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.
Community-based nursing, p. 33
Community health nursing, p. 32
Incident rates, p. 32
Population, p. 32
Public health nursing, p. 32
Vulnerable populations, p. 33
• Interactive Learning Activities
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 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).
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.
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.