Community-Based Nursing Practice
• Explain the relationship between public health and community health nursing.
• Differentiate community health nursing from community-based nursing.
• Discuss the role of the community health nurse.
• Discuss the role of the nurse in community-based practice.
• Identify characteristics of patients from vulnerable populations that influence the community-based nurse’s approach to care.
• Describe the competencies important for success in community-based nursing practice.
http://evolve.elsevier.com/Potter/fundamentals/
Community-based care focuses on health promotion, disease prevention, and restorative care. Because patients move quickly from acute care settings, there is a growing need to organize health care delivery services where people live, work, socialize, and learn (Swiadek, 2009). One way to achieve this goal is through a community-based health care model. Community-based health care is a collaborative, evidence-based model designed to meet the health care needs of a community (Downie, Ogilve, and Wichmann, 2005). A healthy community includes elements that maintain a high quality of life and productivity. For example, safety and access to health care services are elements that enable people to function productively in their community (U.S. Department of Health and Human Services [USDHHS], 2010). As community health care partnerships develop, nurses are in a strategic position to play an important role in health care delivery and improve the health of the community.
The focus of health promotion and disease prevention continues to be essential for the holistic practice of professional nursing. The history of nursing documents the roles of nurses in establishing and meeting the public health goals of their patients. Within community health settings, nurses are leaders in assessing, diagnosing, planning, implementing, and evaluating the types of public and community health services needed. Community health nursing and community-based nursing are components of a health care delivery system that improve the health of the general public.
Community-Based Health Care
It is important to understand the focus of community-based health care. Community-based health care is a model of care that reaches everyone in the community (including the poor and underinsured), focuses on primary rather than institutional or acute care, and provides knowledge about health and health promotion and models of care to the community. Community-based health care occurs outside traditional health care institutions such as hospitals. It provides services to individuals and families within the community for acute and chronic conditions (Stanhope and Lancaster, 2010).
Today the challenges in community-based health care are numerous. Social lifestyles, political policy, and economics all influence public health problems and subsequent health care services. Some of these problems include an increase in homeless and immigrant populations, an increase in sexually transmitted infections, underimmunization of infants and children, patients with chronic illnesses, and life-threatening diseases (e.g., patients living with human immunodeficiency virus [HIV] and other emerging infections). More than ever before, health care reform is necessary to bring attention to the health care needs of all communities.
Achieving Healthy Populations and Communities
The U.S. Department of Health and Human Services Public Health Service designed a program to improve the overall health status of people living in this country. The Healthy People Initiative was created to establish ongoing health care goals (see Chapter 6). The 2020 document strives to ensure that Healthy People 2020 is relevant to diverse public health needs and seizes opportunities to achieve its goals. Since its inception, Healthy People has become a broad-based, public engagement initiative with thousands of citizens helping to shape it at every step along the way. The overall goals of Healthy People 2020 are to increase life expectancy and quality of life and eliminate health disparities through an improved delivery of health care services (USDHHS, 2010).
Improved delivery of health care occurs through assessment of health care needs of individuals, families, and communities; development and implementation of public health policies; and improved access to care. For example, assessment includes systematic data collection on the population, monitoring the health status of the population, and accessing available information about the health of the community (Stanhope and Lancaster, 2010). A comprehensive community assessment can lead to community health programs such as adolescent smoking prevention, sex education, and proper nutrition. Some examples of assessment include gathering information on incident rates for identifying and reporting new infections or diseases, determining adolescent pregnancy rates, and reporting the number of motor vehicle accidents by teenage drivers.
Health professionals provide leadership in developing public policies to support the health of the population (Stanhope and Lancaster, 2010). Strong policies are driven by community assessment. For example, assessing the level of lead poisoning in young children often leads to a lead cleanup program to reduce the incidence of lead poisoning. Likewise more people are choosing to remain in their homes for end-of-life care. Assessing the numbers of people in the community who need end-of-life care can lead to evidence-based practices for addressing both the needs of the nurses and the home care needs of these patients (Smith and Porock, 2009) (Box 3-1).
Improved access to care ensures that essential community-wide health services are available and accessible to the total community (Stanhope and Lancaster, 2010). Examples include prenatal care programs for the uninsured and educational programs to ensure the competency of public health professionals. Population-based public health programs focus on disease prevention, health protection, and health promotion. This focus provides the foundation for health care services at all levels (see Chapter 2).
The five-level health services pyramid is an example of how to provide community-based services within existing health care services in a community (see Fig. 2-1 on p. 17). In this population-focused health care services model, the goals of disease prevention, health protection, and health promotion provide a foundation for primary, secondary, and tertiary health care services.
A rural community often has a hospital to meet the acute care needs of its citizens. However, a community assessment might reveal that there are minimal services to meet the needs of expectant mothers, reduce teenage smoking, or provide nutritional support for older adults. Community-based programs are able to provide these services and are effective in improving the health of the community. On the other hand, when a community has the resources for providing childhood immunizations, flu vaccines, primary preventive care services are able to focus on child developmental problems and child safety.
Public health services aim at achieving a healthy environment for all individuals. Health care providers apply these principles for individuals, families, and the communities in which they live. Nursing plays a role in all levels of the health services pyramid. By using public health principles you are better able to understand the types of environments in which patients live and the types of interventions necessary to help keep patients healthy.
Community Health Nursing
Frequently the terms community health nursing and public health nursing are used interchangeably, although they are different. A public health nursing focus requires understanding the needs of a population or a collection of individuals who have one or more personal or environmental characteristics in common (Stanhope and Lancaster, 2010). Examples of populations include high-risk infants, older adults, or a cultural group such as Native Americans. A public health nurse understands factors that influence health promotion and health maintenance, the trends and patterns influencing the incidence of disease within populations, environmental factors contributing to health and illness, and the political processes used to affect public policy. For example, the nurse uses data on increased incidence of playground injuries to lobby for a policy to use shock-absorbing material rather than concrete for new public playgrounds.
Public health nursing requires preparation at the basic entry level and sometimes requires a baccalaureate degree in nursing that includes educational preparation and clinical practice in public health nursing. A specialist in public health has a graduate level education with a focus in the public health sciences (American Nurses Association [ANA], 2007).
Community health nursing is nursing practice in the community, with the primary focus on the health care of individuals, families, and groups in a community. The goal is to preserve, protect, promote, or maintain health (Stanhope and Lancaster, 2010). The emphasis of such nursing care is to improve the quality of health and life within that community. In addition, the community health nurse provides direct care services to subpopulations within a community. These subpopulations often have a clinical focus in which the nurse has expertise. For example, a case manager follows older adults recovering from stroke and sees the need for community rehabilitation services, or a nurse practitioner gives immunizations to patients with the objective of managing communicable disease within the community. By focusing on subpopulations, the community health nurse cares for the community as a whole and considers the individual or family as only one member of a group at risk.
Competence as a community health nurse requires the ability to use interventions that include the broad social and political context of the community (Stanhope and Lancaster, 2010). The educational requirements for entry-level nurses practicing in community health nursing roles are not as clear as those for public health nurses. Not all hiring agencies require an advanced degree. However, nurses with a graduate degree in nursing who practice in community settings are considered community health nurse specialists, regardless of their public health experience (Stanhope and Lancaster, 2010).
Nursing Practice in Community Health
Community-focused nursing practice requires a unique set of skills and knowledge. In the health care delivery system nurses who become expert in community health practice usually have advanced nursing degrees, yet the baccalaureate-prepared generalist is also quite competent in formulating and applying population-focused assessments and interventions. The expert community health nurse understands the needs of a population or community through experience with individual families and working through their social and health care issues. Critical thinking is important in applying knowledge of public health principles, community health nursing, family theory, and communication in finding the best approaches in partnering with families.
Successful community health nursing practice involves building relationships with the community and being responsive to changes within the community. For example, when there is an increase in the incidence of grandparents assuming child care responsibilities, the community health nurse becomes an active part of a community by establishing an instructional program in cooperation with local schools and assists and supports grandparents in this caregiving role. The nurse knows the community members, needs, and resources and then works in collaboration with community leaders to establish effective health promotion and disease prevention programs. This requires working with highly resistant systems (e.g., welfare system) and trying to encourage them to be more responsive to the needs of a population. Skills of patient advocacy, communicating people’s concerns, and designing new systems in cooperation with existing systems help to make community nursing practice effective.
Community-Based Nursing
Community-based nursing care takes place in community settings such as the home or a clinic, where the focus is on the needs of the individual or family. It involves the safety needs and acute and chronic care of individuals and families, enhances their capacity for self-care, and promotes autonomy in decision making (Stanhope and Lancaster, 2010). You use critical thinking and decision making for the individual patient and family—assessing health status, diagnosing health problems, planning care, implementing interventions, and evaluating outcomes of care. Because nurses provide direct care services where patients live, work, and play, it is important that nursing care remains focused on the individual and family and that the values of the individual, family, and the community are respected and incorporated (Reynolds, 2009).
Community-based nursing centers function as the first level of contact between members of a community and the health care delivery system (Fig. 3-1). Ideally health care services are provided near where patients live. This approach helps to reduce the cost of health care for the patient and the stress associated with the financial burdens of care. In addition, these centers offer direct access to nurses and patient-centered health services and readily incorporate the patient and the patient’s family or friends into a plan of care. Community-based nursing centers often care for the most vulnerable of the population (Kaiser et al., 2009).
FIG. 3-1 Patient and family receiving care in a community-based care center. (Courtesy Mass Communication Specialist 2nd Class Daniel Viramontes.)
With the individual and family as the patients, the context of community-based nursing is family-centered care within the community. This focus requires a strong knowledge base in family theory (see Chapter 10), principles of communication (see Chapter 24), group dynamics, and cultural diversity (see Chapter 9). You learn to partner with your patients and families so ultimately the patient and family assume responsibility for their health care decisions.
Vulnerable Populations
In a community setting nurses care for patients from diverse cultures and backgrounds and with various health conditions. However, changes in the health care delivery system have made high-risk groups the principal patients. For example, you are not likely to visit low-risk mothers and babies. Instead, adolescent mothers or mothers with drug addiction are more likely to receive home care services. Vulnerable populations are groups of patients who are more likely to develop health problems as a result of excess health risks, who are limited in access to health care services, or who depend on others for care. Individuals living in poverty, older adults, people who are homeless, immigrant populations, individuals in abusive relationships, substance abusers, and people with severe mental illnesses are examples of vulnerable populations. Public and community health nursing and primary care providers share health care responsibility for health promotion, screening, and early detection and disease prevention for vulnerable populations. These patients have intense health care needs that are unmet or ignored or require more care than can be provided in outpatient or hospital settings (Kaiser et al., 2009). Vulnerable individuals and their families often belong to more than one of these groups. In addition, health care vulnerability affects all age-groups (Sebastian, 2010).
Vulnerable patients often come from varied cultures, have different beliefs and values, face language and literacy barriers, and have few sources of social support. Their special needs will be a challenge for you as you care for increasingly complex acute and chronic health conditions.
To provide competent care for vulnerable populations, you need to assess these patients accurately (Box 3-2). In addition, you need to evaluate and understand a patient’s and family’s cultural beliefs, values, and practices to determine their specific needs and the interventions that will most likely be successful in improving their state of health (see Chapter 9). It is important not to judge or evaluate your patient’s beliefs and values about health in terms of your own culture, beliefs, and values. Communication and caring practices are critical in learning a patient’s perceptions of his or her problems and then planning health care strategies that will be meaningful, culturally appropriate, and successful.
Barriers to access and use of services often lead to adverse health outcomes for vulnerable populations (Rew et al., 2009). Because of these poorer outcomes, vulnerable populations have shorter life spans and higher morbidity rates. Members of vulnerable groups frequently have multiple risks, which make them more sensitive to the cumulative effects of individual risk factors. It is essential for community-based nurses to assess members of vulnerable populations by taking into account the multiple stressors that affect their patients’ lives. It is also important to learn the patients’ strengths and resources for coping with stressors. Complete assessment of vulnerable populations enables a community health nurse to design interventions within the context of a community (Rew et al., 2009).
Immigrant Population
Researchers predict that the immigrant population will reach a 54% majority by 2050 (U.S. Census Bureau, 2009). Immigrant populations face multiple diverse health issues that cities, counties, and states need to address. These health care needs pose significant legal and policy issues. For some immigrants access to health care is limited because of language barriers and lack of benefits, resources, and transportation. Immigrant populations often have higher rates of hypertension, diabetes mellitus, and infectious diseases; decreased outcomes of care; and shorter life expectancies (Stanhope and Lancaster, 2010).
Frequently the immigrant population practices nontraditional healing practices (see Chapter 9). Although many of these healing practices are effective and complement traditional therapies, it is important that you know and understand all of your patient’s health care practices.
Certain immigrant populations left their homes as a result of oppression, war, or natural disaster (e.g., Afghans, Bosnians, and Somalis). Be sensitive to these physical and psychological stressors and consequences and identify the appropriate resources to help understand your patients and their health care needs (Stanhope and Lancaster, 2010).
Effects of Poverty and Homelessness
People who live in poverty are more likely to live in hazardous environments, work at high-risk jobs, eat less nutritious diets, have multiple stressors in their lives, and be at risk for homelessness. Patients with low income levels not only lack financial resources but also live in poor environments and face practical problems such as poor or unavailable transportation. Homeless patients have even fewer resources than the poor. They are often jobless and do not have the advantage of shelter and must continually cope with finding a place to sleep at night and finding food. Chronic health problems tend to worsen because of poor nutrition and the inability to store nutritional foods. In addition, the homeless population is usually walking the streets and neighborhoods to seek shelter, and they lack a balance of rest and activity (Schanzer et al., 2007). There is a startling increase in adolescent homelessness. The homeless adolescent is usually without a nuclear family and has greater health care risks because of immaturity, which increases the prevalence of risky behaviors (Rew et al., 2008).
Patients Who Are Abused
Physical, emotional, and sexual abuse and neglect are major public health problems affecting older adults, women, and children. Risk factors for abusive relationships include mental health problems, substance abuse, socioeconomic stressors, and dysfunctional family relationships (Landenburger and Campbell, 2010). For some, risk factors may not be present. When dealing with patients at risk for or who have suffered abuse, it is important to provide protection. Interview patients you suspect are abused at a time when the patient has privacy and the individual suspected of being the abuser is not present. Patients who are abused may fear retribution if they discuss their problems with a health care provider. Most states have abuse hot lines that nurses and other health care providers must notify when they identify an individual as being at risk.
Patients Who Abuse Substances
Substance abuse is a term that describes more than the use of illegal drugs. It also includes the abuse of alcohol and prescribed medications such as antianxiety agents and opioid analgesics. A patient with substance abuse often has health and socioeconomic problems. The socioeconomic problems result from the financial strain of the cost of drugs, criminal convictions from illegal activities used to obtain drugs, communicable disease from sharing drug paraphernalia, and family breakdown. For example, health problems for cocaine users often include nasal and sinus disorders and cardiac alterations that are sometimes fatal (Decker et al., 2006; Schanzer et al., 2007). Objectively assess your patient’s substance use in terms of the amount, frequency, and type of use to gain useful information to assist the patient. Frequently these patients avoid health care for fear of judgmental attitudes and concerns over being arrested by the police.
Patients with Mental Illnesses
When a patient has a severe mental illness such as schizophrenia or bipolar disorder, multiple health and socioeconomic problems need to be explored. Many patients with severe mental illnesses are homeless or live in poverty. Others lack the ability to remain employed or even to care for themselves on a daily basis (Cunningham et al., 2006). Patients suffering from mental illness often require medication therapy, counseling, housing, and vocational assistance. In addition, they are at a greater risk for abuse and assault.
Patients with mental illnesses are no longer routinely hospitalized in long-term psychiatric institutions. Instead, resources are offered within the community. Although comprehensive service networks are in every community, many patients still go untreated. Many patients are left with fewer and more fragmented services, with little skill in surviving and functioning within the community. Collaboration with multiple community resources is essential when helping patients with severe mental illness to obtain adequate health care.
Older Adults
With the increasing older-adult population, simultaneous increases in the number of patients suffering from chronic diseases and a greater demand for health care services are seen. You need to view health promotion in the older adult from a broad context. Take time to understand what health means to older-adult patients and the steps they take to maintain their own health and improve their level of function (Meiner and Leuckenotte, 2006). Thorough assessment and appropriate community-based interventions provide an opportunity to improve the lifestyle and quality of life of older adults (Table 3-1).
TABLE 3-1
Common Health Problems in Community-Dwelling Older Adults
| PROBLEM | Nursing Roles and Interventions |
| Hypertension | Monitor blood pressure and weight; educate about nutrition and antihypertensive drugs; teach stress management techniques; promote an optimal balance between rest and activity; establish blood pressure screening programs; assess patient’s current lifestyle and promote lifestyle changes; promote dietary modifications by using techniques such as a diet diary. |
| Cancer | Obtain health history; promote monthly breast self-examinations and annual Papanicolaou (Pap) smears and mammograms for older women; promote regular physical examinations; encourage smokers to stop smoking; correct mistaken beliefs about processes of aging; provide emotional support and quality of care during diagnostic and treatment procedures. |
| Arthritis | Educate adult about management of activities, correct body mechanics, availability of mechanical appliances, and adequate rest; promote stress management; counsel and assist family in improving communication, role negotiation, and use of community resources; teach adult to be cautious of false advertisements that promise a cure for arthritis. |
| Confusional states | Provide for a protective environment; promote activities that reinforce reality; assist with adequate personal hygiene, nutrition, and hydration; provide emotional support to the family; recommend applicable community resources such as adult day care, home care aides, and homemaker services. |
| Dementia | Maintain the best possible functioning, protection, and safety; foster human dignity; demonstrate to the primary family caregiver techniques to dress, feed, and toilet adult; provide frequent encouragement and emotional support to caregiver; act as an advocate for patient when dealing with respite care and support groups; protect patient’s rights; provide support to maintain family members’ physical and mental health; maintain family stability; recommend financial services if needed. |
| Medication use and abuse | Obtain drug history; educate adult about safe medication storage, the danger of polypharmacy, the risks of drug-drug and drug-food interactions, and general information about drug (e.g., drug name, purpose, side effects, dosage); instruct adult about presorting techniques (using small containers with one dose of drug that are labeled with specific administration times). |
Data from Stanhope M, Lancaster J: Foundations of nursing in the community: community-oriented practice, ed 3, St Louis, 2010, Mosby; and Meiner S, Lueckenotte AG: Gerontologic nursing, ed 3, St Louis, 2006, Mosby.
Competency in Community-Based Nursing
Nurses in community-based practices need a variety of skills and talents to successfully assist patients to meet their health care needs. To be successful in this setting you will be a caregiver, case manager, change agent, patient advocate, collaborator, educator, counselor, and epidemiologist (Teeley et al., 2006). These skills work together to help the patient remain in the home near his or her family and support system.
Caregiver
First and foremost is the role of caregiver. In the community setting you manage and care for the health of the community. You apply the nursing process (see Unit 3) in a critical thinking approach to ensure appropriate, individualized nursing care for specific patients and their families. In addition, you individualize care within the context of the patient’s community so long-term success is more likely. Together with the patient and family you develop a caring partnership to recognize actual and potential health care needs and identify needed community resources. As a caregiver, you also help to build a healthy community, which is one that is safe and includes elements to enable people to achieve and maintain a high quality of life and function.
Case Manager
In community-based practice, case management is an important competency (see Chapter 2). It is the ability to establish an appropriate plan of care based on assessment of patients and families and to coordinate needed resources and services for the patient’s well-being across a continuum of care. Generally a community-based case manager assumes responsibility for the case management of multiple patients. The greatest challenge is coordinating the activities of multiple providers and payers in different settings throughout a patient’s continuum of care. An effective case manager eventually learns the obstacles, limits, and even the opportunities that exist within the community that influence the ability to find solutions for patients’ health care needs.
Change Agent
A community-based nurse is also a change agent. This involves identifying and implementing new and more effective approaches to problems. You act as a change agent within a family system or as a mediator for problems within a patient’s community. You identify any number of problems (e.g., quality of community child care services, availability of older-adult day care services, or the status of neighborhood violence). As a change agent you empower individuals and their families to creatively solve problems or become instrumental in creating change within a health care agency. For example, if your patient has difficulty keeping regular health care visits, you determine why. Maybe the health clinic is too far and difficult to reach, or perhaps the hours of service are incompatible with the patient’s transportation resourses. You work with the patient to solve the problem and help identify an alternative site such as a nursing clinic that is closer and has more convenient hours.
To effect change you gather and analyze facts before you implement the program. This requires you to be very familiar with the community itself. Many communities resist change, preferring to provide services in the established manner. Before analyzing facts, it is often necessary to manage conflict among the health care providers, clarify their roles, and clearly identify the needs of the patients. If the community has a history of poor problem solving, you will have to focus on developing problem-solving capabilities (Stanhope and Lancaster, 2010).
Patient Advocate
Patient advocacy is more important today in community-based practice because of the confusion surrounding access to health care services. Your patients often need someone to help them walk through the system and identify where to go for services, how to reach individuals with the appropriate authority, what services to request, and how to follow through with the information they receive. It is important to provide the information necessary for patients to make informed decisions in choosing and using services appropriately. In addition, it is important for you to support and at times defend your patients’ decisions.
Collaborator
In a community-based nursing practice you need to be competent in working not only with individuals and their families but also with other related health care disciplines. Collaboration, or working in a combined effort with all those involved in care delivery, is necessary to develop a mutually acceptable plan that will achieve common goals (Stanhope and Lancaster, 2010). For example, when your patient is discharged home with terminal cancer, you collaborate with hospice staff, social workers, and pastoral care to initiate a plan to support end-of-life care for the patient and support the family. For collaboration to be effective, you will need mutual trust and respect for each professional’s abilities and contributions.
Counselor
Knowing community resources is a critical factor in becoming an effective patient counselor. A counselor helps patients identify and clarify health problems and choose appropriate courses of action to solve those problems. For example, in employee assistance programs or women’s shelters, a major amount of nurse-patient interaction is through counseling. As a counselor you are responsible for providing information, listening objectively, and being supportive, caring, and trustworthy. You do not make decisions but rather help your patients reach decisions that are best for them (Stanhope and Lancaster, 2010). Patients and families often require assistance in first identifying and clarifying health problems. For example, a patient who repeatedly reports a problem in following a prescribed diet is actually unable to afford nutritious foods or has family members who do not support good eating habits. You need to discuss with your patient factors that block or aid problem resolution, identify a range of solutions, and then discuss which solutions are most likely to be successful. You also encourage your patient to make decisions and express your confidence in the choice the patient makes.
Educator
In a community-based setting you have an opportunity to work with single individuals and groups of patients. Establishing relationships with community service organizations offers educational support to a wide range of patient groups. Prenatal classes, infant care, child safety, and cancer screening are just some of the health education programs provided in a community practice setting.
When the goal is to help your patients assume responsibility for their own health care, your role as an educator takes on greater importance (Stanhope and Lancaster, 2010). Patients and families must gain the skills and knowledge needed to learn how to care for themselves. Assess your patient’s learning needs and readiness to learn within the context of the individual, the systems with which the individual interacts (e.g., family, business, and school), and the resources available for support. Adapt your teaching skills so you can instruct the patient within the home setting and make the learning process meaningful. In this practice setting you have the opportunity to follow patients over time. Planning for return demonstration of skills, using follow-up phone calls, and referring to community support and self-help groups give you an opportunity to provide continuity of instruction and reinforce important instructional topics (see Chapter 25).
Epidemiologist
As a community health nurse, you also apply principles of epidemiology. Your contacts with families, community groups such as schools and industries, and health care agencies place you in a unique position to initiate epidemiological activities. As an epidemiologist, you are involved in case finding, health teaching, and tracking incident rates of an illness. For example, a cafeteria worker in the local high school is diagnosed with active tuberculosis (TB). As a community health nurse, you help find new TB exposures or active disease within the worker’s home, employment network, and community.
Nurse epidemiologists are responsible for community surveillance for risk factors (e.g., tracking incidence of elevated lead levels in children and identifying increased fetal and infant mortality rates, increases in adolescent pregnancy, presence of infectious and communicable diseases, and outbreaks of head lice). Nurse epidemiologists protect the level of health of the community, develop sensitivity to changes in the health status of the community, and help identify the cause of these changes.
Community Assessment
When practicing in a community setting, you need to learn how to assess the community at large. Community assessment is the systematic data collection on the population, monitoring the health status of the population, and making information available about the health of the community (Stanhope and Lancaster, 2010). This is the environment in which patients live and work. Without an adequate understanding of that environment, any effort to promote a patient’s health and institute necessary change is unlikely to be successful. The community has three components: structure or locale, the people, and the social systems. To develop a complete community assessment, take a careful look at each of the three components to identify needs for health policy, health programs, and needed health services (Box 3-3).
When assessing the structure or locale, you travel around the neighborhood or community and observe its design, the location of services, and the locations where residents meet. You obtain the demographics of the population by accessing statistics on the community from a local public health department or public library. Acquire information about existing social systems such as schools or health care facilities by visiting various sites and learning about their services.
Once you have a good understanding of the community, perform all individual patient assessments against that background. For example, when assessing a patient’s home for safety, you consider the following: does the patient have secure locks on doors? Are windows secure and intact? Is lighting along walkways and entryways operational? As you conduct the patient assessment, it is important to know the level of community violence and the resources available when help is necessary. Always assess an individual in the context of the community.
Changing Patients’ Health
In community-based practice, nurses care for patients from diverse backgrounds and in diverse settings. It is relatively easy over time to become familiar with the available resources within a particular community practice setting. Likewise, with practice you learn how to identify the unique needs of individual patients. However, the challenge is promoting and protecting a patient’s health within the context of the community. For example, can a patient with lung disease have the quality of life necessary in a community that has a serious environmental pollution problem? Similarly, nurses bring together the resources necessary to improve the continuity of care that patients receive. You are a key figure in reducing the duplication of health care services and locating the best services for a patient’s needs.
Perhaps the most important theme to consider is how well you understand your patients’ lives. This begins by establishing strong, caring relationships with patients and their families (see Chapter 7). As you gain experience, after being accepted by a patient’s family you are able to advise, counsel, and teach effectively and understand what truly makes the patient unique. The day-to-day activities of family life are the variables that influence how you will adapt nursing interventions. The time of day a patient goes to work, the availability of the spouse and patient’s parents to provide child care, and the family values that shape views about health are just a few examples of the many factors you will consider in community-based practice. Once you acquire a picture of a patient’s life, you then design interventions to promote health and prevent disease within the community-based practice setting.
Key Points
• Principles of public health nursing practice focus on assisting individuals and communities with achieving a healthy living environment.
• Essential public health functions include community assessment, policy development, and access to resources.
• When population-based health care services are effective, there is a greater likelihood that the higher levels of services will contribute efficiently to health improvement of the population.
• The community health nurse cares for the community as a whole and assesses the individual or family within the context of the community.
• Successful community health nursing practice involves building relationships with the community and being responsive to changes within the community.
• The community-based nurse’s competence is based on decision making at the level of the individual patient.
• The special needs of vulnerable populations are a challenge that nurses face in caring for these patients’ increasingly complex acute and chronic health conditions.
• A community-based nurse is competent as a caregiver, collaborator, educator, counselor, change agent, patient advocate, case manager, and epidemiologist.
• Patients are more likely to accept a change if it is more advantageous, compatible, realistic, and easy to adopt.
Clinical Application Questions
Preparing for clinical practice
You are managing community care for Katie, age 17, who has cerebral palsy and is severely disabled. Because of the impact of this adolescent’s disability, you are also providing care to Monica, age 50, who is a single parent. Katie is the youngest of three children. Her siblings are Josh, age 22, and Marilyn, age 19. Katie attends the special education program of the local school district, and Monica works as a teachers’ aide in another school in the district. Katie will remain in the special education program until she is 21. Monica does not know what will happen when Katie is 21, and she has not investigated any other community resources for Katie in the last 10 years. Both siblings are in college and live in the home and are helpful in Katie’s care. Josh will graduate from college, and his mother is encouraging him to move from the home.
1. What do you need to assess in the community to identify resources that provide family support in the care of a disabled child?
2. What resources do you need to identify for the family to assist Katie’s siblings in moving from the home and beginning their careers?
3. What can you do to help the family begin to envision the new family structure as Josh and Marilyn move out of the home?
Answers to Clinical Application Questions can be found on the Evolve website.
Are you ready to test your nursing knowledge?
1. A community nurse in a diverse community is working with health care professionals to provide prenatal care for underemployed and underinsured South African women. Which overall goal of Healthy People 2020 does this represent?
1. Assess the health care needs of individuals, families, or communities
2. Develop and implement public health policies and improve access to care
3. Gather information on incident rates of certain diseases and social problems
4. Increase life expectancy and quality of life and eliminate health disparities
2. Using Healthy People 2020 as a guide, which of the following would improve delivery of care to a community? (Select all that apply.)
2. Implementing public health policies
4. Determining rates of specific illnesses
5. Reducing the number of fast food restaurants in the community
3. A nursing student in the last semester of the baccalaureate nursing program is beginning the community health practicum and will be working in a community-based clinic with a focus on asthma and allergies. What is the focus of the community health nurse in this clinic setting? (Select all that apply.)
1. Decreasing the incidence of asthma attacks in the community
2. Increasing healthy food choices for school lunches
3. Assessing for factors that contribute to asthmatic attacks in the community
4. Providing asthma education programs for the teachers in the local schools
4. A nurse caring for a Bosnian community identifies that the children are undervaccinated and the community is unaware of resources. The nurse assesses the community and determines that there is a health clinic within a 5-mile radius. The nurse meets with the community leaders and explains the need for immunizations, the location of the clinic, and the process of accessing health care resources. Which of the following practices is the nurse providing? (Select all that apply.)
1. Educating about community resources
2. Teaching the community about illness prevention
3. Promoting autonomy in decision making
4. Improving the health care of the children in the community
5. Vulnerable populations of patients are those who are more likely to develop health problems as a result of:
1. Chronic diseases and homelessness
3. Lack of transportation, ability to perform self-care but are homeless
4. Excess health risks, limits in access to health care services, and dependency on others for care
6. Which of the following are major public health problems commonly affecting older adults? (Select all that apply.)
7. The local health department received information from the Centers for Disease Control and Prevention that the flu was expected to be very contagious this season. The nurses set up flu vaccine clinics in local churches and senior citizen centers. This activity is an example of which level of prevention?
8. A neighborhood with old homes is undergoing a lot of restoration. Lead paint was used in the buildings. The clinic is initiating a lead screening program. This activity is an example of which level of prevention?
9. In an occupational health setting, the nurse determines that a large number of employees smoke and designs an employee assistance program for smoking cessation. This is an example of which nursing role:
10. The nurse in a community health clinic notices an increase in the number of positive tuberculosis skin tests from students in a local high school during the most recent academic year. After comparing these numbers to the previous years, a 10% increase in positive tests was found. The nurse contacts the school nurse and the director of the health department. Together they begin to expand their assessment to all students and employees of the school district. The community health nurse is acting in which nursing role(s)? (Select all that apply.)
11. In the community clinic the nurse provides care for a 40-year-old woman who takes insulin to manage her diabetes. The patient is having increased difficulty managing her disease, and the nurse wants her to consider a new insulin pump to help her control it. Which of the following increases the likelihood that the patient will accept this new insulin pump? (Select all that apply.)
1. Supporting the patient as she tries the insulin pump on a limited basis
2. Identifying why the patient is reluctant to use the insulin pump
3. Telling the patient that many other patients you know use the insulin pump successfully
4. The patient’s perception that the insulin pump is more consistent with her health care goals than insulin administration
12. The nurse in a new community-based clinic is requested to complete a community assessment. Order the steps for completing this assessment.
13. On the basis of an assessment, the nurse identifies an increase in the immigrant population group in the community. How would he or she determine some of the health needs of this population? (Select all that apply.)
1. Identify which two health needs the immigrant population views as most important
2. Apply information from Healthy People 2020
3. Determine how the population uses available health care resources
14. A patient is worried about her 76-year-old grandmother who is in very good health and wants to live at home. The patient’s concerns are related to her grandmother’s safety. The neighborhood does not have a lot of crime. Using this scenario, which of the following are the most relevant to assess for safety?
1. Crime rate, locks, lighting, neighborhood traffic
2. Lighting, locks, clutter, medications
15. The nurse is working with the county health department on a task force to fully integrate the goals of Healthy People 2020. How does the nurse determine which goals need to be included or updated? (Select all that apply.)
Answers: 1. 4; 2. 1, 2, 3, 4; 3. 1, 2, 4; 4. 1, 2, 4; 5. 4; 6. 1, 2, 3, 5; 7. Tertiary intervention; 8. Secondary intervention; 9. 2; 10. 1, 3; 11. 1, 2, 4; 12. 1, 3, 2; 13. 1, 2, 3, 4; 14. 2; 15. 1, 2, 3.
References
American Nurses Association. Standards of public health nursing practice. Washington, DC: The Association; 2007.
Cunningham, P, et al. The struggle to provide community-based care to low-income people with mental illnesses. Health Affairs. 2006;25(3):694.
Edwards, H, et al. A randomized controlled trial of a community nursing intervention: improved quality of life and healing for clients with chronic leg ulcers. J Clin Nurs. 2009;18:1541.
Gordon, LG, et al. A cost-effectiveness analysis of two community models of nursing care for managing chronic venous leg ulcers. J Wound Care. 2006;15:348.
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Stanhope, M, Lancaster, J. Foundations of nursing in the community: community-oriented practice, ed 3. St Louis: Mosby; 2010.
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US Census Bureau, US Population Projections. 2009 National Population Projections, updated 2009 http://www.census.gov/population/www/projections/index.html. [Accessed December 2010].
US Department of Health and Human Services, Public Health Service, Healthy People 2020: a systematic approach to health improvement. Washington, DC: US Government Printing Office; 2010. http://www.healthypeople.gov/2020/about/new2020.aspx [Accessed August 2010].
Research References
Decker, S, et al. From the streets to assisting living: perceptions of vulnerable population. J Psychoc Nurs Mental Health Serv. 2006;44(6):18.
Downie, J, Ogilve, S, Wichmann, H. A collaborative model of community health nursing. Contemp Nurse. 2005;20:180.
Kaiser, L, et al. Public and community health nursing interventions with vulnerable primary care clients: a pilot study. J Comm Health Nurs. 2009;26:87.
Rew, L, et al. Interaction of duration of homelessness and gender in adolescent sexual health indicators. J Nurs Scholarship. 2008;40:109.
Rew, L, et al. Development of a dynamic model to guide health disparities research. Nursing Outlook. 2009;57(3):132.
Schanzer, B, et al. Homelessness, health status, and health care use. Am J Public Health. 2007;97:464.
Smith, R, Porock, D. Caring for people dying at home a research study into the need of community nurses. Int J Palliative Nurs. 2009;15(12):601.