�History, Settings, and Roles of Community Health Nursing (CHN)��Lecture # 2

Objectives

At the end of this lecture, students will be able to:

• Describe the stages of community health nursing’s development.
• Identify the core public health functions basic to community health nursing.
• Describe and differentiate among seven different roles of the community health nurse.
• Discuss the seven roles within the framework of public health nursing functions.
• Describe seven settings in which community health nurses practice.

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History of Community Health Nursing

• Four general stages mark the development of CHN
• Early Home Care (before the mid-1800s): the focus in sick and poor individuals who cared by their relative women and the focus was curative. Near 1850, Nightingale’s work started
• District nursing (Mid 1800s to 1900): the Influence of Nightingale continued to provide care for all sick and poor people at home with the focus on curative/less in prevention. During this era voluntary (e.g. Lillian Wald) and some governmental formal organization of visiting nursing (district nursing) were developed

History of Community Health Nursing

3. Public health nursing (1900-1970): district nurse expanded and Lillian Wald used the term Pubic Health Nursing with focus on family and orientation in curative and prevention

4. Community Health Nursing (1970 to present): focus on total community and oriented to population health, services address health promotion; illness prevention with many kinds of agencies including some independent practice

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Societal influences on the development of CHN

• Six major societal influences have shaped the development of community health nursing:

1. Advanced technology

• Example advancement in treatment technology → better health care → increase life expectancy → more needs (more work by nurses outside hospitals)
• Industrialization →urbanization → many health-related problems (spread of diseases, stress)→ more care is needed
• Social media can enable the CHNs to reach large number of people

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Societal influences on the development of CHN

2. Progress in causal thinking

• Identifying causative agent and the interactions among a causative agent →people need education, preventive services

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2. Changes in education

• More educated people → need to know every thing
• More educated nurses → more scientific inquiry → more responsibilities

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Societal influences on the development of CHN

4. The changing demographics and role of women

• Changing demographics, such as shifting patterns in immigration, varying numbers of births and deaths →need nursing care including prevention and promotion
• Women gain rights to be independent such as right to work → more women entered nursing → improvement in the nursing science

5. Economic factors (e.g. health care costs, access, limited funds for public health): Unemployment and the rising in cost of living and health care → people have no health insurance, insurance doesn’t cover everything → focus on prevention

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Societal influences on the development of CHN

6. Consumer movement

• Consumers have become more aggressive in demanding quality services, their right to be informed about services and to participate in decisions → basic changes in the philosophy of health care (CHNs, active nurses)

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The Core public health functions

• CHNs work as partners within a team of professionals (public health and other disciplines), nonprofessionals, and consumers to improve the health of populations.
• Core public health functions of CHN (primary responsibilities) direct the work of all CHNs in settings, all assumed roles and at three levels of service: to individuals, to families, and to communities

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The Core public health functions

•  Functions are:

1. Assessment is the systematic collection, assembly, analysis, and dissemination of information about the health of a community.

• Aim: to determine health needs, health risks, environmental conditions, political agendas, and financial and other resources
• Data gathering methods:

1)Interviewing people in the community, key community leaders, families, etc 2)Surveys

3) Public records (e.g. mortality rate, birth rate, prevalence rate, etc.) 4) Research findings

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The Core public health functions

2. Policy Development: Policy development uses the scientific information gathered during assessment to create comprehensive public health policies

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3. Assurance

• Assurance activities are the activities that make certain that services are provided as intended. e.g. assure safe levels of communicable disease surveillance and outbreak control

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The Core public health functions

•  Essential service components of the core functions:
• Monitor health status to identify and solve community health problems.
• Diagnose and investigate health problems and health hazards in the community.
• Inform, educate, and empower people about health issues.
• Mobilize community partnerships and action to identify and solve health problems.
• Develop policies and plans that support individual and community health efforts.

The Core public health functions

•  Essential service components of the core functions:
• Enforce laws and regulations that protect health and ensure safety.
• Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
• Ensure competent public and personal health care workforces.
• Evaluate effectiveness, accessibility, and quality of personal and population-based health services.
• Research for new insights and innovative solutions to health problems.

Roles of Community Health Nursing (CHN)

1. Clinician role

• The most familiar role of the community health nurse
• The clinician role in community health means that the nurse ensures health services are provided not just to individuals and families, but also to groups and populations.
• It requires different skills to assess collective needs and tailor service accordingly.

Roles of Community Health Nursing (CHN)

1. Clinician role

• CHN clinician role emphasizes holism, health promotion, and skill expansion:

A. Holistic Practice

• At the individual level holistic nursing care encompasses the comprehensive and total care of the client in all areas, such as physical, emotional, social, spiritual, and economic.
• Take into consideration all things or factors that may affect population

Roles of Community Health Nursing (CHN)

1. Clinician role

B. Focus on Wellness (health promotion): CHN provides service in the entire health continuum with focus on promotion of health and prevention of illness.

Roles of Community Health Nursing (CHN)

1. Clinician role

C. Expanded Skills

• Skills go more than just physical care skills to skills in observation, listening, communication, counseling, collaboration, and skills needed in paying attention to community-wide psychological, environmental, and sociocultural factors.
• CHN have to use epidemiology and biostatistics, community organization and development, research, program evaluation, administration, leadership, and effective change

Roles of Community Health Nursing (CHN)

2. Educator role or health teacher role:

• Health teaching is an important part of nursing practice and is one of the major functions of the CHN
• Health education role is emphasized in illness prevention and health promotion
• This role is useful in promoting community health especially for the following two reasons:
• Community clients are usually not acutely ill and can absorb and act on health information.
• The educator role in CHN is significant because a wider audience can be reached (not one-on-one or small groups).

Roles of Community Health Nursing (CHN)

2. Educator role or health teacher role:

• High level of health consciousness or motivation to achieve higher levels of wellness is a factor that enhances the educator role (e.g. middle-aged men discharged from the hospital after a heart attack →exercise program, smoking cessation, and alter eating habits)
• Sometimes, the CHN facilitates client learning through referrals to more knowledgeable sources or through use of experts on special topics.

Roles of Community Health Nursing (CHN)

3. Advocate Role

• Every patient or client has rights such as the right to receive just, equal, and humane treatment.
• Goals of this role:
• As an advocate for the clients, CHNs show clients (such as battered women or migrant workers) what services are available, those to which they are entitled, and how to obtain them.
• As an advocate for the clients, CHNs make the system more responsive and relevant to the needs of clients.

Roles of Community Health Nursing (CHN)

3. Advocate Role

• Why Advocate? The current health care system is often characterized by fragmented and depersonalized services, and many clients especially the poor, the disadvantaged, those without health insurance, & people with language barriers frequently are denied their rights.
• CHN may explain to clients which services to expect and which services they ought to receive, to make referrals as needed, and to write letters to agencies or health care providers for them.
• CHN may guide clients through the complexities of the system, and assure the satisfaction of their needs.

Roles of Community Health Nursing (CHN)

4. Manager Role

• CHNs are participative managers; that is, they participate with clients, other professionals, or both to plan and implement services

Roles of Community Health Nursing (CHN)

4. Manager Role

• Manager role include:
• Exercising/carrying out administrative direction toward the accomplishment of specified goals by assessing clients’ needs, planning and organizing to meet those needs, directing and leading to achieve results, and controlling and evaluating the progress to ensure that goals are met.
• Serving as manager when overseeing client care as a case manager, supervising ancillary staff, managing caseloads, running clinics, or conducting community health needs assessment projects.

Roles of Community Health Nursing (CHN)

4. Manager Role

Four basic functions of the management process:

1) Planning:

• CHN as a planner sets the goals and direction for the organization or project and determines the means to achieve them.
• Planning includes defining goals and objectives (short-and long-term), determining the strategy for reaching them, and designing a coordinated set of activities for implementing and evaluating them.

Roles of Community Health Nursing (CHN)

4. Manager Role

Four basic functions of the management process:

2) Organizing:

• This function involves designing a structure within which people and tasks function to reach the desired objectives (arrange matters so that the job can be done)
• Organizing includes deciding on the tasks to be done, who will do them, how to group the tasks, who reports to whom, and where decisions will be made

Roles of Community Health Nursing (CHN)

4. Manager Role

Four basic functions of the management process:

3) Leading:

• As a leader, the nurse directs, influences others to effect change that will positively impact people’s health and move them toward a goal.
• Also, involves motivating people, directing activities, ensuring effective two-way communication, resolving conflicts, and coordinating (means bringing people and activities together, so that they function in harmony while pursuing desired objectives) the plan.

Roles of Community Health Nursing (CHN)

4. Manager Role

Four basic functions of the management process:

4) Controlling and evaluating:

• A controller: monitors the plan and ensures that it stays on course, make adjustments or corrections to reach the desired results or goals.
• Evaluator: compares and judges performance and outcomes against previously set goals and standards

Roles of Community Health Nursing (CHN)

4. Manager Role

• As manager, CHNs engage in different types of behaviors or parts of the manager role:
• Decision-making
• Transferring of information e.g. Spokesperson
• Engaging in interpersonal relationships

Roles of Community Health Nursing (CHN)

4. Manager Role

Basic management skills and competencies that CHNs as successful mangers must have:

1. Human skills: the ability to understand, communicate, motivate, delegate, and work well with people
2. Conceptual skills: refer to the mental ability
3. Technical skills: refer to the ability to apply special management-related knowledge and expertise to a particular situation or problem

Roles of Community Health Nursing (CHN)

4. Manager Role

• Case management as it is at individual level can be applied at the aggregates level by CHNs.
• Case management as it is at individual levelis the systematic process by which a nurse assesses clients’ needs, plans for and coordinates services, refers to other appropriate providers, and monitors and evaluates progress to ensure that clients’ multiple service needs are met in a cost-effective manner

Roles of Community Health Nursing (CHN)

4. Manager Role

• At the aggregates level (e.g. battered women) CHNs have to overseeing and ensuring that population health-related needs are met (immediate needs for safety, security, food, finances, and child care, permanent housing, employment, counseling, and financial and legal resources for battered women)

Roles of Community Health Nursing (CHN)

5. Collaborator Role

• Collaborator: the one who works jointly with others in a common endeavor, cooperating as partners.
• Everyone on the team has an important and unique contribution to achieve the aim
• CHNs work with clients, other nurses, physicians, health educators, social workers, physical therapists, nutritionists, occupational therapists, psychologists, epidemiologists, biostatisticians, secretaries, environmentalists, city planners, and legislators.

Roles of Community Health Nursing (CHN)

5. Collaborator Role

• The collaborator role requires skills in communicating and in acting assertively as an equal partner.
• The collaborator role may involve functioning as a consultant.

Roles of Community Health Nursing (CHN)

5. Collaborator Role

• Collaborator role example: a school nurse noticed a rise in the incidence of drug use in her schools. She initiated a counseling program after joint planning with students, parents, teachers, the school psychologist, and a local drug rehabilitation center.

Roles of Community Health Nursing (CHN)

• 6. Leadership Role
• The leadership role focuses on effecting change: the CHN becomes an agent of change

Roles of Community Health Nursing (CHN)

6. Leadership Role

• This role involves:
• Initiate changes that positively affect people’s health.
• Influence people to think and behave differently about their health and the factors contributing to it
• Recognizes the complex set of factors contributing to health outcomes and works to address those myriad factors in affecting needed change.

Roles of Community Health Nursing (CHN)

6. Leadership Role

• Example of this role: working with a team of professionals to direct and coordinate projects such as a project to eliminate smoking in public areas
• An important attribute of the leadership role is to be visionary; have a vision or the ability to see what can be and leads people on a path toward the goal (long- and short-term goals).

Roles of Community Health Nursing (CHN)

• 7. Researcher Role
• In this role, CHNs engage in the systematic investigation, collection, and analysis of data for solving problems and enhancing community health practice.
• The researcher role (at all levels) helps to determine needs, evaluate effectiveness of care, and develop a theoretic basis for community health nursing practice.

Roles of Community Health Nursing (CHN)

• 7. Researcher Role
• Community health nurses practice the researcher role at several levels: simplest inquiry to the most complex epidemiologic study

Roles of Community Health Nursing (CHN)

• 7. Researcher Role
• Attributes of the researcher role:
• Questioning attitude: Example: children attending a day care center appear to have excessive bruises on their arms and legs. What is the incidence of reported child abuse in this community? What could be done to promote earlier detection and improved reporting?

Roles of Community Health Nursing (CHN)

• 7. Researcher Role
• Attributes of the researcher role:
• Careful observation: CHNs have to have sharp ability to notice things as they are, including deviations from the norm and subtle changes suggesting the need for nursing action.
• Open-mind and use analytic skills
• Tenacity or firmness: an investigation until facts are uncovered and a satisfactory answer is found.

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Setting for CHN practice

1. Homes:

• Homes are the most frequently used setting forCHN practice.
• In homes, all of the community health nursing roles are performed to varying degrees.
• In homes, CHN may make continued care and follow-up for a clients who are discharged from acute care institutions such as hospitals (as a result of changes in the health care delivery system associated with shifting in health economics and service delivery)

Setting for CHN practice

1. Homes:

• In homes, CHN sees clients in a family and environmental context, and service can be tailored to the clients’ unique needs.

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• The characteristics of home settings:
• Clients are vary: may be a poor, rich, educated, illiterate child or an elderly or a pregnant woman. May be family, single parent family, extended family
• See clients in their real environment
• The client is familiar to the environment but not the nurse (client is host and the nurse is a guest)
• No equipment and staff as used to have at hospital

Setting for CHN practice

1. Homes:

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• The characteristics of home settings:
• See clients in their real environment
• The client is familiar to the environment but not the nurse (client is host and the nurse is a guest)
• No equipment and staff as used to have at hospital

Setting for CHN practice

2. Ambulatory Service Settings

• Ambulatory service settings are places in which clients come for day or evening services that do not include overnight stays.
• Examples of such settings:
• Day care centers: such centers for physically disabled or adults with behavioral health issues
• Health departments where clients may come for assessment and referral or counseling.
• Places where services are offered to selected groups: migrant camps, at correctional facilities, in children’s day care centers, and in coal-mining communities.

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Setting for CHN practice

3. Schools

• Nurses from health agencies or the school system.
• All kinds of Schools:
• Public and private schools at preschool settings, elementary and intermediate levels
• Vocational or technical schools, junior colleges, and college and university settings schools
• Specialized schools: such as those for the developmentally disabled

Setting for CHN practice

3. Schools

• CHN roles in school settings (overlapping) include:
• Clinician:
• First-aid provider such as handling minor problems, such as headaches and cuts
• Keeping track of immunizations
• Educator: personal hygiene, diet
• Interprofessional collaborator
• Advocator
• Manager
• Leader
• Researcher.

Setting for CHN practice

4. Occupational Health Settings

• In business and industry settings in caring for employee.
• Employee health is important to the individual lives, the productivity of business, and the wellbeing of the entire nation.
• Business and industry settings are expected to provide a safe and healthy work environment, in addition to the insurance for healthcare by providing such healthy snacks (fruit at breaks), build or have exercise facilities, health education programs, and offer financial incentives for losing weight or staying well

Setting for CHN practice

4. Occupational Health Settings: Roles:

1. Clinician
2. Health educator
3. Advocator: assuring appropriate job assignments for workers and adequate treatment for job-related illness or injury
4. Collaborator: CHN collaborate with other health care providers and company management to offer better services to their clients.
5. Leaders and managers: developing new health services in the work setting such as weight control.
6. Researcher

Setting for CHN practice

5. Residential Institution:

Residential Institution is any place where clients reside:

1. Nursing homes
2. Continuing care centers
3. Sheltered workshops and group homes for clients who share specific needs such as mentally ill or developmentally disabled children, inpatient hospice program
4. Camps such as camping programs for children or adults who have chronic or terminal illnesses

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Setting for CHN practice

5. Residential Institution:

5. Correctional institution (prison/jail): may have the same health care needs as the general public + additional health and social service because of the reason for the incarceration (e.g. drug abuse) and that place them at increased risk for select health problems (e.g. AIDS).

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• Residential institutions are good for CHN to practice health promotion because clients are more accessible, their needs can be readily assessed, and their interests can be stimulated.

Setting for CHN practice

6. Faith Communities

• Faith community nursing involves efforts to improve the health of faith community members through education, screening, referral, treatment, and group support.
• Faith community nursing called church-based health promotion, parish nursing, or primary care parish nursing practice.
• In some communities, faith community nurses are the most acceptable primary care providers.
• The goal is to enhance and extend services available in the larger community but not to duplicate these services.

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Correctional institution (prison/jail): may have the same health care needs as the general public + additional health and social service because of the reason for the incarceration (e.g. drug abuse) and that place them at increased risk for select health problems (e.g. AIDS).

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• Residential institutions are good for CHN to practice health promotion because clients are more accessible, their needs can be readily assessed, and their interests can be stimulated.

Setting for CHN practice

7. Community at Large(domestic and international)

• Remember, CHN is a specialty of nursing that is defined by the nature of its practice, not its location, and it can be practiced anywhere.
• Examples of such settings:
• CHN may work with a parenting group in a town hall.
• CHN may work elderly population

Setting for CHN practice

7. Community at Large (domestic and international)

• CHN may work with community-based organizations such as a support group for parents experiencing violent death of a child.
• CHN may work in health care planning committees or legislation
• CHN may work to assists with flood relief in another in another country