Community-Based Nursing Care of the Child and Family

Christine A. Brosnan, Sandra L. Upchurch and Martina R. Gallagher

http://evolve.elsevier.com/wong/essentials

Nursing in the Community

The health of children and their families is greatly influenced by their community, and nurses can make a significant contribution by working with the community to promote children’s health. Nurses working with pediatric populations in the community need an understanding of the concepts and processes critical to address pediatric concerns from a community health perspective. Healthy communities provide not only excellent medical care but also a nurturing, safe place for children to live and grow. Healthy communities and cities address concerns through collaboration between and among citizens, health care providers, businesses, and governmental and private agencies (Riner, 2008).

This chapter discusses community health nursing as it relates to children. First, it identifies and defines the concepts and principles that serve as the basis of community health nursing. Then it describes the community health nursing process, step by step. It includes a box that demonstrates use of the process to address a very real child health concern: obesity.

There are several ways to define a community. A community is a group of individuals with shared characteristics or interests who interact with each other (Rector, 2010). A community is a system that includes children and families, the physical environment, educational facilities, safety and transportation resources, political and governmental agencies, health and social services, communication resources, economic resources, and recreational facilities. The community is also the client of the community health nurse (Anderson and McFarland, 2010). Community health initiatives are directed at either the general health of the community as a whole or at specific populations within the community that have unique needs. In this context, populations can be described as groups of people who live in a community and have characteristics in common (e.g., school-age children). Target populations or subpopulations are more narrowly defined groups (e.g., nonimmunized preschoolers, obese middle school children) toward whom nurses direct activities to improve the health status of individuals in the group. Common values often guide behaviors of populations and subpopulations in relation to health promotion and disease prevention (McEwen and Nies, 2011; Williams, 2010).

Community-oriented care involves a collaboration of individuals and groups, including health care providers, advocates, government, managed care organizations, businesses, children, and families, within a specific community. The goal of the collaborative effort is to provide services that promote the child health initiatives of Healthy People 2020.* Community care is “without walls” in that the services of the health care system are frequently redesigned to meet the changing needs of the community. Those involved in community care partner with the community to identify, plan, intervene, and evaluate activities that improve the community’s health (Anderson and McFarlane, 2010).

Community Health Nursing

Community health nursing focuses on promoting and maintaining the health of individuals, families, and groups in a community setting. Community health nursing is a synthesis of nursing and public health. It is population focused and involves collaboration with other disciplines to assess, plan, and implement care that emphasizes personal responsibility for health and self-care by community members (Warner, 2010; Williams, 2010). Community health nursing, at its best, empowers communities by enabling its members to gain the knowledge and skills needed to fulfill their own needs.

Although community health concepts can be used to address health concerns in any setting, traditional community health settings include home health agencies, schools, physician offices, ambulatory health clinics, emergency departments (EDs), triage call centers, insurance agencies, health departments, international relief agencies, health education agencies, juvenile detention facilities, camps, daycare centers, foster care facilities, hospice centers, and rehabilitation agencies. The American Nurses Association (1986) has established nine standards for community health nursing to guide practice across settings. They include the following categories: theory, data collection, diagnosis, planning, intervention, evaluation, quality assurance and professional development, interdisciplinary collaboration, and research. The revised scope and standards of public health nursing (American Nurses Association, 2007) describe the major components and measurement criteria for each standard.

Roles and Functions

The roles and functions of the community health nurse continue to evolve. In the future, more pediatric nurses will be working in community settings. The Health Resources and Services Administration (2004) reported that 14.9% of the total registered nurse work force was employed in a community or public health setting and 11.5% in ambulatory care. Only 56.2% of registered nurses were employed in hospital settings. An example of the role evolution is the need for competent public health/community health nurses to work during times of natural disasters, public health threats, and terrorism attacks (Box 2-1).

Box 2-1

Evolving Role of the Pediatric Nurse

Natural and Human-Made Disasters

Communities are affected by disasters, either natural disasters such as hurricanes and wildfires or human-made disasters such as terrorist attacks. During disasters, communities may not have the resources to respond and recover on their own. Pediatric nurses in all settings need to know disaster management stages, which include:

Prevention—Identification of disaster risks; education about what actions to take

Preparedness and planning

For individuals and families—Training in first aid, an emergency disaster kit, a predetermined place to meet, and a communication plan

For communities and agencies—Determination of the lines of authority and communication; coordination of personnel, supplies, and equipment; evacuation; rescue; and care of the dead

Response—Begins after the disaster; plans are implemented, which may include shelter in place for individuals, evacuation, or search and rescue. Calmness and patience are essential characteristics for all individuals involved

An important question for nurses to consider: Will nurses care for patients in the community during the disaster, or will they stay with their own family? (See Internet Resources.)

Modified from Mendias EP, Grimes DE: Preventing and managing community emergencies: disasters and infectious diseases. In Anderson ET, McFarlane J, editors: Community as partner: theory and practice in nursing, Philadelphia, 2010, Lippincott Williams & Wilkins and Summerlin EB: Natural and man-made disasters. In Nies MA, McEwen M, editors: Community/public health nursing: promoting the health of populations, Philadelphia, 2011, Saunders.

Traditionally, the roles of community health nurses included caregiver, advocate, case manager, case finder, counselor, educator, epidemiologist, group process leader, health planner, and manager. For example, the nurse employed in a pediatric outpatient clinic functions in a number of roles to provide care to a child with type 2 diabetes. The nurse provides case management by coordinating care between the disciplines, counseling by supporting the child and family through developmental crisis, and case finding by identifying risk factors in the child’s siblings.

The Institute of Medicine (1988) developed a list of core functions to guide the work of public health professionals, including nurses. The core functions are directed to population-wide services and to personal and home services for people at risk. The population-wide service is based on assessment of health status monitoring and disease surveillance, policy development, and assurance that policies are translated into service. The Council on Linkages Between Academia and Public Health Practice (2001), a group of university educators and public health professionals, further delineated the core functions and developed a list of skills to improve the ability of all public health workers, including nurses, to implement them. The eight categories of skills include analytic/assessment, policy development/program planning, communication, cultural competency, community dimensions of practice, basic public health sciences, financial planning and management, and leadership and systems thinking. Thus pediatric nurses employed in a managed care environment may be asked to develop a creative approach to teaching children from different cultures who have asthma about peak flow meters during ED visits. Included in the request may be a mechanism to evaluate the cost of the approach and the occurrence of repeated ED visits.

Nursing Alert

Nurses must be able to communicate and work with professionals from other disciplines. This includes being able to understand the terms used by demographers, epidemiologists, and economists.

Demography

Demography is the study of population characteristics. Demographic characteristics include age, gender, race or ethnicity, socioeconomic status, and education. Individuals, families, and communities may have demographic characteristics that affect their health risks (Cashaw, 2008). Risk is an increased probability of developing a disease, injury, or illness. Age is one of the most important risk factors for disease prevention and certain health conditions. For example, infants are most likely to die as a result of congenital malformations, children and adolescents as a result of accidents, and middle-aged adults as a result of cancer (National Center for Health Statistics, 2011). Gender also plays an important role. Males are at much greater risk of hemophilia A and B than females. Race or ethnicity has long been associated with increased risk for disease and disability, but it is now thought that, aside from genetic predisposition, there is a complicated relationship between minority status and socioeconomic status that increases the risk for disease and disability (Smith, 2000). Low socioeconomic status predisposes children to a variety of problems. Poor children are more likely to be obese and to have untreated dental problems. They are more likely to have no regular site for medical care and to be treated in EDs (National Center for Health Statistics, 2011).

Epidemiology

Epidemiology is the science of population health applied to the detection of morbidity and mortality in a population. The epidemiologic process identifies the distribution and causes of disease or injury across a population (Cashaw, 2010). It also serves as an important component in developing health programs. For example, Healthy People 2020 incorporates the process to develop a set of health objectives for the United States. Health professionals in community, state, and national health care organizations use the objectives as a guide to develop programs that have the greatest impact on the health of children.