Introduction

Chapters 1 and 2 should have started to build up your knowledge and understanding of the community, the diverse roles of nurses and other practitioners and agencies, and the range of services that they provide for people of all ages and social groups. Chapters 3 and 4 focus on what you can expect from practice learning in the community and how to get the most out of your experience.

The approaches to care and ways of working differ, depending on the community care setting and the care provider. However, these differences should not be viewed as barriers or lines of demarcation between settings. A person-centred approach to care is about the person and their care pathway, which should be seamless between primary and secondary care and between different providers of health and social care in the community. The learning environment in the community will certainly feel very different to the hospital learning environment, not only because of what you can learn here but also how you learn. This chapter looks at some of these differences and gives you some insight into what you can expect.

The student’s experience will depend on the learning experiences on offer in the locality and the learning outcomes that need to be achieved during the placement. However, with your mentor, an appropriate range of experience tailored to meet essential skills and outcomes can be identified. (Chapter 4 looks in more detail at learning outcomes and we focus on nursing practice in the community later in this chapter.)

The first two chapters have given an overview of roles and services in the community. Some differences in provision between hospital and community are obvious and others not so clear. To consider this in a more focused way, the following case study illustrates how overall aims for a patient (Mr Jackson) are the same but the approach and the emphasis in the hospital and community is different.

What makes the community setting different?

In Chapters 1 and 2, community was discussed as a context for health and social care and the practitioners that provide services there. But nursing in the community is about the people who live in the community and who are the users or potential service users. Wherever nurses practice, they have contact with people from a diverse range of backgrounds. However, in a hospital, the context itself can restrict expressions of individuality and diversity. In the community, people are at home in their own world and this is where the wide spectrum of diversity is experienced and expressed.

As society becomes increasingly multicultural, nurses must be sensitive and responsive to a wide range of differing beliefs, traditions and practices in relation to health, illness and life events such as birth and death.

It is a privilege to visit anyone’s home but as a student on a community placement, home visits and opportunities to get to know families from different ethnic and cultural backgrounds are invaluable experiences for learning and understanding the beliefs and traditions of other cultures. Holland and Hogg (2010) discuss cultural understanding and lack of prejudice as fundamental in ensuring quality and equality of healthcare provision. However, these core elements do not only apply to cultural diversity but also relate to age, gender, disability, religion, belief, political, social and health status, sexual orientation, lifestyle and health behavioural factors. Depending on the community profile of your placement area, community practice learning can offer learning experiences to develop your knowledge and understanding of people’s health needs and beliefs that would not be available in other practice settings. For example community nurses are often successful in engaging people that are described as ‘hard to reach’ by traditional health services, by providing services for homeless people, travelling families, refugees and asylum seekers.

The NMC (2008) makes clear that the care of people is a nurse’s first concern, treating them as individuals and respecting their dignity. A number of standards in the NMC Code apply, including those shown in Table 3.1.

As more services are delivered in the community, acute hospitals concentrate on the provision of specialist care and services such as surgery and acute events. Many of the examples in Table 3.2 reflect this shift in the balance of care. They also reflect the importance of promoting health, addressing inequality, preventing illness and empowering people to take more responsibility for their health. This is not to say that these issues are not important in secondary care or that some of the services listed in Table 3.2 are not provided there. Rather, that the community setting facilitates this way of working and consequently, a greater emphasis is given. A good example of this is ‘person-centred care’. This has been described by Innes et al (2006) as care that focuses on the people using the service; promotes independence and autonomy; provides reliable and flexible services; enables users and carers to choose the services they need; and tends to be provided by teams of health and social care providers working in partnership. Of course, person centredness is an ambition of quality care wherever it is given but care in the community lends itself particularly to this approach.

What makes nursing in the community different?

The principles that underpin nursing practice apply to all settings, as do the skills and competencies that are required for high-quality nursing care. However, in order to provide the types of services and adopt the approaches listed above, community nurses need specific skills to work in a different way. The NMC has identified some of the key characteristics of delivering nursing care in community environments (NMC 2010):

Approaches to practice learning in the community

Traditional approaches to practice learning tend to rely on NHS settings with students allocated to either hospital wards or community health centres. It has not been unusual for programmes to place a greater emphasis on nursing in hospital and consequently, students have spent a greater proportion of their practice learning experience in a hospital environment. A perceived or actual shortage of placements in the community and in primary care has made this difficult to change in some areas.

With the emphasis on relevance to the programme learning outcomes, the NMC is encouraging universities to move away from traditional approaches and to develop new and creative practice learning opportunities. Newer approaches are more flexible and allow students to move between settings and experience services provided by a wider range of organisations, including social enterprises, the independent sector, schools and social services, as well as the NHS. Flexible models are more likely to give students the opportunity to gain a more holistic understanding of the patient’s experience, following their journey as they move between services and different care environments.

The way in which practice learning is organised depends very much on the design of the nursing programme and the stage of implementation of new models of practice learning. It also depends on the type of practice experience that is available in the area, the range of services and how they have developed to meet the health needs of the population in that locality. Consequently, there is wide variation between universities in the length, timing and structure of periods of practice learning. However, to be approved by the NMC, all programmes must meet the NMC standards for pre-registration nursing education, and consequently, practice learning must meet the following standards:

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