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Community-Based Nursing Practice Media Resources CD COMPANION

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• NCLEX® Review • Glossary • English/Spanish Audio Dictionary

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Concepts in Health Care

OBJECTIVES • 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 communitybased practice.

• Explain the characteristics of patients from vulnerable populations that inﬂuence a nurse’s approach to care. • Describe the competencies important for success in community-based nursing practice. • Describe elements of a community assessment.

One of the priorities of the community agency is to reach out to the leaders within the community to create an environment of trust and safety, which will hopefully lead more people to increase their use of the services provided. Kim is working with her community nurse preceptor to develop community meetings. These meetings will explain the role of the community nurses in the delivery of care to the community, reinforce the privacy and confidentiality of the services, and describe the types of services they provide.

Bosnian Community Kim Callahan is a senior student in a community health nursing course. Her clinical experience comes from working in a community nursing service within a large city. The majority of patients receiving care from the agency are Bosnian immigrants. One major aspect of care the community nursing service provides is well-child examinations and immunizations to get the children ready to enter the public school system. In addition, Kim and her classmates conducted an assessment of the community’s health care needs and health care practices. This is a close community facing many challenges. Although there is an absence of chronic disease, there is a lack of general preventive health care practices. This includes routine immunizations, well-baby examinations, well-women examinations, and basic screenings for hypertension, cholesterol, etc. Many members of the community do not have adequate insurance and as a result do not receive proper medical care. The community nursing service has funds to provide mobile primary prevention via a health care van that goes out to the community. Nurse practitioners and community health nurses are the primary care providers. Some services provided include well-baby examinations and immunizations. They also offer well-woman examinations such as Pap smears and mammography and screenings for hypertension, colorectal cancer, and cholesterol. However, many members of the community are suspicious of the free care and doubt that the examinations and results are confidential.

KEY TERMS community-based nursing, p. 43 community health nursing, p. 43 incident rates, p. 41

population, p. 42 public health nursing, p. 42 vulnerable populations, p. 44

ecause of the rapid pace of today’s health care climate, patients usually move quickly from acute care, hospitalbased settings to community-based care that focuses on health promotion, disease prevention, or restorative care. There continues to be a growing need to organize health care delivery services where people live, work, and learn. One way to achieve this goal is through a community-based health care model (Flynn, 1998). Community-based health care organizations frequently spend resources on keeping individuals healthy and well, providing illness care in the patient’s home environment and containing costs (U.S. Department of Health and Human Services [USDHHS], 2000a). With this new focus, nursing is in a position to play an important role in health care delivery. The focus of keeping individuals healthy and well has always been appropriate to the holistic practice of professional nursing.

B

CHAPTER 3 Nursing’s history documents the roles of nurses in establishing and meeting the public health goals of their patients and their families. Within the community health settings, nurses are leaders in assessing, implementing, and evaluating the types of public and community health services the community needs. Community health nursing and community-based nursing are components or parts of health care delivery necessary to improve the health of the general public.

Community-Based Health Care As a nurse it is important for you to gain an understanding of community-based health care. Historically, governmentfunded agencies support community health programs to improve the safety and adequacy of food supplies and to provide a safe water supply and adequate sewage disposal. Public health policy is largely responsible for the increase in life expectancy for Americans during the last century (Stanhope and Lancaster, 2004). Today the challenges in community-based health care are many. Social lifestyles, political policy, and economic ambitions have all influenced some of the major public health problems, including the following: an increase in sexually transmitted diseases, environmental pollution, underimmunization of infants and children, and the appearance of new life-threatening diseases (e.g., acquired immunodeficiency syndrome [AIDS] and other emerging infections). More than ever before, the health care system needs a commitment to reform and 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 (see Chapter 1). The Healthy People Initiative was first created to establish health care goals for the year 2000. The Healthy People Initiative continually revises these goals. For example, the overall goals of Healthy People 2010 are to increase the life expectancy and quality of life and to eliminate the inequality of health among populations (USDHHS, 2000b). The current revision, Healthy People 2010, is designed to improve the delivery of health care services to the general public. There are many ways to accomplish this. Assessing the health care needs of individuals, families, or members of the community; developing and implementing public health policies; and improving access to care are ideas to improve delivery (Clark and others, 2003). For example, assessment sometimes includes the use of community meetings to identify and collect specific data about a population’s health practices. The assessment also includes monitoring the population’s health status, such as the commonness of communicable diseases or fre-

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quency of asthma. In addition, further community assessment occurs by accessing available information about the health of the community (Stanhope and Lancaster, 2004). Examples of assessment include, but are not limited to, the following: gathering information on incident rates for certain cancers, identifying and reporting emerging infections, determining adolescent pregnancy rates, and reporting the number of motor vehicle accidents by teenage drivers. Public policy development and implementation refers to health professionals providing leadership in developing policies that support the population’s health. Health professionals will use research-based findings in developing policies. For example, a health professional suggests the use of immunization to reduce infectious disease and suggests using seatbelts and initiating new driving restrictions for new teenage drivers to reduce disability due to motor vehicle accidents. Assurance refers to the role of public health in making sure that essential community-wide health services are available and accessible (Stanhope and Lancaster, 2004). Examples of assurance include the provision of prenatal care to the uninsured and beginning 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 the existing health care services in a community (Figure 3-1). For example, a rural community may have a hospital to meet the acute care needs of its patients. However, community assessment notes that there are few services to meet the needs of expectant mothers, to reduce teenage smoking, or to provide nutritional support for older adults. Community-based programs that provide these three services will improve the health of the specific populations, as well as the population of the community. When the lower-level services are accessible and effective, there is a greater likelihood that the higher tiers will contribute to the total health of the community (U.S. Public Health Service, 1995). For example, if there is inadequate mosquito control in a community, it becomes more difficult to enforce health promotion efforts and to prevent mosquito-borne diseases. On the other hand, when a community has the resources for providing childhood immunizations, primary preventive care services are able to focus on higher-tier services, such as child developmental problems and child safety. The principles of public health practice aim at achieving a healthy environment for all individuals to live in. These principles apply to 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 will be able to better understand the types of environments in which patients live and the types of interventions necessary to help keep patients healthy.

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Tertiary health care Secondary health care

Primary health care

Clinical preventive services Population-based health care services FIGURE 3-1 Health services pyramid. (From Stanhope M, Lancaster J: Community and public health nursing, ed 6, St. Louis, 2004, Mosby.)

Community Health Nursing Frequently you hear the terms community health nursing and public health nursing used interchangeably (SmithBattle, Diekemper, and Leander, 2004). There are some similarities. A public health nursing focus requires understanding the needs of a population, or a collection of individuals who have in common one or more personal or environmental characteristics (Stanhope and Lancaster, 2004). Examples of populations include high-risk infants, older adults, or a cultural group such as Native Americans. A public health professional understands factors that influence health promotion and health maintenance of groups. They also understand 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. A public health nurse requires preparation at the basic entry level. Sometimes a public health nurse requires a baccalaureate degree in nursing that includes educational preparation and clinical practice in public health nursing. A specialist in public health is prepared at the graduate level with a focus in the public health sciences (American Nurses Association [ANA], 1999). Community health nursing is a nursing approach that combines knowledge from the public health sciences with professional nursing theories to safeguard and improve the health of populations in a community (ANA, 1999; Ayers,

Kim meets with community leaders and members to assess the beliefs and concerns of the community. She identifies a lack of understanding in the community regarding health care practices in this country. In addition, the community has some misunderstandings and fear of health care services that the community agency and van provide. Kim recognizes that members of this community came from a war-ravaged county where resources for health promotion were nonexistent. As a result, she understands the concerns and lack of understanding about community care and how this affects the use of services provided by the community health agency. She operates under the ethical principle of beneficence and wants to do the most good for the most people in this case. She respects the community’s beliefs and their current level of health care knowledge. Kim wants to assist the community agency to meet the health care needs of the Bosnian community. If she views the community as a patient, Kim will focus her care on the total community. She continually assesses the community’s knowledge and acceptance of the health care services provided. In addition, Kim identifies community leaders to serve as “point persons” or contacts in educational programs designed to meet the health care needs of the community. These programs will also help to change the community’s misconceptions and fear of the services provided.

Bruno, and Langford, 1999). The focus of such nursing care is somewhat broader than that of public health, with an emphasis on the health of a community. In addition to considering the needs of populations, the community health nurse provides direct care services to subpopulations within a community. These subpopulations are occasionally a clinical focus in which the nurse has gained 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 to be only one member of a group at risk. Competence as a community health nurse requires the ability to use interventions. These interventions take into account how community problems resolve within the broad social and political context (Stanhope and Lancaster, 2004). The educational requirements for entry-level nurses practicing in community health nursing roles are not as clear-cut as those for public health nurses. A hiring agency does not always require an advanced degree. However, nurses with a graduate degree in nursing who practice in community settings are community health nurse specialists, regardless of their public health experience (Stanhope and Lancaster, 2004).

CHAPTER 3

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 may have advanced nursing degrees, yet nurses with less education also become quite competent in formulating and applying population-focused assessments and interventions (Diekemper, SmithBattle, and Drake, 1999). The expert community health nurse comes to understand the needs of a population or community through experience with individual families and working through their social and health care issues. Critical thinking becomes important for the nurse who applies knowledge of public health principles, community health nursing, family theory, and communication in finding the best approaches in partnering with families. Diekemper and others (1999) interviewed community health nurses to hear their stories and to understand what population-focused practice involves. Often community health nurses see their practice evolve “naturally” as they serve families and communities. The best situation for this is when the working environment does not restrict the nurse’s ability to work closely with members of the community. A successful community health nursing practice involves building relationships with the community and responding to changes within the community (Diekemper and others, 1999). For example, you notice an increase in the number of grandparents assuming child care responsibilities. You, as a community nurse, establish an instructional program in cooperation with local schools to assist and support grandparents in this caregiving role. The community health nurse becomes an active part of a community. This means knowing the community’s members, needs, and resources and then working 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 Community-based nursing involves the acute and chronic care of individuals and families to strengthen their capacity for self-care and promotes independence in decision making (Ayers and others, 1999). Care takes place in community settings such as the home or a clinic; however, the focus is nursing care of the individual or family (Feenstra, 2000). As with other practice settings, your community practice competence is based on critical thinking and decision making at the level of the individual patient—assessing health status, selecting nursing interventions, and evaluating outcomes of

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care. Because direct care services are provided where patients live, work, and play, it is important that you know the diverse needs of the individual and family and appreciate the values of a multicultural community (Zotti, Brown, and Stotts, 1996). In so doing, community nursing practice provides a means to improve, protect, and enhance the quality of health of all who reside in a specific community (Sakamoto and Avilla, 2004). The philosophical foundation for community-based nursing is a model that views human systems as open and interactive with the environment (Chalmers and others, 1998). In this model your patient exists within the larger systems of family, community, culture, and society. The social interaction units seen in Figure 3-2 depict four circles: the inner circle of the patient and the immediate family, the second circle of people and settings that have frequent contact with the patient and family, the third circle of the local community and its values and policies, and the outer circle of larger social systems such as government and church (Ayers and others, 1999). As a nurse in a community-based practice setting, you need to understand the interaction of all of the units while caring for your patient and family. Usually you provide care for your patient in the area of the first three circles. For example, in your community practice clinical experience you are working with a home care nurse who has a patient newly diagnosed with diabetes. You work closely with the patient and family to create a comprehensive plan for the patient’s health. As the nurse-patient relationship evolves, you begin to understand your patient’s habits or lifestyle patterns. You learn how these change when the patient is with friends and co-workers. Together you anticipate ways to plan the patient’s exercise schedule and meal routines. Knowing the resources available in the community (e.g., medical supply shops for glucose monitoring supplies and local diabetes association support groups) helps you to provide comprehensive support for the patient’s needs. Community-based nursing is family-centered care that takes place within the community (Ayers and others, 1999). This focus requires you to be knowledgeable about family theory (see Chapter 21), principles of communication (see Chapter 9), group dynamics, and cultural diversity (see Chapter 17). This knowledge helps you to partner with patients and families and to understand their health care needs. Ultimately you assist your patients and their families to assume responsibility for their health care decisions. The families become involved in planning, decision making, implementation, and evaluation of health care approaches.

Vulnerable Populations In the community you will 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 community health nurse’s principal patients. For example, it is unlikely that you will

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State Government

Local Church

Extended Family

Individual/ Immediate Family

Friends

Neighbors

Co-workers

Local Community National Government

Church Denomination

FIGURE 3-2 These concentric circles represent the social interaction units of the human ecology model. (From Ayers M, Bruno AA, Lanford RW: Community-based nursing care: making the transition, St. Louis, 1999, Mosby.)

visit low-risk mothers and babies. Instead, you are more likely to make home visits to adolescent mothers or mothers with drug addiction. Vulnerable populations of patients are those who are more likely to develop health problems as a result of excess risks, who have limits in access to health care services, or who are dependent on others for care. Individuals living in poverty, older adults, homeless persons, individuals in abusive relationships, substance abusers, severely mentally ill persons, and new immigrants are examples of vulnerable populations (Hwang, 2000). Vulnerable individuals and their families often belong to more than one of these groups. In addition, health care vulnerability affects all age-groups (Corrarino and others, 2000). Sometimes vulnerable individuals are a specific population with a unique health care problem. For example, the older adult who has received heart transplantation has unique health care needs (Baas and other, 2002). Frequently, vulnerable patients come from varied cultures, have different beliefs and values, face language barriers, and have few sources of social support (Chalmers and others, 1998). Their special needs create challenges for nurses in caring for increasingly complex acute and chronic health conditions.

To become competent in the care of vulnerable populations, it is especially important for you to provide culturally appropriate care. Chapter 17 addresses factors influencing individual differences within cultural groups and the nurse’s role in providing culturally appropriate care. To be culturally competent, you need to appraise and understand a patient and family’s cultural beliefs, values, and practices. This is necessary to determine their specific needs and the interventions that will be successful in improving the patient’s state of health. It is not enough for you to be sensitive to your patient’s cultural uniqueness. Your communication skills and caring practices are critical in identifying and understanding your patient’s perceptions of his or her problems and planning health care strategies that will be meaningful, culturally appropriate, and successful. Vulnerable populations typically experience poorer outcomes than those patients with ready access to resources and health care services. Dramatically shorter life spans and higher death rates are real threats to members of ethnically and racially diverse minority groups (Barr and others, 2002; Hwang, 2000). Members of vulnerable groups frequently have cumulative risks or combinations of risk factors that make them more sensitive to the adverse effects of individ-

CHAPTER 3

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Guidelines for Assessing Members of Vulnerable Population Groups

Setting the Stage

• Create a comfortable, nonthreatening environment. • Obtain information about the culture so you have an understanding of their practices, beliefs, and values that affect their health care. • Provide a culturally competent assessment by understanding the meaning of the patient’s language and nonverbal behavior. • Be sensitive to the fact that your patients may have priorities other than their health care. These may include financial, legal, or social issues. You need to assist them with these concerns before you begin a health assessment. • Work together with other health care and social need providers. If your patient needs financial assistance, consult a social worker. If there are legal issues, provide your patient with a resource. Do not attempt to provide financial or legal advice. Nursing History of an Individual or Family

• Because you often have only one opportunity to conduct a nursing history, obtain an organized history of all of the essential information you need to help the individual or family during that visit. • Collect data on a comprehensive form that focuses on the specific needs of the vulnerable population with whom you work. However, remember to be flexible so that you do not overlook important health information. For example, if you are working with an adolescent mother, you are focusing on obtaining a nu-

tritional history on both the mother and baby. Be aware of the developmental needs of the adolescent mom and listen to her social needs as well. • Identify the patient’s developmental needs, as well as health care needs. Remember, your goal is to collect enough information to provide family-centered care. • Identify any risks to the patient’s immune system. This is especially important for vulnerable patients who are homeless and sleep in shelters. Physical Examination and Home Assessment

• It is important that you complete as thorough a physical and/or home assessment as possible. However, only collect data that you will use and is important to providing care to your patient and family. • Be alert for signs of physical abuse or substance abuse (e.g., inadequately clothed to hide bruising, underweight, runny nose). • Sharpen your observation skills when assessing your patient’s home. Is there adequate water and plumbing? What is the status of the utilities? Are foods and perishables stored properly? Are there signs of insects or vermin? Look at the walls. Is the paint peeling? Are the windows and doors adequate? Are there water stains on the ceiling, evidence of a leaky rook? What is the temperature? Is it comfortable? What does the outside environment look like: Are there vacant houses/lots nearby? Is there a busy intersection? What is the crime level?

Modified from Stanhope M, Lancaster J: Community and public health nursing, ed 6, St. Louis, 2004, Mosby.

ual risk factors (Rew and others, 2001). When you assess members of vulnerable populations, it is important to take into account the multiple stressors that affect their lives. It is also important to learn your patients’ strengths and resources for coping with stressors. Box 3-1 summarizes guidelines to follow when assessing members of vulnerable population groups. POOR AND HOMELESS PERSONS. People who live in poverty are more likely to live in hazardous or dangerous environments, work at high-risk jobs, eat less nutritious diets, and have multiple stressors in their lives. When comparing the life expectancy of European Americans and AfricanAmericans, researchers found the causes of the differences to be related to low socioeconomic status rather than race (Barr and others, 2002; Hwang, 2000). Patients with low income not only lack financial resources, but also may reside in poor living environments and face practical problems such as poor or unavailable transportation. In general the homeless population has even fewer resources than the poor. They do not have the advantage of shelter and cope with finding a place to sleep at night and finding food. Chronic health problems worsen because the homeless have no place to store medications, if they can afford them, and do not get nutritious meals. In addition, they lack a healthy balance of rest and activity due to walking

throughout the day to meet basic needs and because of vagrancy laws that prohibit loitering (Hwang and Bugeja, 2000). There is a high incidence of mental illness, personality disorder, and substance abuse among the homeless population. Homeless adolescents are increasing, and this vulnerable population has more social, behavioral, physical, and health risks. Community-based nurses are frequently the only health care provider available to these youth (Rew and others, 2001). In the community setting it is important that you help these patients to identify the available resources (e.g., mobile health care unit [Figure 3-3]), eligibility for assistance, and the interventions to improve their health status. ABUSED PATIENTS. Physical, emotional, and sexual abuse, as well as neglect, are major public health problems affecting older adults, women, and children (Rew and others, 2001; Sebastian, 1996). Risk factors for abusive relationships include mental health problems, substance abuse, socioeconomic stressors, and dysfunctional family relationships. Sometimes there are not any risk factors present. It is important to provide protection for patients at risk for or who have suffered abuse. Interview patients at a time when their privacy is ensured and the individual suspected of being the abuser is not present. Victims of abuse fear retribution if they discuss their problems with a health care provider. Most

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FIGURE 3-3 The homeless population has unique health care needs.

states have abuse hot lines and laws that require you to notify the hot lines if you suspect a patient is at risk. SUBSTANCE ABUSERS. Substance abuse describes more than the use of illegal drugs. This term also includes the abuse of alcohol and prescribed medications, such as antianxiety agents and opioid analgesics. A patient with substance abuse has health and socioeconomic problems. The socioeconomic problems result from the financial strain of the cost of drugs, criminal convictions from illegal activities used to obtain drugs, communicable disease from sharing drug equipment, and family breakdown. For example, health problems for cocaine users include nasal and sinus disorders and cardiac alterations that are sometimes fatal (Stanhope and Lancaster, 2004). You need to objectively assess substance use in terms of the amount, frequency, and type of substance used. It is important that you do not show any judgment or disapproval to your patient. Frequently these patients avoid health care for fear of judgmental attitudes by health care providers and concern over being turned in to the police. SEVERELY MENTALLY ILL PERSONS. When a patient has a severe mental illness (e.g., depression or schizophrenia) or severe personality disorders (bipolar disorder), there are multiple health and socioeconomic problems you must explore. Many patients with pervasive mental illnesses are homeless or marginally housed. Others lack the ability to maintain employment or to even care for themselves on a daily basis. Patients suffering from pervasive mental illness require medication therapy, counseling, housing, and vocational assistance. In addition, mentally ill patients are at greater risk for abuse and assault (Eckert, Sugar, and Fine, 2002). The mentally ill are no longer routinely hospitalized in long-term psychiatric institutions. Instead, the goal is to offer community resources; however, not all communities have

service networks to deal with this (Stanhope and Lancaster, 2004). Many patients have few or limited services and little skill in surviving and functioning within the community. There are an increased number of young mentally ill persons who have had only episodic hospital care. Collaboration with multiple community resources is a key to helping the pervasively mentally ill receive adequate health care. OLDER ADULTS. Because people are living longer, there is an increase in the older adult population. This means more patients suffer from chronic disease and there is a greater demand for health care services provided in a community setting. Many associate old age with poor health and disease, not with health promotion and prevention (Barr and others, 2002). However, it is important that you view health promotion from a broad context. This begins with your understanding of what health means to older adults and the steps they can take to maintain their own health (Zahn and others, 1998). When people are able to control their own health, they are able to reduce disability from chronic disease (Baas and others, 2002). There is an opportunity to improve the lifestyle of older adults and their quality of life. Table 3-1 describes the major health problems older adults encounter and the role of community health nurses.

Competency in Community-Based Nursing As a nurse in community-based practice, you need a variety of skills and talents to be successful. You will assist patients with their health care needs and in developing relationships within the community. The Pew Health Professions Commission (1991) recommended competencies for health care professionals. One of the competencies they recommended is the practice of prevention and caring for the community’s health (Dower, O’Neil, and Hough, 2001). You need to apply the nursing process (see Chapter 7) in a critical thinking approach to ensure good, individualized nursing care for specific patients and their families. Additional competencies discussed here will help you deliver care within the context of the patient’s community, which will assist with long-term success of the care objectives.

Case Manager In community-based practice, case management is an important competency. Case management means making an appropriate plan of care based on assessment of patients and families and to coordinate needed resources and services for the patient’s well-being across a continuum of care. Generally, in a community setting a nurse is responsible for the case management of more than one patient. This usually involves patients who need coordination of different health care services (e.g., patients with neurological disease, trauma victims, psychiatric patients, and pa-

CHAPTER 3

TABLE 3-1

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Major Health Problems in Older Adults and Community Health Nursing Roles and Interventions

Problem

Community Health Nursing Roles and Interventions

Hypertension

Monitor blood pressure and weight; educate about nutrition and antihypertensive drugs; teach stress management techniques; promote a good balance between rest and activity; establish blood pressure screening programs; assess patient’s current lifestyle and promote lifestyle changes; promote dietary modifications by using techniques such as a diet diary. Obtain health history; promote monthly breast self-examinations and yearly Pap smears and mammograms for older women; promote regular physical examinations; encourage smokers to stop smoking; correct misconceptions about processes of aging; provide emotional support and quality of care during diagnostic and treatment procedures. Help adult avoid the false hope and expense of arthritis fraud; educate adult about management of activities, correct body mechanics, availability of mechanical appliances, and adequate rest; promote stress management; counsel and assist the family to improve communication, role negotiation, and use of community resources. Provide support in a well-lighted, glare-free environment; use printed aids with large, well-spaced letters; assist adult with cleaning eyeglasses; help make arrangements for vision examinations and obtain necessary prostheses; teach adult to be cautious of false advertisements.

Cancer

Arthritis

Visual impairment (e.g., loss of visual acuity, eyelid disorders, opacity of the lens) Hearing impairment (e.g., presbycusis) Cognitive impairment

Alzheimer’s disease

Dental problems

Drug use and abuse

Substance abuse

Speak with clarity at a moderate volume and pace, and face audience when performing health teaching; help make arrangements for hearing examination and obtain necessary prostheses; teach adult to be cautious of false advertisements. Provide complete assessment; correct underlying causes of disease (if possible); provide for a protective environment; promote activities that reinforce reality; assist with personal hygiene, nutrition, and hydration; provide emotional support to the family; recommend applicable community resources such as adult day care, home care aides, and homemaker services. Maintain high-level functioning, protection, and safety; encourage human dignity; demonstrate to the primary family caregiver techniques to dress, feed, and toilet adult; provide frequent encouragement and emotional support to caregiver; act as an advocate for patient when dealing with respite care and support groups; make sure to protect the patient’s rights; provide support to maintain family members’ physical and mental health; maintain family stability; recommend financial services if needed. Perform oral assessment and refer as necessary; emphasize regular brushing and flossing, proper nutrition, and dental examinations; encourage patients with dentures to wear and take care of them; calm fears about dentist; help provide access to financial services (if necessary) and access to dental care facilities. Get drug use history; educate adult about safe storage, risks of drug, drug-drug, and drug-food interactions; give general information about drug (e.g., drug name, purpose, side effects, dosage); instruct adult about presorting techniques (using small containers with one dose of drug that are labeled with specific times to take drug). Arrange and monitor detoxification if appropriate; counsel adults about substance abuse; promote stress management to avoid need for drugs or alcohol; encourage adult to use self-help groups such as Alcoholics Anonymous and Al-Anon; educate public about dangers of substance abuse.

Data from Stanhope M, Lancaster J: Community and public health nursing, ed 6, St. Louis, 2004, Mosby; Baas LD and others: The challenge of managing the care of older heart transplant recipients, AACN Clin Issues 13(1):114, 2002; Hwang SW: Mortality among men using homeless shelters in Toronto, Ontario, JAMA 283(16):2152, 2000; Hwang SW, Bugeja AL: Barriers to appropriate diabetes management among homeless people in Toronto, Can Med Assoc J 163(2):161, 2000.

tients with complex medical conditions). The greatest challenge for you is coordinating the activities of many different providers and payers, in different settings, throughout a patient’s continuum of care. Although you may work in one location, you influence the selection and monitoring of care provided in other settings by formal and informal caregivers (Stanhope and Lancaster, 2004). To be an effective case manager you need to learn the roadblocks, shortages, and opportunities that exist within

the community to find solutions for patients’ health care needs. Case management with individual patients and families reveals the big picture of health services and the health status of a community.

Collaborator When you practice in a community-based nursing setting, you competently work with individuals and their families and other related health care disciplines. Collaboration, or

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working with others to care for a patient, is important so that you make a mutually acceptable plan that will achieve common goals (Ayers and others, 1999). For example, when the hospital discharges your patient with terminal cancer, you collaborate with hospice staff, social workers, and pastoral or religious care to start a plan to support the patient and family. For collaboration to be effective, there needs to be mutual trust and respect for each professional’s abilities and contributions. Similarly, patients need to trust the health care providers. Teamwork is central to serving the patient well. Together with other health care professionals you will explore patient issues, know the contributions each professional offers, and clarify roles. This will help you to develop a plan of care that patient and health care providers can accept and support.

Educator When working in a community setting you will need to be an educator, or teacher for your patients. You will have opportunities to work with single individuals and groups of patients. As an educator, you establish relationships with community service organizations. These organizations will help you to offer educational support to a wide range of patient groups. Some health education programs that occur in a community practice setting are perinatal classes, infant care, child safety, and cancer screening (Corrarino and others, 2000). With the goal of helping patients assume responsibility for their own health care, the role of educator takes on greater importance in community-based nursing than in other types of care (Ayers and others, 1999). You expect patients and families to gain the skills and knowledge they need to learn how to care for themselves (see Chapter 10). In community-based practice you need to assess your patient’s learning needs and readiness to learn as an individual, the systems the individual interacts with (e.g., family, business, and school), and the resources available for support. Likewise you adapt your teaching skills to instruct within the home setting and make the learning process meaningful. In this setting you have an opportunity to follow patients over time. As a result, you can plan to return for a review of skills, use follow-up phone calls, and refer the patient to community support and self-help groups. This follow-up gives you the opportunity to continue instruction and to reinforce important instructional topics. Evaluation of patient learning occurs over time, requiring patience and commitment.

Counselor As a counselor, you assist your patients in identifying and clarifying health problems and in choosing appropriate solutions for problems (Ayers and others, 1999). For example, if you work in employee assistance programs or women’s shelters, a major amount of your patient interaction is through counseling. In this role you are responsible for providing information, listening objectively, and being supportive, caring, and trustworthy. Counselors do not make deci-

sions; they help patients reach decisions that best suit them (Stanhope and Lancaster, 2004). In a community-based practice setting you will face many situations where counseling is an important skill. Patients and families often need help first identifying or clarifying health problems. For example, you have a patient who repeatedly reports a problem in following a prescribed diet. After questioning the patient, you find that the problem is really that the patient cannot afford nutritious foods and has family members who do not support good eating habits. In this case, you may discuss with your patient factors that cause the problem, identify a range of solutions, and then discuss which solutions are most likely to be successful. As a counselor you encourage patients to make decisions and give them confidence in the choices they make. To be an effective counselor you need to know what resources a community offers to patients. Frequently patients go outside their own family to obtain the support that is necessary to improve their health status. You need to know these resources well to direct your patients to appropriate resources. Be able to answer questions such as, What services do agencies provide? Is the staff accessible? What are the reimbursement limitations, and do these affect access? and Is there coordination between agencies within the community?

Patient Advocate Patient advocacy, or supporting patients, is perhaps even more important today in community-based practice because of the confusion surrounding access to health care services. Your patients often need someone to help them walk through the system. This means identifying where to go for services, how to reach the individuals with the appropriate authority, what services to request, and how to follow through with the information they received. You will be the one who presents the patient’s point of view to obtain the appropriate resources. It is important that you provide patients necessary information to make informed decisions in choosing services appropriately.

Change Agent You will also act as a change agent, or someone who creates change, in a community-based setting. As a competent change agent, you will seek to implement new and more effective approaches to problems (Ayers and others, 1999). You act as a change agent within a family system or intercede with problems that reside within the patient’s community. You use your assessment skills to identify any number of problems (e.g., quality of community child care services, availability of older adult day care services, or the status of neighborhood violence). It is important to empower individuals, their families, and their community to creatively solve problems or become instrumental in creating change within a health care agency. To make changes you must be very familiar with the community itself. Many communities are resistant to change.

CHAPTER 3

BOX 3-2

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Success Factors in Adopting Change

• Patient perceives the change as more advantageous that other alternatives. The nature of the innovation determines what specific type of relative advantage (e.g., social, economic, community good) is important to those who adopt the change. For example, a community health center wants to initiate a school-based exercise and nutrition program. The parents of the children and the school are equally concerned about the weight problem and lack of regular exercise programs. • The change is compatible with existing values, past experiences, and needs of potential adopters. A change agent will determine the needs of patients and recommend changes that fulfill those needs. Before starting the school-based exercise and nutrition program, the organizers identified that 40% of the children in the school were at least 15 pounds overweight. • Try the innovation or change on a limited basis. Patients adopt new ideas more quickly when they can experiment with them.

Patients trying out a new technology can find out how it works in their own situation. The school-based exercise and nutrition program was initiated for all third and fourth graders in the elementary school. • Simple innovations or changes are easier to adopt than complex ones. An innovation must be easy to understand and use. These two grades were chosen because they have the same physical education teacher and eat lunch during the same period. • Communities adopt change when you communicate results clearly and when the results are visible. At the end of a 10-week period, 10% of all overweight children lost at least 10 pounds, and 80% of all eligible children participated in the program. The school elected to phase in the program for all the elementary school children.

Data from Rogers EM: Diffusion of innovation, ed 5, New York, 2004, Free Press.

They prefer to continue providing services as they always have. Before you can implement any change it is necessary to manage conflict between the health care providers involved in the patient’s care, clarify their roles, and clearly identify the needs of the patients (Box 3-2). If the community has a history of poor problem solving, focus on developing problem-solving capabilities (Stanhope and Lancaster, 2004). For example, you have a patient who has trouble making routine health care visits. First, you help the patient find the source of the problem. In this case, the patient has limited access to transportation. You make the suggestion for the patient to visit an alternative site, such as a nursing clinic, because it is closer and its hours are more convenient for the patient.

ing social systems, such as schools or health care facilities, visit various sites and learn about their services. Once you have a good understanding of the community, perform any individual patient assessment against that background. For example, you are assessing a patient’s home for safety. Does the patient have secure locks on doors? Are windows secure and intact? Is lighting along walkways and entryways working? As you conduct the assessment, know the level of community violence and the resources that are available to the patient when help is necessary. No individual patient assessment should occur in isolation from the environment and conditions of the patient’s community.

Changing Patients’ Health Community Assessment When you practice in a community setting, it is important that you learn how to assess the community at large. This is the environment where your patients live and work. Without an adequate understanding of that environment, any effort to promote the patient’s health and to institute necessary change is unlikely to be successful. The community has three components or parts: structure or locale, the people, and the social systems. A complete assessment involves a careful look at each component to begin to identify needs for health policy, health program development, and service provision (Box 3-3). When assessing the structure or locale, you travel around the neighborhood or community and observe its design, the location of services, and the locations where residents meet. A public library or the local health department is a great source for accessing statistics to assess the demographics of the community. To get information about exist-

In a community-based practice you will care for patients from diverse backgrounds and in diverse settings. It is relatively easy over time to become familiar with the resources that are available within a particular community practice setting. With practice you learn how to identify the unique needs of individual patients. However, the challenge is how to promote and protect a patient’s health within the context of the community. Can a patient with lung disease, for example, have the quality of life necessary when the patient’s community has a serious environmental pollution problem? Likewise, it is important to bring together the resources necessary to improve the continuity of care that patients receive. Be a leader in reducing the duplication of health care services and locating the best services for a patient’s needs. Perhaps the most important theme to consider to be an effective community-based nurse is to understand patients’ lives. This begins when you are able to establish

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Unit I

BOX 3-3

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Community Assessment

Structure

• Name of community or neighborhood • Geographical boundaries • Environment • Water and sanitation • Housing • Economy Population

• • • •

Age distribution Sex distribution Growth trends Density

• Educational level • Predominant cultural groups • Predominant religious groups

Kim has spent the last 12 weeks of her 14-week rotation working with the community agency and leaders in the Bosnian community. The goal is to provide educational programs to explain how the clinic provides services and the confidentiality of the services. The program will also explain that the services are free to patients who do not have adequate insurance or financial resources. Kim presented a series of three programs in the homes of four Bosnian leaders. Kim worked with the leaders on the design of the educational programs and continued to evaluate the community’s response to the programs and health care needs. Throughout this period there was a gradual increase in the use of the services within the agency and the van. In addition, young women within the community have asked for some prenatal classes. Kim also perceived a greater acceptance within the community. After the first 3 weeks following Kim’s class, there are fewer “missed” appointments, and the members of the community share more relevant health care concerns with her. Finally, Kim feels a sense of confidence and competence in developing community health care programs. She has learned the importance of including the community and the community leaders in all aspects of program building from the assessment of needs through program development and evaluation. As Kim prepares to finish her clinical experience she discusses the long-term health care goals of the community. In addition, she introduces the next student to the community and the community leaders to provide continuity in health care program development.

Social System

• • • • • • •

Educational system Government Communication system Transportation system Welfare system Volunteer programs Health system

strong, caring relationships with patients and their families (see Chapter 16). This is a challenge when you have little time available to spend with patients. However, as your expertise grows, you are able to advise, counsel, and teach effectively. As you gain an understanding of the needs of the community, you also gain an awareness of what truly makes your patients unique. The day-to-day activities of family life are the variables that influence how you adapt your nursing interventions. Here are a few examples of factors you will consider in community-based practice: the time of day a patient goes to work, the availability of the spouse and patient’s parents to provide child care, and the family values that shape views about health. Once you acquire a picture of a patient’s life, you introduce interventions to promote health and prevent disease so that the picture becomes enhanced.

KEY CONCEPTS • The principles of public health nursing practice aim at as• •

• •

sisting individuals with acquiring a healthy environment in which to live. Essential public health functions include assessment, policy development, and access to resources. When population-based health care services are effective, there is a greater likelihood of the higher tiers of services contributing efficiently to health improvement of the population. The community health nurse cares for the community as a whole and considers the individual or family to be only one member of a group at risk. A successful community health nursing practice involves building relationships with the community and being responsive to changes within the community.

• The community-based nurse’s competence is based on decision making at the level of the individual patient.

• Vulnerable individuals and their families often belong to more than one vulnerable group.

• The special needs of vulnerable populations form the

• • •

backdrop for the challenges nurses face in caring for these patients’ increasingly complex acute and chronic health conditions. Chronic health problems are common and worsen among the homeless because they have few resources. An important principle in dealing with patients at risk or who have suffered abuse is protection of the patient. Patients who are substance abusers often avoid health care for fear of being turned in to criminal authorities.

CHAPTER 3

• A community-based nurse is competent as a collaborator, •


51

• Assessment of a community includes three elements:

educator, counselor, change agent, and patient advocate. Factors that increase the likelihood of a change being accepted and adopted include: that the change is advantageous, compatible, realistic, and easy to adopt.

structure or locale, the people, and the social systems.

CRITICAL THINKING Within the Bosnian community, Katrina Dudek is a 30-yearold widow with two children. One is 3 years and the other is 6 months. She arrived in the community 5 months ago. Her husband was killed in a raid in their home in her native country. She is very fearful when anyone other than her close neighbors and friends enter her home. The community health nurse wants to work with Mrs. Dudek to determine the health care needs of her children and herself. The community health agency has not been successful in providing any care to Mrs. Dudek and her children.

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IN

PRACTICE

1. What key element would be helpful for initiating care for this family? 2. Mrs. Dudek is fearful about providing immunization history about her children. What is your action? 3. Although Mrs. Dudek is vulnerable to health care problems because she is new to this country, there are other factors that increase her vulnerability. What might some of these factors be?

NCLEX® REVIEW 1. Community health nursing is a nursing approach that merges knowledge from professional nursing theories and the: 1. Population sciences 2. Public health sciences 3. Environmental sciences 4. Mental health sciences 2. A patient has a history of asthma with six hospitalizations over the past 2 years. She does try to control her illness and appropriately uses her inhalers and other prescribed medications. What level of prevention corresponds to her disease management? 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Health promotion 3. Vulnerable populations are those who are more likely to develop health problems as a result of:

1. Chronic diseases, homelessness, and poverty 2. Lack of transportation, dependent on others for transportation 3. Excess risks, limited access to health care 4. Limited access to health care, lack of transportation 4. Major health care problems in older adults in community settings include: 1. Polypharmacy, poverty, abuse, sensory loss, and chronic illness 2. Acute illness and abandonment 3. Poverty and inadequate support systems 4. Acute illness, inadequate support systems, and poverty 5. Which of the following is not part of a community system? 1. Information about the structure of the community 2. Information about the population of the community 3. Information about the social system of the community 4. Information about building codes of the community

REFERENCES American Nurses Association: Standards of public health nursing practice, Washington, DC, 1999, The Association. Ayers M, Bruno AA, Langford RW: Community-based nursing care: making the transition, St. Louis, 1999, Mosby. Baas LD and others: The challenge of managing the care of older heart transplant recipients, AACN Clin Issues 13(1):114, 2002. Barr RG and others: The national asthma education and prevention program (NAEPP), Arch Intern Med 162(15):1761, 2002. Chalmers KI and others: The changing environment of community health practice and education: perceptions of staff nurses, administrators, and educators, J Nurs Educ 37:109, 1998. Clark MJ and others: Involving communities in community assessment, Public Health Nurs 20(6):456, 2003.

Corrarino JE and others: The Cool Kids Coalition: a community effort to reduce scald burn risk in children. MCN Am J Matern Child Nurs 25(1):10, 2000. Diekemper M, SmithBattle L, Drake MA: Bringing the population into focus: a natural development in community health nursing practice, part I, Public Health Nurs 16:3, 1999. Dower C, O’Neil E, Hough H: Profiling the professions: a model for evaluating emerging health professions, San Francisco, 2001, Center for Health Professions, University of California, San Francisco. Eckert LO, Sugar N, Fine D: Characteristics of sexual assault in women with a major psychiatric diagnosis, Am J Obstet Gynecol 186(6):1284, 2002.

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Feenstra C: Community based and community focused: nursing education in community health, Public Health Nurs 17(3):165, 2000. Flynn BC: Communicating with the public: community-based nursing research and practice, Public Health Nurs 15(3):155,1998. Hwang SW: Mortality among men using homeless shelters in Toronto, Ontario, JAMA 283(16):2152, 2000. Hwang SW, Bugeja AL: Barriers to appropriate diabetes management among homeless people in Toronto, Can Med Assoc J 163(2):161, 2000. Pew Health Professions Commission: Health America: practitioners for 2005, Durham, NC, 1991, The Commission. Rew L and others: Correlates of resilience in homeless adolescents, J Nurs Scholarsh 33(1):33, 2001. Rogers EM: Diffusion of innovations, ed 5, New York, 2004, Free Press. Sakamoto SD, Avilla A: The public health nursing practice manual: a tool for public health nurses, Public Health Nurs 21(2):179, 2004. Sebastian JG: Vulnerability and vulnerable populations: an introduction. In Stanhope M, Lancaster J, editors: Community health nursing: process and practice for promoting health, ed 4, St. Louis, 1996, Mosby. SmithBattle L, Diekemper M, Leander S: Moving upstream: becoming a public health nurse, part II. Public Health Nurs 21(2):95, 2004.

Stanhope M, Lancaster J: Community and public health nursing, ed 6, St. Louis, 2004, Mosby. U.S. Department of Health and Human Services, Public Health Service: Healthy People 2010, ed 2, vol 1, part A focus area 7, Educational and community-based programs, Washington, DC, 2000a, U.S. Government Printing Office, www.healthypeople.gov. U.S. Department of Health and Human Services, Public Health Service: Healthy People 2010: A systematic approach to health improvement, Washington, DC, 2000b, U.S. Government Printing Office, www.healthypeople.gov/implementation. U.S. Public Health Service: A time for partnership: prevention report, Rockville, Md, December 1994/January 1995, Office of Disease Prevention and Health Promotion. Zhan L and others: Promoting health: perspectives from ethnic elderly women, J Community Health Nurs 15:31, 1998. Zotti ME, Brown P, Stotts RC: Community-based nursing versus community health nursing: what does it all mean? Nurs Outlook 44(5):211, 1996.

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