Between 1980 and 2008, the number of nurses employed in community, health, and ambulatory care settings more than doubled (USDHHS, HRSA, BHP, 2010). The decline in the percentage of nurses employed in hospitals and subsequent increase in nurses employed in community settings indicates a shift in focus from illness and institutional-based care to a focus on health promotion and preventive care. This shift will likely continue into the future as alternative delivery systems, such as ambulatory and home care, will employ more nurses (Gaines, Jenkins, and Ashe, 2005; Inglis, 2004; Way and MacNeil, 2007).

Community/public health nursing is the synthesis of nursing practice and public health practice. The major goal of community health nursing is to preserve the health of the community and surrounding populations by focusing on health promotion and health maintenance of individuals, families, and groups within the community. Thus, community/public health nursing is associated with health and the identification of populations at risk rather than with an episodic response to patient demand.

The mission of public health is social justice, which entitles all people to basic necessities such as adequate income and health protection and accepts collective burdens to make this possible. Public health, with its egalitarian tradition and vision, conflicts with the predominant U.S. model of market justice that only entitles people to what they have gained through individual efforts. Although market justice respects individual rights, collective action and obligations are minimal. An overinvestment in technology and curative medical services within the market justice system has stifled the evolution of a health system designed to protect and preserve the health of the population. There is a need for an ethic of social justice, for it is society’s responsibility, rather than the individual’s, to meet the basic needs of all people. Thus there is a need for public funding of prevention efforts to enhance the health of our population.

Current U.S. health policy advocates changes in personal behaviors that might predispose individuals to chronic disease or accident. This policy promotes exercise, healthy eating, tobacco cessation, and moderate consumption of alcohol. However, simply encouraging the individual to overcome the effects of unhealthy activities lessens focus on collective behaviors necessary to change the determinants of health stemming from such factors as air and water pollution, workplace hazards, and unequal access to health care. Because living arrangements, work/school environment, and other sociocultural constraints affect health and well-being, public policy must address societal and environmental changes, in addition to lifestyle changes, that will positively influence the health of the entire population.

With ongoing changes in the health care system and increased employment in community settings, there will be greater demands on community health nurses to broaden their public health perspective. The Code of Ethics of the American Nurses Association (ANA) (2001) promotes social reform by focusing on health policy and legislation to positively affect accessibility, quality, and cost of health care. Community and public health nurses, therefore, must align themselves with public health programs that promote and preserve the health of populations by influencing sociocultural issues such as human rights, homelessness, violence, and stigma of illness. This allows nurses to be positioned to promote the health, welfare, and safety of all individuals.

This chapter examines health from a population-focused, community-based perspective. Therefore it requires understanding of how people identify, define, and describe related concepts. The following section explores six major ideas:

The definition of health is evolving. The early, classic definition of health by the World Health Organization (WHO) set a trend toward describing health in social terms, rather than in medical terms. Indeed, the WHO (1958, p. 1) defined health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”

Social means “of or relating to living together in organized groups or similar close aggregates” (American Heritage College Dictionary, 1997, p. 1291) and refers to units of people in communities who interact with each other. “Social health” connotes community vitality and is a result of positive interaction among groups within the community with an emphasis on health promotion and illness prevention. For example, community groups may sponsor food banks in churches and civic organizations to help alleviate problems with hunger and nutrition. Other community groups may form to address problems of violence and lack of opportunity, which can negatively affect social health.

In the mid-1980s, the WHO expanded the definition of health to include the following socialized conceptualization of health:

Saylor (2004) pointed out that the WHO definition considers several dimensions of health. These include physical (structure/function), social, role, mental (emotional and intellectual), and general perceptions of health status. It also conceptualizes health from a macro perspective, as a resource to be used rather than a goal in and of itself.

The nursing literature contains many varied definitions of health. For example, health has been defined as “a state of well-being in which the person is able to use purposeful, adaptive responses and processes physically, mentally, emotionally, spiritually, and socially” (Murray, Zentner, and Yakimo, 2009, p. 53); “actualization of inherent and acquired human potential through goal-directed behavior, competent self-care, and satisfying relationships with others” (Pender, Murdaugh, and Parsons, 2006, p. 22); and a state of a person that is characterized by soundness or wholeness of developed human structures and of bodily and mental functioning (Orem, 2001).

The variety of characterizations of the word illustrates the difficulty in standardizing the conceptualization of health. Commonalities involve description of “goal-directed” or “purposeful” actions, processes, responses, or behaviors and possessing “soundness,” “wholeness,” and/or “well-being.” Problems can arise when the definition involves a unit of analysis. For example, some authors use the individual or “person” as the unit of analysis and exclude the community. Others may include additional concepts, such as adaptation and environment, in health definitions and then present the environment as static and requiring human adaptation, rather than as changing and enabling human modification.

For many years, community and public health nurses have favored Dunn’s (1961) classic concept of wellness, in which family, community, society, and environment are interrelated and have an impact on health. From his viewpoint, illness, health, and peak wellness are on a continuum; health is fluid and changing. Consequently, within a social environment, the state of health depends on the goals, potentials, and performance of individuals, families, communities, and societies.

The definitions of community are also numerous and variable. Baldwin and colleagues (1998) outlined the evolution of the definition of community by examining definitions that appeared in community health nursing texts. They determined that, before 1996, definitions of community focused on geographical boundaries, combined with social attributes of people. Through citing several sources from the later part of the decade, the authors observed that geographical location became a secondary characteristic in the discussion of what defines a community.

In recent nursing literature, community has been defined as “a collection of people who interact with one another and whose common interests or characteristics form the basis for a sense of unity or belonging” (Allender, Rector, and Warner, 2009, p. 6); “a group of people who share something in common and interact with one another, who may exhibit a commitment with one another and may share a geographic boundary” (Lundy and Janes, 2009, p. 16); “a group of people who share common interests, who interact with each other, and who function collectively within a defined social structure to address common concerns” (Clark, 2008, p. 27); and “a locality-based entity, composed of systems of formal organizations reflecting society’s institutions, informal groups and aggregates” (Shuster and Goeppinger, 2008, p. 344).

Maurer and Smith (2009) further addressed the concept of community and identified four defining attributes: people, place, interaction, and common characteristics, interests, or goals. Combining ideas and concepts, in this text, community is seen as a group or collection of locality-based individuals, interacting in social units and sharing common interests, characteristics, values, and/or goals.

Maurer and Smith (2009) noted that there are two main types of communities: geopolitical communities and phenomenological communities. Geopolitical communities are those most traditionally recognized or imagined when considering the term community. Geopolitical communities are defined or formed by both natural and manmade boundaries and include cities, counties, states, and nations. Other commonly recognized geopolitical communities are school districts, census tracts, zip codes, and neighborhoods. Phenomenological communities, on the other hand, refer to relational, interactive groups. In phenomenological communities, the place or setting is more abstract, and people share a group perspective or identity based on culture, values, history, interests, and goals. Examples of phenomenological communities would be schools, colleges, and universities; churches, synagogues, and mosques; and various groups or organizations.

A community of solution is a type of phenomenological community. A community of solution is a collection of people who form a group specifically to address a common need or concern. The Sierra Club, whose members lobby for the preservation of natural resource lands, and a group of disabled people who challenge the owners of an office building to obtain equal access to public buildings, education, jobs, and transportation are examples. These groups or social units work together to realize a level of potential “health” and to address identified actual and potential health threats and health needs.

Population and aggregate are related terms that are often used in public health and community health nursing. Population is typically used to denote a group of people having common personal or environmental characteristics. It can also refer to all of the people in a defined community (Maurer and Smith, 2009). Aggregates are subgroups or subpopulations that have some common characteristics or concerns (Clark, 2008). Depending on the situation, needs, and practice parameters, community health nursing interventions may be directed toward a community (e.g., residents of a small town), a population (e.g., all elders in a rural region), or an aggregate (e.g., pregnant teens within a school district).