counseling.
A disease- or illness-prevention approach included assessing the
family’s eating patterns and their knowledge of diabetes risks among
the Mexican American population. The intervention included teach-
ing about risks and supporting the family to adopt patterns of eating
and activity that could decrease their risk. Information was also pro-
vided about health insurance plans for which the family was eligible
in order to increase its ability to receive preventive care.
Family health promotion is not aimed directly at the diabetes, even
though the measures will contribute indirectly to risk reduction. An
98 JOURNAL OF HOLISTIC NURSING / March 1999

additional assessment of the family’s interests and strengths might

lead to a nursing intervention of exploring enjoyable physical recrea-
tion for the family unit that enhances its well-being, cohesiveness,
and autonomy.

Aggregate Care
In the clinic where the woman with NIDDM was initially seen, the
nurse became aware that a large number of Mexican American
women came to clinic with the same profile: being overweight, hav-
ing few activities outside their homes, feeling tired, and having inade-
quate control of their blood sugar. An example of illness-related care
for this aggregate was to start a women’s group that included teach-
ing about culturally relevant foods, cooking favorite foods with less
fat and glucose, physical activity, foot care, and social support. This
group support allowed the women to learn from one another and
from the leaders how to better manage their diabetes. This need was
supported by the findings in a study by Alcozer (1998) in which the
sample of Mexican American women described having glucose in
their urine as borderline and glucose in their blood as diabetes. Edu-
cation to increase the women’s awareness of diabetes and the need for
medical care was important to assist them to receive safe treatment
for their diabetes.
Disease prevention care was based on identifying an at-risk popu-
lation of young Mexican American women with a parent or grand-
parent who had diabetes and teaching well-balanced nutrition and
physical activity to reduce the risks of a future diagnosis of NIDDM.
This need was also supported by Alcozer’s (1998) study that showed
that all the women with diabetes had either a parent or grandparent
with diagnosed diabetes. Preventive teaching to reduce the risk was
done individually and in groups at the clinics, high schools, commu-
nity centers, and churches.
Health promotion care, also based on identifying an aggregate of
older Mexican American women, was concerned with providing care
designed to assist them to enhance their health and well-being. Exam-
ples of programs were cooking classes to teach well-balanced nutri-
tion and development of a program of enjoyable physical activities
that were relevant to their culture and their need for support. Another
example of health promotion care would be to work with the commu-
nity to increase the number of senior programs for this aggregate.
Laffrey, Kulbok / COMMUNITY HEALTH NURSING 99

Community Care
At its broadest level, care was directed to the community-as-client.
Illness-related care included assessing the community for the preva-
lence of various diseases and health problems. NIDDM was identi-
fied as one of the major concerns in this Mexican American commu-
nity. Therefore, the community was also assessed for the adequacy of
health service providers for clients who had diabetes. Nursing inter-
ventions included participating in meetings with local health provid-
ers to plan for increased services and planning for mass diabetes
screening programs at various locations in the community. Another
intervention was to contact providers to donate free or low cost serv-
ices to uninsured persons who were not able to pay for medical care.
Disease prevention care to the community-as-client included par-
ticipating with other community leaders and residents to develop
community education programs about diabetes risks, prevention
through nutrition, weight management, and physical activity. Public
service announcements about prevention measures were also devel-
oped for airing on the Spanish language radio station. An important
prevention program was the Walk Texas Program, in which walking
groups were publicized and carried out in several areas of the com-
munity (Atwood, Stancic, Chan, & Falck, 1997). These programs were
specifically aimed at preventing NIDDM and its complications.
Community health promotion programs included participation in
planning for accessible recreation areas and health fairs; educating
restaurant owners about the need for low fat, low sugar menu selec-
tions; and participating in a healthy city initiative. Another activity
currently in the planning stage is to develop walking groups for the
yearly health fair. People will be given a token for each time they walk
around the perimeter of the fairgrounds (approximately 1/6 mile)
and a gift, such as a T-shirt, for walking a set number of circuits.

Implications for Holistic Community Practice

The Integrative Model can be a useful framework to facilitate and
organize complex care related to multiple levels of the client system
and foci of care. All levels are essential, but the same person cannot
perform all the levels. It takes a team of providers working in partner-
ship with the community to assure that holistic community care is
provided. Nurses are an important part of this team. The care of indi-
vidual patients must be planned and implemented in the context of
100 JOURNAL OF HOLISTIC NURSING / March 1999

their families, aggregates of which they are a part, and the local com-
munity. Because hospital stays have been shortened, all nurses need a
community perspective for the care that they provide. In addition,
they must develop the skills to work in teams to assure that compre-
hensive care is continued for patients after they leave the hospital.
Within the community, nursing is provided by several different
groups of providers. Home health nurses, clinic nurses, and nurse
practitioners provide care chiefly to individuals, and this care may
also include the family. Traditionally, the family has been viewed as
important because of its impact on the identified patient. Viewing the
family as a unique focus of attention, assessments can be broadened
to include health risks and strengths that can assist the family to iden-
tify and move toward greater health potential. Family care can have
far-reaching effects not only on the member identified as the patient,
but also on its overall health. Although a concern with the family-as-
client is accepted as part of the focus for community health nurses,
increasing emphasis is being placed on the family-as-client for all
nurses. The major difference from the traditional view is whether the
family is assessed because of its impact on the patient, or whether it is
assessed for its own health promoting and health limiting patterns
that warrant nursing interventions.
Many nurses working in the community are in roles that place
them chiefly with individuals, as noted above. This kind of care is
appropriately defined as care of clients in the community or
community-based care. These nurses are in an excellent position to
identify others in the population with similar health needs (e.g., a
large number of pregnant teens or a suspected high rate of alcohol or
drug use in a population). Although these nurses’ practices may not
specifically include assessing aggregates’ needs and strengths, holis-
tic community care can be achieved if their observations are shared
with nurses or other health professionals whose practice is directly
aggregate focused. It is by working together that the circle of care can
be broadened from treating individuals to assessing and treating the
aggregate and community.
Many community and public health nurses concentrate on these
larger units as their major focus of care. This care is appropriately
called community-oriented or population-focused care. These nurses
are also vital to the team, and they must have an understanding that
the aggregates and communities include families and individuals.
Thus, when individual problems come to their attention, referrals can
Laffrey, Kulbok / COMMUNITY HEALTH NURSING 101

be made to those whose focus is more directly the individual or

family.
As though one were looking through a telephoto lens, the Inte-
grated Model allows varied perspectives. The client can be seen up
close as a lone individual, with the family, aggregate, or community
in the background. On the other hand, the larger panorama can be
seen as a whole, with its components less clearly focused. The major
question that distinguishes the two perspectives is whether the
focus is on the individual as the central concern, or whether assuring
the development of larger systems of care for families, aggregates,
and communities is also addressed. To be considered holistic
community-oriented health care, this broader level must be included,
even when care begins with the individual. This conceptual distinc-
tion of individual focus and community focus may provide clarity
when developing nursing roles across specialty areas in the evolving
health care system of tomorrow. Identifying one’s practice at a given
level and as a system of care can assist nurses and other health provid-
ers to plan team approaches whereby each makes a contribution.
Thus, the team would then function in an integrated manner to meet
the totality of needs.
The Integrative Model is a conceptual frame of reference that can
direct multilevel community health nursing. Hamilton and Bush
(1988) stated that “the greatest purpose that a community health
nursing organizing framework could serve would be the identifica-
tion of the client of community health nursing practice” (p. 149). Ulti-
mately, all of nursing is community health nursing, and as renegotia-
tions of roles continues, the model can assist nurses to delimit the
level of client system with which they are concerned—within a per-
spective of the other levels.
All levels of client focus are important if nursing is to contribute
meaningfully to health promotion. If the goal of community health is
to “open up health for all people” (Hudson-Rudd, 1994, p. 122), we
must move beyond two preoccupations: (a) the individual is the cen-
tral domain of nursing, and (b) the dichotomy between acute care and
community health nursing. We cannot limit ourselves to a concern
with the individual’s responsibility for health while we neglect the
social and environmental contexts of people’s lifestyles (Hudson-
Rudd, 1994). The complexity of health care is such that no one nurse
or specialty can attend to all levels of client system or foci of care. It
takes a team to promote health, with each member making a unique
102 JOURNAL OF HOLISTIC NURSING / March 1999

contribution and working in partnership with other team members to

address comprehensive and holistic community care.

REFERENCES
Alcozer, F. R. (1998). The experiences of Mexican American women with type 2 dia-
betes. Unpublished doctoral dissertation, University of Texas, Austin.
Atwood, R., Stancic, N., Chan, W., & Falck, V. (1997, September). Walk Texas!
Roundtable session presented at the 1997 International Conference on Ag-
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Shirley Cloutier Laffrey, R.N., Ph.D., M.P.H., C.S., is an associate professor at

the University of Texas at Austin. Her research interests include health-promoting
behaviors with an emphasis on physical activity and exercise among community-
residing Mexican American women, age 60 or older.
Pamela A. Kulbok, R.N., D.N.Sc., is an associate professor at the University of
Virginia. Her research interests include patterns of healthy and risky behaviors
across the life span, with a current focus on adolescents and young adults.