Procedures & Theories of Community Health Nursing PM Thressiamma
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Introduction to Community Health and Community Health NursingChapter 1

“Prevention is better than cure”
Community health nursing practice is a philosophy of nursing service delivery that involves preventive, promotive, protective and rehabilitative care to the publics. Or in other words it is door-to-door services to the specific community. By this services community health nurse provides “health care” through community diagnosis, investigations of major health problems, health surveillance, monitoring and evaluating the community health status for preventing diseases, disability and promoting, protecting and maintaining “health” in order to create conditions in which people can be healthy.
Public health nursing practice is the synthesis of nursing theory and public health theory applied to prevent, promote preserve and maintain the health of population.
Community-based nursing practice is a setting—specific practice whereby care is provided for “sick” individuals and families where they live. The emphasis of practice is acute and chronic care and the provision of comprehensive, coordinated and continuous services. Nurses who deliver community-based care are generalists or specialists in all area like midwifery, pediatrics, psychiatric, nursing medical surgical nursing, mental health nursing, school health, occupational health and specialty care in all settings.
Community-based nursing practice is the synthesis of nursing theory and public health theory applied to promoting and preserving health of populations. The focus of practice in the community as a whole and the effect of the community health status on the health of individuals, families and groups. Care is provided within the context of preventing diseases, disabilities and promoting and protecting the health of community as a whole. It means a cent percent prevention of diseases and protection from diseases.
 
HEALTH STATUS AND RESOURCES
 
Goals
  1. To increase the expectancy of life at birth for each community member through their own involvement and participation.
  2. To achieve and maintain optimum health of the people, through their practices.
  3. To counter act physical and social environment conditions.
  4. To contribute the reinforcement and improvement of nursing practice at community settings.
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Figure 1.1: Better health status through its objectives and goals
 
OBJECTIVES OF COMMUNITY HEALTH NURSING (FIG. 1.1)
  1. To increase the average span of human life.
  2. To decrease the infant and maternal mortality rate.
  3. To decrease morbidity rates.
  4. To increase the physical, mental and social well-being of individual.
  5. To increase the pace of adjustment of the individual to his environment.
  6. To provide positive health to the mankind through quality care.
 
MEANING AND DEFINITIONS
World Health Organization defines “health as dynamic state of physical, mental, social and spiritual well-being and not merely absence of disease or infirmity” 1990 (Fig. 1.2).
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Figure 1.2: Definition of health according to WHO
In recent years this statement has been amplified to include the ability to lead a “socially and economically productive life”.
Dr Imogene King defines health as a dynamic state in the life cycle of an organism that implies continuous adoption to stresses in the internal and external environment through optimum use of one's resources to achieve maximum potential for daily living.
Health is the achievement of a state of harmony between man's internal and external milieu (Liverpool School of Tropical Medicine).
Health in its broadest sense is a dynamic state in which the individual adapts to change in internal and external environment to maintain a state of well-being. The internal environments include many factors that influence health, including genetic and psychological variables, intellectual and spiritual dimensions and disease processes.
The external environment includes factors outside the person that may influence health including the physical environment, social relationships and economic variables. Because 3both environment continuously change the person to adapt and maintain a state of well-being.
 
COMMUNITY
World Health Organization defines “community” as a social group determined by geographical boundaries and/or world common values and interests. Its members know and interact each other. It functions within a social structure and exhibits and creates certain norms, values and social institutions.
A community may be defined “as a group of inhabitants living together in a localized area under the same general regulations and having common interests, functions, needs and organizations.
 
COMMUNITY HEALTH
According to CEA, Winslow (1920), Community health is the science and art of preventing disease, prolonging life and promoting health and efficiency through organized efforts for:
  1. The sanitation of the environment.
  2. The control of communicable diseases.
  3. The education of the individual through personal hygiene.
  4. Early diagnosis and preventive care of disease.
  5. The development of social machinery so as to enable every citizen to realize his/her birth right of health and longevity, to ensure every individual a standard of living, adequate enough for the maintenance of good health.
According 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 health care provided for the community.
 
PUBLIC HEALTH NURSING
Public health nursing can be defined as the practice of promoting and protecting the health of populations by using knowledge from nursing, social and public health sciences. (American Public Health Associations, 2006).
Public health nursing described as population focused, community-oriented nursing practice that emphasizes the prevention of disease and disability (Quad Council, 1999).
Public health nursing practice takes place through community assessment, policy development and assurance activities of nurses working in partnerships with nations, states, districts, blocks organization groups, families and individuals. Nurses are expected to have organizational and political skills along with nursing and public health knowledge to assess the needs and strengths of the population, design interventions to mobilize resources for action and promote equity of opportunity for health.
 
Definition of Public Health Nursing
American Public Health Nursing (1982) defines as follows:
“Public health nursing synthesizes the body of knowledge from the public health sciences and professional nursing theories for the purpose of improving the health of the entire community. This goal lies at the heart of primary prevention and health promotion, and is the foundation for public health nursing practice. To accomplish this goal, public health nurses work with groups, families and individuals, as well as in multidisciplinary teams and program. Identifying subgroups (aggregates) within the population which are at the high-risk of illness, disability or premature death, and directing resources 4towards these groups, is the most effective approach for accomplishing the goal of public health nursing. Success in reducing the risk and in improving the health of the community depends on the involvement of consumers specially group experiencing health risks, and others in the community health planning and in self-help activities”.
According to American Nurses Association (ANA 1980), defines community health nursing as follows:
“Community Health Nursing” is a synthesis of nursing and public health practice applied to promoting and preserving the health of people. 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 of the people as a whole, nursing directed to individuals, families, or groups contributes to the health of the total population. Health education, promotion, maintenance and management, coordination and continuity of health care are utilized in a holistic approach to the management of the health care of the individuals, families and groups in a community. The nurses actions, acknowledge, the need for comprehensive health planning recognize the influences of social and ecological issues, give attention to populations at risk and utilize, dynamic forces which influence change.”
Community health nursing is the field of nursing in which the family and community are the patients/clients. Although it is concerned with the total health illness spectrum, its primary focus is on the prevention of diseases and the promotion and maintenance of the highest level of health and well-being.
The community health nurse works collaborately with families and groups in identifying their health problems and nursing needs in determining nursing care plans, in mobilizing appropriate community resourses and in evaluating the nursing services. She collaborates in replanning, implementing the community health programs and assumes leadership in interpreting nursing and defining nursing needs.
Dr Virginia Henderson, considers the function of the present day nurse is to be unique, “to assist the individual, sick or well in the performance of those activities contributing to health or its recovery (or peaceful death) that he would perform, if he had the necessary strength, will or knowledge. And to do this, in such a way as to help him gain independence as rapidly as possible.
Nursing is the most noble profession on earth, more than a mission, through its spiritual quality, in that, its primary aim is to serve humanity not only by giving comprehensive care, to the sick and injured but serving the needs of the mind of well-individual and the spirit as well.
 
FUNCTIONS OF COMMUNITY
The unique functions of the community/society/people within the geographical locality would be as follows:
  1. To assess the use of space for living.
  2. To determine the available resources for development.
  3. To develop and utilize the resources which is available for the betterment of health.
  4. To develop constructive thoughts towards education, economic production and co-ordination within and between the organizations.
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  5. To transmit civilized culture, ideas, beliefs and traditions to new generations.
  6. To provide opportunities for interaction between individuals and groups.
  7. To participate and involve governmental and societal developmental programs.
  8. To evaluate periodical developmental strategies and re-plan and re-organize new strategies to improve the status of society.
 
PRINCIPLES OF COMMUNITY HEALTH NURSING
In recent years, the health care system has been criticized for its rapidly rising health care costs, inequalities and quality services provided from one area of the country to another, and a general lack of accessibility to health services. At present concept of community health nursing is to prevent the diseases, promote and project the health of the people with less budget. For which we have to adapt the principles of primary health care, i.e. equitable distribution, manpower development, community participation, appropriate technology and multisectoral approach.
In India, a developing country, socio-economically average, very poor technical manpower and having major health problems.
The personnel, who involves in community health should have more devotion, towards service commitment, sacrifice and concern about their duties and responsibilities. To achieve the expected goals and targets, the community health nurse should have certain important functions. He/she should be able to initiate the programs with the help of village committees, effectively conducts health education programs, supervises antenatal care, postnatal care, conducting deliveries arranging health check-up camps, conducting immunization programs, participates in different national and international programs, assist in research projects and helps in evaluation program, conduct monthly conferences, etc.
To achieve the objectives of community she/he should follow certain important principles.
  1. As a community health nurse she/he should be a member and work for the health team. Health team consists of medical officers male and female medical officers, Block Health Education officers, Senior Health Assistants, male and female, Junior Health Assistants, male (Health Inspector) and female (ANM) 3 or 4. Refractionist, pharmacist and laboratory technicians. The team as a whole plans and executes the health programs.
    The effectiveness of the program depends upon the overall efficiency of the community health nurse that means the qualifications, training, interpersonal relationship with the families involvement of village leaders, local politicians, involvement of local committee members, local associations and involvement of other departmental leaders or multisectoral approach, the responsibility, familiarity, etc. If the team members share equal responsibilities and functions, will avoid duplication and repetition.
  2. The public health nurse/community health nurse should function under health authority.
    He/she should be an employee of State Government, Corporation or a Municipality.6
    She should have systematic fixed planned schedule which is organized by the health/medical authorities and health supervisors and is held personally responsible by government for the health activities in his/her area.
  3. As a member of health team he/she should have clearly defined objectives and purposes.
    She/he should develop professional relationship-based on a common objective within the framework. It is essential to supervise and visit the Junior Health Assistants or Midwives and meet local health practitioners for the smooth conduct of the program and achievement of objectives.
  4. A community health nurse must be non-political and nonreligious in her post, position and activities.
    A community health nurse should not interfere with any political or religious beliefs. She/he should have a broad understanding of culture, social customs, religious beliefs, healthy and unhealthy practices. But as a member of health team she should encourage the people to practice the best and she should be role model to others in this aspect.
  5. The community health nurse should be qualified as a full fledged nurse.
    Since the community health nurse (CHN) is the authority to prevent the diseases, to promote the health of the people to preserve the people's health in people's hand, she should posses high qualification.
    Professionally prepared nurse, at least to have baccalaureate degree with diploma in public health nursing is the required basic qualification, because she/he is the only authorized health person should take immediate decision in case of emergency care and regular working conditions. In Indian set-up only diploma holders are working as community health nurses. In this reason-many of the objectives are not achieving, since many years of implementation.
  6. Community health nursing service should be based on the needs of the client and community.
    The health program should be planned on the felt needs of the community/population. Any program which will initiate by the health authorities through community health nurse. The felt needs will be identified and diagnosed through proper data basis and survey by the community health nurse or by health team.
  7. The community health nurse must never accept bribes gifts from the community/society.
    A community health nurse should never accept any kind of gifts or bribes. If it necessitates to collect the fees or prizes of should follow rules and regulations of materials which is supplied by the Government, the receipt should be recorded/acknowledged and the amount should be deposited with the proper health officers as soon as possible.
  8. A community health nurse should utilize the available resources within the community and provide proper services to each family.
    As a team member one should utilize the available resources within the community/family and achieve the objectives without harming others feelings. That means the CHN should work according to the socioeconomic 7condition/financial position of the families.
  9. Community health nurse should responsible for continuous health services in her jurisdiction.
    Like any other settings in community settings a regular and continuation of services/care is very essential for achieving the fullest potentials/benefit to the treatment or change of practices and attitudes towards positive health.
  10. Community health nurse services must be equally available to the entire community.
    A community health nurse should provide comprehensive services to the entire population regardless of caste, creed, origin, class, age, sex and nationality. According to the basic needs of the community people she/he should be impartial in services and win the hearts of the people. Her activities, functions and duties must be acceptable and appreciable by whole community.
  11. There should be facilities for personal development through continuing education provided by the health authorities.
    Basic qualification should be standardized like other education. Minimum qualification should be 10 + 2. If the health personal have higher education it will be beneficial to the individual, groups, societies and the industry/world. In existing system scope of development is very less rare.
  12. Supervision and guidance are needed to produce a high quality of work.
    Each and every step of the Jr HAF towards positive health should be supervised, if there is any drawbacks will be rectified and corrected by the health authorities. Many of new techniques and methods are very difficult to understand and applied to the practices.
  13. Health authorities should organize periodical in-service education programs.
    A fixed periodical in-service education program should be available in specific places. Meanwhile arrange to conduct periodical evaluation and upgradation certification for further promotions.
  14. Health services should be realistic in terms of available personnel and facilities.
    In practical areas, practicability of the services in specific community may sometimes very hard. With the help of community resources like manpower and material should be utilize for the success of the program. The aims and goals of the program will be depend on the coordination and participation by the population.
  15. Maintain adequate reports and records which is essential to community health services.
    It is one of the essential aspect in community health nursing. Adequate reports and records should be developed and supplied by the health authorities. Periodical evaluation and appraisal is required for quality maintenance. The required points should be added and the unwanted columns should be removed. Keep updated everytime.
  16. Community health nurse should develop professional interest through active involvement and participation.8
    As health team member she/he should be actively fresh in terms of physical, mental, social and spiritual aspect of positive health of self and others. Adapt principles of primary health care and philosophies of nursing education.
  17. The community health nurse does not provide material relief to patients/clients but refer the patient to appropriate hospital(s).
    It means that she should not distribute specific medication which is prescribed by self/others. He/she should motivate the client/patient in a required direction to maintain/solve the health problems through appropriate techniques.
  18. Community health nurse should motivate the people should participate in planning relating to goals for attainment of health.
    She/he should mould/motivate the publics/society to take part in panchayat meetings whenever, they conducts and she should make an opportunity to making suggestions and opinions related to health problems in the grass root level.
  19. There should be provision for maintaining the highest degree of work satisfactions.
    The government/the employer should provide good salary to maintain optimum standard, working hours, transportation facilities, conveyance allowance, vacation, sick leave and regular increment.
  20. There should be provision of adequate qualified nurses willing to service in the community level.
    For the attainment of quality ser-vices, according to the health planning committee recommendations a standard ratio should be maintained for example. 1 community health nurse: 5,000 populations in urban areas.
    1 community health nurse: 2,000 populations in hilly areas.
 
EDUCATIONAL PREPARATION FOR PUBLIC HEALTH NURSING
The educational expectations for public health nursing were highlighted at the 1984 consensus conference on the essentials of public health nursing practice and education sponsored by the United States, Department of Health and Human Services (USDHHS) division of nursing. At the basic or entry level, a public health nurse is one who “holds a baccalaureate degree in nursing that includes specific educational preparation and supervised clinical practice in public health nursing”.
Specialists in public health nursing are defined as those who are prepared at the graduate level with either a mater's or doctoral degree, with a focus in the public health sciences (Consensus conference, 1985).
The consensus statement specifically pointed out that the public health nursing specialist should be able to work with population groups and to assess and intervene successfully at the aggregate level. The efforts began with healthy people in 1980 and continued with promoting health, preventing diseases 1990, health objective for the nation and healthy people, 2000. We are now moving in to the future with healthy people, 2010. (USDHHS).
India is a thickly populated country having 114 crores population, the basic preparation required to assist the community health nursing needs are as follows. According to Government of Karnataka/India qualification required for junior health assist (female) 9training for 18 months course is SSLC pass. According to seniority basis, she will be promoted as senior health assistant female after 6 months supervisory training. It is not adiquate qualification to meet the basic needs of the society. At least a baccalaureate degree is required to make proper decisions, judgment, plans, implementation and evaluation. One should wait till when the dreams come true in Indian settings.
Most of the people, average 70 percent are living in rural areas and remote areas in India having less health facilities and substandard services. Almost 30 percent of the people living in urban settings having cent percent health care facilities.
 
ROLES AND HEALTH CARE SYSTEM IN PUBLIC HEALTH NURSING (FIG. 1.3)
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Figure 1.3: Model shows role of community health nurse (CGN)
 
As Program Director
This role is vital in community health nursing. It is nothing but administration role. In Indian settings those who are in senior positions, considered with essential qualifications required for the specific post. The core function in community health care should adapt preventive strategies, which will have great impact on the populations. As program director, she/he should focus on the health status, environment, cultural practices of population, physiology, physical, biological, sociocultural practice of the community should coordinate the functional activities within in the framework of the program.
 
Planner
As community health nurse planner have the responsibility of well-planned day-to-day activities. Fixed programs should be planned well in advance with the coordinators, Block health education officers. Senior health assistants, Junior health assistants and other functionaries of community health.
 
As a Program Organizer
In community health settings can find out many program which may be directed to prevent the disease or eradicate the same/or may be motivational programs. According to the goals, and objectives of the program community health nurse/public health nurse has to organize it well in advance for future generations. She/he should have an idea about the program, assess the settings, implementation through whom, what is the expected objective outcome of the functions and what is the need for the needed hour, also need to be organized.
 
Decision Maker
In community oriented nursing program a public health, nurse specialist is considered as the decision maker, because she/he should 10have the knowledge of population focused practices, philosophies, activities, policies, objectives and experiences than clinical oriented nurse specialists.
She/he should make the key decisions about how the program should start, how it goes, what should be the activities, what is the expected outcome, what strategies they are adapting for the better preventive care, who are all implementing the delegation of powers also need to be decide earlier.
 
As an Advocate
A population-focused/community oriented nurse is an advocate of clients rights in relation to preventive, promotive, protective, preservative, curative and rehabilitative care.
The consumer of health care, the clients have every right to question the loses, potentials and other lacunae from the agency/organization. When there is problems related to the health aspects of the person, as a public health nurse/community health nurse, should act as an advocate through explanations, protection and define the rights of the client/patients.
 
Supervisory Role
As a community health nurse supervisor/public health nursing supervisor should have the knowledge and responsibilities of in and out of the program. He/she should have the qualities of supervision such as better ability of judgment, impartial in understanding of others emotions, attitudes, having full awareness of the existing situations and various settings of public health nursing care/community services.
 
As an Investigator
As a community health nurse she/he should investigate the health needs of the individual, family, groups and society. As an investigator she/he should identify present and potential problems and resources related to the community. She should gather the data through interview technique, observation, laboratory analysis, epidemiological surveys, census and analyse the health care services by the government and private, attitudes of the people, related to health services or control the health problems and evaluate the effectiveness of services.
 
As a Researcher
Today, nurses are challenged to make critical and informed decision about clients problem occurring within the context of a complex and rapidly changing health care system. The history of nursing reveals, since Florence Nightingale initiated nursing research during 1860's.
As a community health nurse, one should have the knowledge and possess the role of research in reducing the mortality, morbidity through hygienic environment, sanitation, good nutrition and increasing the body of knowledge towards the commitment and devotion of services to development of mankind.
 
Nurse Practitioners
The services of nurse practitioner is vital in comprehensive nursing care, whose scope of practice includes providing preventive, promotive, curative and rehabilitative services to clients of all ages in community. It is essential to investigate the state's nurse practice act to determine the limitations and the laws related to this arrangement. A nurse practitioner has to coordinate with various agencies or may practice with a group of health providers to serve as rural / an urban underserved, areas successfully.11
 
Direct Care Provider
The community health nurse/public health nurse is authorized to provide required care to the individual, family, group and the community. He/she carries standing orders of physicians/medical officers while giving continued care to the needy person, during home visits at their own door steps. She/he can provide direct bed care, hygienic care, active and passive exercises to the needy client, first aid care, emergency care and treatment of minor ailments.
 
Health Educator
The goal of achieving health for all by 2010, India as a WHO member country has to promote its health through various health education program.
When one conducts health education program, those should adapt required norms and principles such as, gain attention of the audience, should assure the level of knowledge, inform the objectives clearly, utilize proper audiovisual aids, provide effective learning guidance, ensure the feedback, assess performance and enhance retention and transfer of knowledge.
At any situation she/he should provide effective learning to individual, family group and community.
 
As an Evaluator
As a public health nurse/community health nurse, she/he should assure the value of health activities through the behavioral changes of the consumer or by assessing the status of overall health of the individual, family or society. This can be assess through various indicators of health—like infant mortality rate, maternal mortality rate, crude birth rate, crude death rate, life expectancy, female educational status, average marriage age for male and female, etc.