Community-oriented nursing and community-based nursing

What is public health?

Public health is a scientific discipline that includes the study of epidemiology, statistics, and assessment—including attention to behavioral, cultural, and economic factors—as well as program planning and policy development. In recent years, efforts in the United States to change the way in which health care is delivered have focused heavily on looking at ways to change the delivery of medical care and on health insurance. Limited attention has been focused on looking at the health of the population. Although people are excited when a new drug is discovered that cures a disease or when a new way to transplant organs is perfected, it is important to know about the significant gains in the health of populations that have come largely from public health accomplishments. For example, public health has influenced the safety and adequacy of food and water, sewage disposal, public safety from biological threats, and changes in personal behaviors such as smoking. The dramatic increase in life expectancy for Americans during the 1900s, from less than 50 years in 1900 to 77.9 years in 2007, is credited primarily to improvements in sanitation, the control of infectious diseases through immunizations, and other public health activities (U.S. Department of Health and Human Services [USDHHS], 2010a). Population-based preventive programs launched in the 1970s were also largely responsible for the more recent changes in tobacco use, blood pressure control, dietary patterns (except obesity), automobile safety restraint, and injury control measures that have fostered declines in adult death rates. A more than 50% decline in stroke and coronary heart disease deaths has occurred. Overall death rates for children have declined by about 40% (USDHHS, 2010a).

Another way of looking at the benefits of public health practice is to look at how early deaths can be prevented. The U.S. Public Health Service estimates that medical treatment can prevent only about 10% of all early deaths in the United States, whereas population-focused public health approaches could help prevent about 70% of early deaths in America through measures targeted to the factors that contribute to those deaths. Many of these contributing factors are behavioral, such as tobacco use, diet, and sedentary lifestyle. Other factors that affect health are the environment, social conditions, education, culture, economics, working conditions, and housing (Healthy People 2020, USDHHS, 2010b).

The passage of the Affordable Care Act of 2010 created and charged the National Prevention, Health Promotion and Public Health Council with developing the National Prevention and Health Promotion strategy to focus on community-oriented approaches to prevention and wellness to “reduce the incidence and burden of the leading causes of death and disability.” The strategy identifies the five leading causes of death as heart disease, cancers, stroke, chronic lower respiratory disease, and unintentional injuries. Other priorities named are behavioral and mental health, substance use, and domestic violence screenings. In addition, the four health-promoting behaviors associated with the underlying causes of death that will be targeted through prevention measures are tobacco use, nutrition, physical activity, and underage and excessive alcohol use (USDHHS, 2010c).

Public health practice is of great value. The Centers for Medicare and Medicaid Services (CMS) (2012) reported that only 3% (up from 1.5% in 1960) of all national health expenditures supported population-focused public health functions. Unfortunately, the public is largely unaware of the contributions of public health practice. Federal and private monies were sparse in their support of public health, so public health agencies began to provide personal care services for persons who could not receive care elsewhere. The health departments benefited by receiving Medicaid and Medicare funds. The result was a shift of resources and energy away from public health’s traditional and unique population-focused perspective to include a primary care focus (USDHHS, 2002). As overall health needs become the focus of care in the United States, a stronger commitment to population-focused services is emerging. In July 2008, the Trust for America’s Health released a study that highlighted the effects of preventive services on improving lives and reducing costs as well as ways to change the health care system. The threats of bioterrorism, highlighted by the events of September 11, 2001, and the anthrax scares increase awareness for public safety. Important to the public health community is the emergence of modern-day epidemics and infectious diseases, such as the mosquito-borne West Nile virus and other causes of mortality, many of which affect the very young. Most of the causes are preventable (American College of Physicians, 2012).

Public health is best described as what society collectively does to ensure that conditions exist in which people can be healthy (Institute of Medicine, 2003). Public health is a community-oriented, population-focused specialty area. The overall mission of public health is to organize community efforts that will use scientific and technical knowledge to prevent disease and promote health (Institute of Medicine, 2003). The three public health core functions are assessment, policy development, and assurance.

Public health core functions defined

Figure 1-1 describes public health in America. These functions provide a framework for defining the services to be provided by the public health system. The core functions are defined as follows:

A working group within the U.S. Public Health Service developed the Health Services Pyramid (Figure 1-2). In this pyramid, population-focused public health programs with the goals of disease prevention, health protection, and health promotion provide a foundation for primary, secondary, and tertiary health care services. Each service level in the pyramid is important to the health of the population. The base of the pyramid shows the effective services that support the top tiers and contribute to better health. All tiers of the pyramid need to be adequately financed (U.S. Public Health Service, 1994/2008). Since the pyramid was developed it has been referenced to show how health care services can be offered to specific population groups (Frieden, 2010). In reality, health care in the United States has been organized with the pyramid upside down. That is, more attention, support, and funding are given to tertiary and secondary care than to primary and preventive services including population-focused care. The “How To” box on p. 5 lists the essential public health services.

These services need to be implemented to support the base of the pyramid and to support the services offered through the top tiers of the pyramid. Together, all services at all levels contribute to better health in America.

Population-focused nursing practice

PHN is a specialty with a distinct focus and scope of practice; it requires a special knowledge base. The role of the public health nurse has changed over the years in response to the following:

As noted in Chapter 2, PHN began more than 100 years ago; early public health nurses provided direct care to people, most often in their homes. The Henry Street Settlement, established in New York City in the late 1800s by Lillian Wald, was an early model for PHN. At Henry Street Settlement the nurses took care of the sick in their homes and also looked at the overall population of low-income people in the community from which their home care clients came. The primary focus that has differentiated PHN from other specialties has been the emphasis on the population rather than on single individuals or families. Following the example of Lillian Wald, public health nurses have done the following:

The primary goal of public health—the prevention of disease and disability—is achieved by ensuring that conditions exist in which people can remain healthy. The Policy Development process “How To” box describes ways to distinguish what actually makes up the specialty of PHN.

In 1981 the PHN section of the American Public Health Association (APHA) defined PHN and described how this role contributes to health care delivery. This statement was reaffirmed in 1996 (American Public Health Association, 1996). PHN is defined as a specialty that brings together knowledge from the public health sciences and nursing to improve the health of the community. It is defined by the Quad Council of Public Health Nursing Organizations as population-focused, community-oriented nursing practice. The goals of PHN are “the promotion of health, the prevention of disease and disability for all people through the creation of conditions in which people can be healthy” (American Nurses Association, 2007). Box 1-1 presents the process of PHN from the APHA definition.

Public health nurses, like others in public health, engage in assessment, policy development, and assurance activities. These functions are achieved when nurses work in partnerships with others, including nations, states, communities, organizations, groups, and individuals. Public health nurses carry out this mission by participating in the essential public health services described earlier in the chapter.

Although population-focused practice is the central feature of PHN, many of the skills and activities are used when community-oriented nurses and community-based nurses work in the community. For this reason, these practices are described in detail here. A population or aggregate is a collection of people who share one or more personal or environmental characteristics. Members of a community can be defined in terms of either geography (e.g., a county, a group of counties, or a state) or a special interest (e.g., children attending a particular school). These members make up a population. Generally, there are subpopulations within the larger population. Examples of a subpopulation within a population of a county are high-risk infants younger than 1 year old, unmarried pregnant adolescents, or individuals exposed to a particular event such as a chemical spill.

In population-focused practice, problems are defined (assessments/diagnoses) and solutions (interventions), such as policy development or providing a given preventive service, are implemented for or with a defined population or subpopulation as opposed to diagnoses, interventions, and treatment carried out at the individual level. This contrasts with basic professional education in nursing, medicine, and other clinical disciplines, which emphasizes developing competence in decision making at the level of the individual client by assessing health status, making management decisions (ideally with the client), and evaluating the effects of care. The ways in which nurses provide care to people with high blood pressure can demonstrate how population-focused practice differs from the clinical direct care practice so often used in nursing. Specifically, in a clinical direct care situation a nurse practicing in the community might decide that a person is hypertensive based on certain clinical signs. The nurse would evaluate different interventions to find the best one for this person and implement an intervention such as a change in diet. In contrast, a public health nurse engaged in population-focused practice would ask the following questions:

Public health nurses are typically concerned with more than one subpopulation, and they often deal with the health of the entire community. Assessment, one of the public health core functions, is a logical first step in examining a community setting to determine its health status.

The core public health function of assessment includes the following:

Listed in the “How To” box is a general set of questions that can be used or modified to gather assessment data.

Excellent examples of assessment at the national level are the U.S. Department of Health and Human Services’ efforts to organize the goal-setting, data collection and analysis, and monitoring necessary to develop the series of publications describing the health status and health-related aspects of the U.S. population. These efforts began with Healthy People in 1980 and continued with Promoting Health, Preventing Disease: 1990 Health Objectives for the Nation, Healthy People 2000, Healthy People 2010, and are now moving forward into the future with Healthy People 2020 (USDHHS, 1979, 1991, 2000, 2010b).*

In a local health department, public health nurses would participate in and provide leadership for assessing community needs, the health status of populations within the community, and environmental and behavioral risks. They also look at trends in the factors that determine health in the community, identify priority health needs, and determine the adequacy of existing community resources.

Policy development is a core function of public health and one of the core intervention strategies used by PHN specialists. Policy development relies heavily on planning and begins with the identified needs and priorities set by the people involved. It also includes building constituencies that can bring about policy changes. It is important to know what the powerful people in the community think about a specific public health concern. Health and human services providers, as well as the people who will be served or affected, must be included. PHN is a “with the people,” not a “to the people” or “for the people,” approach to planning. Historically, health care providers have been accused of providing care for or to people without actually involving the recipients in the decisions. The beneficiaries of services in public health need to be included from the very beginning in identifying the need, planning the intervention, and deciding on the format for the evaluation (Box 1-2).

The third core public health function, assurance, focuses on the responsibility of public health agencies to be sure that activities are appropriately carried out to meet public health goals and plans. Not only does PHN include assessment or investigative functions but the role also requires skill in collaboration, consultation, and cooperation. The assurance function makes sure that the activities designed during the policy development or planning phase are carried out. This is done through collaboration with people in a variety of health and human service organizations to promote, monitor, and improve both the availability and quality of providers and services. PHN is not a good field for people who like to work alone. Although considerable opportunity exists for autonomy in thinking and planning, effective and consistent collaboration is vital to success. Assurance does not always mean to provide something. Rather, another agency may provide the needed service. Assurance means making certain that the services determined to be needed are provided by some agency within the community. Further, assurance includes assisting communities to implement and evaluate plans and projects. It includes maintaining the ability of both public health agencies and private providers to manage day-to-day operations, as well as the capacity to respond to critical situations and emergencies.

In PHN, the nurse often reaches out to those who might benefit from a service or intervention. In other forms of nursing, the client is more likely to seek and request assistance. As is discussed in later chapters, often the people or populations most in need of public health services are the least likely to ask for them. Examples include homeless, poor, and mentally ill people. The dominant needs of the population outweigh the expressed needs of one or a few people. Because resources are often limited, careful assessment to identify key needs is important.

However, the special contributions of public health nurse specialists include looking at the community or population as a whole, raising questions about its overall health status and factors associated with that status, including environmental factors (i.e., physical, biological, sociocultural), and working with the community to improve the population’s health status.

Practice focusing on individuals, families, and groups

As mentioned, community-based nursing practice, with its focus on the provision or assurance of care to individuals and families in the community, is different from community-oriented practice. The latter is broader in scope and is a form of care in which the nurse provides health care after doing a community diagnosis to determine what conditions need to be altered for individuals, families, and groups in the community to stay healthy. Although it is hoped that all direct care providers contribute to the community’s health in the broadest sense, not all are primarily concerned with the population focus, or the “big picture.” All nurses in a given community, including those working in hospitals, physicians’ offices, and health clinics, contribute positively to the health of the community. Examples of community settings for treating individuals include ambulatory surgery clinics, outpatient clinics, physician and advanced-practice nursing offices and clinics, and employment and school sites, as well as preschool programs, housing projects, and migrant camps. These sites often provide individual-focused health care services. This contrasts to population-focused services (i.e., services focused on a large group). A specific example is the federally funded program for preschool children, Head Start. From a community-oriented nursing care perspective, nursing services could be provided to individual children by conducting developmental-level screening tests to evaluate each child’s level of cognitive and psychomotor development in contrast to established standards for children of the same age. The community-based nurse may deliver illness care to the children in the school. In contrast, a public health or population-focused approach would look at the entire group of children being served by the program and the characteristics of the facility and its programs to see if they are effective in achieving the goals of making the school population healthier.

Community-oriented nursing

Most nurses practicing in the community and many staff public health nurses—both historically and at present—focus on providing direct care services, including health education, to persons or families outside of institutional settings, either in the home or in a clinic. Historically, the term community health nurse applied to all nurses who practiced in the community, regardless of whether they had preparation in PHN. Thus, nurses providing secondary or tertiary care in a home, school, or clinic or any nurse who did not practice in an institutional setting could be considered a “community health nurse.” To a large extent the development of what has been called community health nursing was influenced by the development within medicine of the specialty of community medicine. At that time both community medicine and community health nursing reached out to the community and began doing community assessments to determine more effectively the needs of the people. Thus, disease prevention and health promotion could be targeted to specific needs in a given community. Specifically, the community health nurse operated from a health care focus based on an understanding of broader community needs.

The nurse is continually evaluating the community to see if changes are occurring that will influence the health of the people who live there. The case study on the Evolve website is an example of community-oriented nursing practice. Work through the case study and answer the questions for understanding this area of specialty.

The practice of community-oriented nursing involves health promotion, health maintenance, health education, management, coordination, and continuity of care in the management of the health care of individuals, families, and groups in a community. A holistic approach is used, and the goal of this care is to provide personal health services that promote and preserve the health of the community in which the clients live. This nurse uses both nursing and public health theory to guide practice.

Evidence that entry-level nurses are practicing effectively in the community includes the following (Turnock, 2009):

• Provides quality services that can control costs

• Focuses on disease prevention and health promotion

• Organizes services where people live, work, play, and learn

• Provides referrals when clients need them

• Works in partnerships and with coalitions and other health care providers

• Works across the life span and with culturally diverse populations

• Works with at-risk populations to promote access to services

• Participates in epidemiological investigations and disaster services

• Develops the community’s capacity for health

• Works with policymakers for policy change

• Works to make the environment healthier

As can be seen, community-oriented nurses emphasize health protection, maintenance, and promotion, and disease prevention, as well as self-reliance among clients. Regardless of whether the client is a person, a family, or a group, the goal is to promote health through education about prevailing health problems, proper nutrition, beneficial forms of exercise, and environmental factors such as safe food, water, air, and buildings. The nurse is likely to be involved in immunizing individuals as well as organizing the immunization programs for vaccinating the community for influenza, for example, and educating the community about the value of this service. Other individual and family services include provision of maternal and child health care, treatment of common communicable and infectious diseases and injuries, and provision of basic screening programs for problems such as lice, vision, hearing, and scoliosis.

Nurses have always been involved in providing family-centered care to individuals, families, and groups across the life span; however, they also work to identify high-risk groups in the community. Once such groups are identified, the nurse can work with others to develop appropriate policies and interventions to reduce risk and provide beneficial services. Both community-oriented nurses and community-based nurses must be aware of cultural diversity and provide care that is appropriate to the needs of the recipient. Likewise, both groups of nurses provide care in homes. The Focus on Quality and Safety Education for Nurses box provides the list of competencies a nurse will need to improve the quality and safety of interventions and outcomes in the community. Compare these competencies to the public health nursing competencies in Appendix C.3.

FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES

Quality and Safety Education for Nurses (QSEN) Competencies

QSEN COMPETENCY	COMPETENCY DEFINITION
Client-Centered Care	Recognize the client or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for client preferences, values, and needs.
Teamwork and Collaboration	Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality care.
Evidence-Based Practice	Integrate best current evidence with clinical expertise and client/family preferences and values for delivery of optimal health care.
Quality Improvement	Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.
Safety	Minimizes risk for harm to clients and providers through both system effectiveness and individual performance.
Informatics	Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.

Prepared by Gail Armstrong, DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver College of Nursing.

LEVELS OF PREVENTION

Related to Public Health

Primary prevention

The public health nurse develops a health education program for a population of school-age children that teaches them about the effects of smoking on health.

Secondary prevention

The public health nurse provides toxin screenings for migrant workers who may be exposed to pesticides.

Tertiary prevention

The public health nurse provides a diabetes clinic for a defined population of adults in a low-income housing unit of the community.

Community-based nursing

As mentioned, the goal of CBN is to manage acute or chronic conditions while promoting self-care among individuals and families (Lundy and Janes, 2009). In CBN the nursing care is family centered, which means that the nurse works to improve the competencies of families to enable them to take better care of themselves. The nurse pays particular attention to the uniqueness of each family and works to plan the most useful interventions. A “cookbook” approach cannot be used because no one nursing approach will fit each family or individual. Cultural diversity is taken into account, as are the situations and stressors facing the person or the family at a given time. The nurse promotes client autonomy and helps clients learn to do as much as possible for themselves.

The nurse practicing CBN is more likely to give direct care to people than are nurses who practice from a community-oriented framework. To plan the most appropriate course of action, the nurse assesses client needs and the services available to meet those needs. Throughout care delivery, the nurse teaches and counsels clients so they can more fully develop their own ways of taking care of themselves. Box 1-3 provides definitions of each of the four key modes of nursing practice seen in the community.

BOX 1-3      DEFINITIONS OF THE FOUR KEY NURSING MODES IN THE COMMUNITY

Community-Oriented Nursing Practice: A philosophy of nursing care delivery that involves generalist or specialist public health and community health nurses providing “health care” through community diagnosis and investigation of major health and environmental problems, health surveillance, monitoring, and evaluation of community and population health status, to prevent disease and disability and promoting, protecting, and maintaining “health” to create conditions in which people can be healthy.

Public Health Nursing Practice: The synthesis of nursing and public health theory applied to promoting and preserving the health of populations. Practice focuses on the community as a whole, and the effect of the community’s health status (resources) on the health of individuals, families, and groups. The goal is to prevent disease and disability and promote and protect the health of the community as a whole. Community health nurse is a term that is often used interchangeably with public health nurse.

Community-Based Nursing Practice: A setting-specific practice in which care is provided for “sick” individuals and families where they live, work, and attend school. The emphasis is on acute and chronic care and the provision of comprehensive, coordinated, and continuous care. These nurses may be generalists or specialists in maternal–infant, pediatric, adult, or psychiatric mental health nursing.

Challenges for the future

Over the past few years, the places in which care is given have changed dramatically. In previous decades the majority of care was given in an inpatient setting. At present, the trend is to move more care into community settings and to reduce the number of hospital days for “sick” clients. A variety of reasons explain the change. First, community care is often much less expensive than hospital care. Because the cost of health care in the United States has risen considerably over the past decade, it is increasingly necessary to find new ways to deliver care that are accessible to the recipients, less expensive, and of adequate quality to meet client needs. Also, care in the community is usually more appealing to people who prefer to remain at home rather than be treated in a hospital. Currently, care is given in homes, schools, and at the work site, as well as in a variety of outpatient clinics. This trend is expected to grow, and it is expected that the role of the nurse in community settings will likewise grow and continue to change. Many factors will affect the changing role of the nurse in the community, such as the new and emerging infectious diseases, the need for emergency preparedness, the increases in chronic illness, and the continued reduction of numbers of days in the hospital for serious illnesses.