Manual of Community Health Nursing Practice Jacintha D’ Souza
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Orientation to Community Health and Community Health NursingUNIT 1

Many factors influence human beings health and life, and therefore, illness has become part of human's life. Health continues to be a neglected entity despite lip services and importance of health is felt only when one becomes sick. However, there is a growing awareness of keeping oneself fit. Creating awareness and motivating the community would result in the promotion of health and prevention of illness. The main ethos of caring for people in the community is enabling those who are classified as vulnerable or at risk to be supported at home.
The definitions of community are numerous and variable.
A community is a social unit in which there is a transaction of a common life among the people making up the unit (Green and Anderson, 1986).
According to Clark (1998), community is a group of people who share some type of bond, who interact with each other, and who function collectively regarding common concerns.
Currently, community is commonly defined as people interacting in social units and sharing common interests (Nies and McEwen, 2001).
If you try to live and work in the community without getting to know and understand the community, you will not be able to work usefully with the people for their better health.
Rural Community
Rural areas or the country or countryside are areas of land that are not urbanized, though when large areas are described, country towns and smaller cities will be included. They have a low population density, and 2typically much of the land is devoted to agriculture and there may be less air and water pollution than in an urban area.
  • The rural community or village, is a settlement of families in natural surroundings
  • Life in the village is close to nature and the occupation is farming
  • The total number of people living in the village is small enough for them all to know each other
  • They have a common culture, with certain habits, traditions and beliefs which guide their conduct and unite them
  • The people are interdependent. As for example, there may be a carpenter, blacksmith, potter, basket weaver, tailor, etc. and they help each other
  • Most village occupations are connected with the products of the farm and land. Products of the land depend on rain
  • Any event in the village affects whole community
  • Life in the village is peaceful and healthier—having fresh food, fresh air, natural relaxation and recreation, etc.
Urban Community
Towns and cities of India make up the urban communities. With about 25% of the population, it is growing rapidly due to various problems the rural people face. Young men and women leave the village for urban areas in search of jobs. Sometimes whole group of families migrate to a distant place to work for a contractor (building, mining or other project). They get advances from the contractor to buy food, and soon may become ‘bonded laborers’ and never get back to their own village. Towns and cities are overcrowded and always growing. They grow because of industrialization.
  • In urban areas, most of the people have work in connection with industry, the manufacturing, trade and transport of goods and materials
  • As more and more people migrate to the cities there is not enough work for all and they settle on any vacant bit of land or on the pavements and so slums are formed3
  • In urban social life relationship is short timed and impersonal
  • There is no feeling of oneness and it is a case of ‘each person for himself’. There is keen competition
  • The basis of urban social life is ‘class’ rather than caste; and social class depends on economic status
  • Some people by working hard, or other means, may get richer quickly and move from lower to middle or even upper class
  • Life is quite different in towns and cities than in the village. Traditions, customs and modes do not have much influence over those living in urban areas
  • Family life is less disciplined, and there is no community support. There is much more mixing among people of very different backgrounds. This brings about changes in habits and attitudes. Family conflicts are common
  • For the individual and for families coming to live in the urban area, conscious efforts need to be made to form good friendships and to live in harmony with others. There are many opportunities for joining social groups for various activities
  • People need to tale up the challenges for forming a new ‘comm-unity’ in the city, for mutual help and action to solve problems.
The widely accepted definition of health is given by the WHO: Health is a dynamic state of complete physical, mental, social and spiritual wellbeing, and not merely an absence of disease or infirmity and an ability to lead a socially and economically productive life (WHO 1998).
It has 4 major components—physical health, mental health, social health and spiritual health.
Orem (1995) defines health as a state of a person that is characterized by soundness or wholeness of developed human structures and of bodily and mental functioning.
Community Health
It is a systematic way of studying the health and diseases present in a community and the pattern of delivery of care. It is sometimes synonymously used as community medicine—a field concerned with the study of health and disease in the human population.4
According to WHO, community health refers to the health status of the members of the community, to the problems affecting their health, and to the totality of healthcare provided to the community.
It involves motivating individuals and families to change the patterns of behavior and to take actions, including seeking medical care which would enable them to achieve optimum health.
According to CEA Winslow, one of the leading figures of the history of community health in the 1920s, community health is the science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community efforts. This definition though ancient is still meaningful, relevant and acceptable.
Scope of Community Health
Community health has now entered an era of individual responsibilities and community participation. The traditional role of the medical persons has been shifted from diagnosis and treatment of individual illness to diagnosis and treatment of all health hazards of the community. Community diagnosis is based on the collection and interpretation of relevant data related to the distribution of population according to age, sex, educational status, religion, caste, birth rate, death rate, rates of incidence, prevalence and attacks of disease. Community treatment or community action are some of the steps decided upon to meet the health needs of the community taking into account the resources available and wishes of the people as revealed by community diagnosis. The health action should avail of all resources available, both private and public as well as encourage community's full participation.
The areas of activities of community health fall into four categories as described below:
  1. Those areas where activities must be on a community basis:
    1. The supervision of food, water and milk supply of a community
    2. The avoidance of pestilence (insect control), famine and disease.
  2. Those areas dealing with preventable illnesses, disabilities or premature death:
    1. Communicable diseases including infestations, e.g. diphtheria, pertusis, tetanus, poliomyelitis, tuberculosis, measles and worm infestation5
    2. Nutritional deficiencies, e.g. the conditions of malnutrition like marasmus, kwashiorkor, night blindness, goiter, nutritional anemia, etc.
    3. Substance abuse, e.g. drug, alcohol
    4. Mental health and illness, i.e. disorders of emotion, personality, behavior, etc.
    5. Allergic manifestations and their community sources
    6. Occupational health includes prevention and treatment of occupational illness and hazards
    7. Non-communicable diseases and conditions like cancer, cerebro-vascular accident, diabetes, and road traffic accidents
    8. Dental health
    9. Maternal and child health, i.e. certain conditions associated with risk of maternity, growth and development, and certain hereditary conditions
    10. Rehabilitation of victims of accidents and diseases
    11. Problems of ageing.
  3. Those areas of health, medical and nursing, which need organized official leadership.
    1. Providing facilities for undergraduates, postgraduates and continuing education programs in concerned fields
    2. Promoting of equitable distribution of health manpower and facilities.
  4. Research area where scientific, clinical and social researches for all the branches of community health including epidemiological studies are conducted.
Purpose of Community Health
The purpose of community health is to help people attain greater levels of health and wellbeing through its various programs.
Some of the purposes are given below:
  1. To ascertain the nature and extent of disease and disability in the community.
  2. To take suitable measures to:
    1. Promote healthy living
    2. Prevent disabilities6
    3. Correct remedial defects
    4. Treat illness
    5. Rehabilitate those with handicaps.
  3. To evaluate the progress and success of current programs.
  4. To conduct research into community causes for diseases and investigate through research improved methods and techniques.
  5. To provide the necessary organization of medical care, healthcare, nursing care required to deal with community ill health.
  6. To educate the public in the prevention of health hazards in the best use of medico-social measures and appropriate technology.
Community Health Nursing
The division of community health nursing practice of ANA defines community health nursing as a field of nursing practice for which there exists a body of knowledge and related skills which is applied in meeting the health needs of communities, families, and individuals in their normal environment such as home, school or place of work.
According to ANA (1980), community health nursing is a synthesis of nursing practices and public health practice applied to promoting and preserving the health of populations. The practice is general and comprehensive. It is not limited to a particular age group or diagnosis, and is continuing, not episodic. The dominant responsibility is to the population as a whole; nursing directed to individuals, families, or groups contributes to the health of the total population. Health promotion, health maintenance, health education and management, coordination, and continuity of care are utilized in a holistic approach to the management of the healthcare of individuals, families and groups in a community.
Community health nursing practice promotes and preserves the health of populations by integrating the skills and knowledge relevant to both nursing and public health. The practice is comprehensive and general, and is not limited to a particular age or diagnostic group; it is continual, and is not limited to episodic care.
“While community health nursing practice includes nursing directed to individuals, families, and groups, the dominant responsibility is to the population as a whole” (ANA, 1986).7
Goals of Community Health Nursing
The goal of nursing is often stated as the core of a definition of nursing. Now the view of nursing has changed from taking care of the sick and ministering to him/her towards recovery, to, assisting the individual to remain well and enjoy life; that means, curative oriented nursing has been changed into community oriented nursing. Community oriented nursing provides supportive, nurturing and therapeutic care not only to individuals, but also to their families and communities.
The goal of community health nursing lies at the heart of primary prevention and health promotion. For our purpose, these goals are categorised as:
  1. Health promotion
  2. Health maintenance
  3. Prevention of illness
  4. Restoration of health and rehabilitation.
Health promotion: Health promotion assumes that patients have a higher potential of health than they presently realise. Health promotion is to increase the level of understanding and the expectations of families, groups, and communities to cope with health and illness problems. This may include changing or modifying health practices, increasing health knowledge, and developing understanding of normal growth and development.
Health maintenance: Nurses in the community work with many clients who are well but need to improve to maintain their level of wellness. Maintenance of health involves the thorough and continuous assessment of both individual and community to ensure that they continue to function at the same level.
Prevention of illness: It is the avoidance of changes in the health status that are harmful to the patient. For example, immunization to prevent occurrence or recurrence of the disease or illness. Prevention of illness encompasses such things as increasing knowledge about preventive measures in relation to specific diseases such as diet, immunization, smoking, alcohol, SEB, exercise, stress, and so on.
Restoration of health: It is to help the client returning to an optimum state of health and wellbeing, recovering to as great an extent as 8possible, whatever health functioning has been lost. This is done by rehabilitation—physical, social, psychological, occupational, etc. The goals of community health nursing, help the patients to cope with health and illness problems, control of diseases, and the restoration and preservation of health. Thus the primary focus of community health nursing practice is to promote health.
According to Smith M and Maurer A, major goals for community health nursing are:
  • Care of the ill, disabled, and suffering in non-hospital settings
  • Support of development and wellbeing throughout the life cycle
  • Promotion of human relatedness and mutual caring
  • Promotion of self responsibility regarding health and wellbeing
  • Promotion of relative safety in the environment while conserving resources.
Prevention of illness and maintenance of health are common goals in all areas of community health. So to meet the goal, the objectives are:
  • Health promotion and specific protection
  • Prevention, control, and eradication of disease
  • Treatment and rehabilitation.
These above objectives are fulfilled by:
  • Home visits
  • Recognising the health needs of the community
  • Assessment of the needs
  • Assessment of community resources
  • Intervention and evaluation
  • Providing health education, etc.
Scope of Community Health Nursing
  • Community health nursing focuses on the care of the individuals, families, groups, and communities
  • The key component of community health nursing—primary healthcare—focuses on the physical, biological, social, psychological, and environmental health of a population9
  • It emphasizes individuals as clients within the context of the community
  • Rather than serving only the subgroups that need care, community health nurses anticipate, estimate, and design measures to interrupt the onset of personal health problems
  • Community health nursing focuses on identifying the problems, purpose, solutions and interventions for the problems
  • Scope of practice in the community includes the focus, major thrust, highest priority, objectives and modes of delivery of care
  • The focus of nursing practice in the community is on the prevention of illness and the promotion and maintenance of health. This determines the major thrust of practice, which is the provision of primary healthcare, with less emphasis on secondary and tertiary level of healthcare
  • The modes of delivery of healthcare—direct care to individuals, families and groups in a certain community and nursing within the community is, delivery of services to the community as a whole. For example, identifying needs of the whole community, development of resources, identifying the internal and external factors affecting the health of the community
  • Nurses in the community facilitate primary healthcare by providing direct service to clients as well as by serving as administrators, co-ordinators, educators and consultants.
The manner in which the nurses contribute to the health of individuals, groups and communities depends on his/her educational background and the specific level of knowledge attained.
Community Health Nurse Preparation
A baccalaureate degree in nursing has been generally accepted as standard qualification for community health practice. The practice is general, comprehensive, not limited to a particular group or diagnosis. She uses a holistic approach when managing the healthcare of individuals, families, and groups in a community. Health promotion, health maintenance, health education, case management, coordination, and continuity of care are essential components of community health nursing practice.10
Scope of a Community Health Nurse
The concept that nurse is only for the care of patients in the hospitals is wearing out now. The scope of a community health nurse is wide. She can function in all the fields efficiently. They are:
Home care: A good number of patients can be adequately cared for at home through the extension of certain hospital services. The concept of nurse practitioner is under experimentation in India. In order to shoulder this responsibility, the visiting nurse requires additional skills such as history taking, recognition of physical signs, and interpretation of the same towards a rational treatment. For example, patients with TB, asthma, HIV/AIDS, etc.
Nursing homes: Community health nurse can also work in nursing homes in order to provide better medical and nursing care.
MCH and family welfare centers: Mothers and children are our priority groups for providing healthcare. The community health nurse is the main spring of all activities of an MCH and FW center. The services comprise RCH, antenatal, natal, and postnatal services. Nurses have also a major role to play in family planning and welfare. During confinement or illness, people are in a receptive mood to accept suggestions for their welfare. Since nurses have a direct approach, they can motivate mothers for family planning.
School health nursing: The scope of nursing is immense in a school health program (Bhore committee recommendation). The school health nurse renders health services to promote and protect the health of the school child. The nurse functions in areas such as early detection of disease, health teaching, immunization, dental health, school sanitation, first aid, school meal program, follow-up and referral services, and maintenance of proper student health records.
Industrial nursing: In the industry, the nurse can function in the areas of:
  1. Care of the sick and injured
  2. Pre-placement and periodic examination
  3. Industrial and plant sanitation
  4. First aid
  5. Industrial safety11
  6. Organization of crèches
  7. Rehabilitation and administration.
Domiciliary nursing
  1. Maternity services—antenatal, delivery, postnatal
  2. Health supervision and disease prevention among newborns, and older children
  3. Service for illness and accidents.
Rehabilitation centers: Rehabilitation implies restoration of all treated cases to the highest level of functional ability, physically, mentally and also socially. It comprises diagnosis, surgical treatment, prosthetic and orthopedic appliances, and physical and mental therapy. Nursing is an important component of health services for the disabled.
Mental health: The functions of the nurse in mental health services comprises early detection, and treatment, rehabilitation, group and individual psychotherapy, mental health education, use of drugs, follow-up, etc. This can be done also during home visits.
Geriatric nursing: The elderly have their own health problems. They need healthcare more than the younger age groups. Ambulatory healthcare is less costly. Healthcare to the geriatric population is provided in many countries by visiting nurses and other health workers. Nurses can also work in special homes where elderly are looked after.
Adolescent health: The total population of adolescent is 1.2 billion. Their total numbers will stay within the range of 1.2 to 1.3 billion. In India, adolescents constitute 22.8% of population. Young people are vulnerable to risky or unwanted sex and other unhealthy behaviors and a host of individual, family and community factors that influence young people's behavior. Hence community health nurse can be a teacher, counselor and a guide to the adolescents.