Chapter 7 COMMUNITY-BASED CARE
There has been a gradual change in Australian health care policies, with an increased focus on community-based health care. These changes have occurred as a result of public health policies aimed at maintaining health and preventing illness, a consumer push for more health care options, earlier discharge from acute hospitals and containment of costs.
This chapter aims to explain the roles of community nurses and the relevance of community assessment. It also clarifies the roles of two types of community nurses: community health nurses, caring for populations, communities, families and individuals; and community-based nurses, who care predominantly for individuals and families. Community-based nursing is discussed in more detail, covering its philosophy, aims, types of clients and aspects of care. The nursing process and its application in community nursing is also discussed.
I really wanted to stay in my own home, I did not want to go into care but I had many health problems, was not able to shower myself or go shopping for groceries any more. When the district nurses started visiting it was such a relief. They help me with my medications and they have organised for people to help me shower, to help with cleaning the house, getting my shopping and paying my bills.
Community-based health services are provided in a wide variety of settings, including community health centres, workplaces, family and child health centres, schools, universities, day care centres, alcohol and drug rehabilitation centres, mental health centres, in homes and on the streets for homeless people. For example, mental health nurses may meet with homeless clients in the street or in a squat.
Community-based health services are involved with health promotion, health education, maintenance of wellbeing, coordination and continuity of care within the community. Community-based health care works within the framework of Primary Health Care or essential health care (Chapter 6), with its focus on increasing access to basic health care, promotion of wellbeing and the prevention of illness, relying on the client being an active partner in care and not just the care recipient.
Many community-based health services are provided at community centres and in the home. As well as community nurses there are many other health care workers who provide community-based health care, both in centres and in people’s homes. Some of these include occupational therapists, physiotherapists, social workers, dietitians, general practitioners, home care workers, volunteers, personal carers and home maintenance workers. Collaborative working relationships between health care workers, institutions and agencies are essential for providing coordinated care for clients in the community.
Community health care workers have more limited access to the range of health workers than health care workers in many inpatient settings. Therefore their roles and partnerships with other health care workers extend beyond their immediate work environment. An awareness of the contributions other workers make and the development of a plan of care in consultation with the client is very important in achieving client outcomes.
The role of the community nurse is determined by the needs of the community they work in. One role of the community nurse is to improve the health of the community. To promote health and encourage changes in health practices, it is necessary to have an understanding of the community. This involves knowing the structure, population and the social systems of the community. The structure of a community includes its boundaries, types of housing, economy, the physical environment, water supply and sanitation.
Knowing the population involves identifying age and sex distributions, growth trends, population density, educational levels, and cultural and religious groups. The social systems of a community include the local government, education, communication, welfare, and health and transport systems.
The community nurse needs to undertake a community assessment before determining the community’s needs. A community assessment provides an understanding of the community’s environment. This incorporates the structure, population and social system of the community. There are several ways of achieving this. The community nurse can make observations of the structure of the community by travelling around the community and meeting with the local people. Statistical data can be collected from sources such as the Australian Bureau of Statistics, local government, existing databases, reports by other agencies and routine service data. To gather information on the social systems, the community nurse could visit agencies such as schools, health care facilities and local government departments.
Sensitivity to community perspectives is important. The initial step is to get to know the community well by seeking out community members and finding out their views on health and their perceived needs. It is vital to involve the community members in this process. The community may be more likely to support any activities for change if they are involved in the identification of the issues, the gathering of data and the plan of action.
In completing a community assessment the nurse should ensure the focus is not solely on identifying problems. The nurse should also look at the strengths and capacity for further development that exist within the community.
A broad definition of the community health nurse is one who practises with a working knowledge of the community, its health care services, networks of care providers and other resources to give holistic, coordinated care to promote wellbeing. The community health nurse role is continuing and comprehensive and is focused on nursing and health care for populations, communities, families and individuals. It is directed towards all age groups and includes health education, health promotion, health assessment and maintenance of health.
The community health nurse liaises with many institutions, organisations, agencies and a wider range of professional disciplines than hospital or institutional-based nurses. The community health nurse also works with the community over a period of time, and therefore has increased opportunities to provide continuing education and ongoing health promotion.
Empowerment is an important issue in community health nursing and is about improving community and client control over issues affecting them. The community health nurse can create a climate for empowerment by enabling access to information and resources, as well as helping communities and clients reach decisions that are appropriate for them. The focus is on community and client choice and autonomy, allowing communities and clients to make their own informed decisions.
The community health nurse has a wide community focus as well as providing nursing care to families and individuals while the community-based nurse focuses their care on individuals and families. The community health nurse is often involved with health promotion and illness prevention as well as the treatment of illness. One of their aims is to improve the health and wellbeing of the people in the community through group work providing health education and health promotion.
The community health nurse needs to be socially responsive, becoming an active part of the community, knowing its members, their needs and the community’s resources to establish effective health promotion and disease prevention programs. The community health nurse needs to assess and plan for care that is equitable, accessible, culturally sensitive and that empowers the community and its members for self-determined health care. It is important for all community health nurses to understand the lived experience of the people for whom they care and to understand community health programs available to members of the community.