Community Nursing

used to describe health promotion and disease prevention among groups of people

"public health"

• public health
• community health

true

• 1). Care is provided outside of an
• institutional healthcare setting (such as a hospital, nursing home, etc.)
• 2). The focus of care is health promotion, maintenance and disease prevention among a specific group of
• people.

public health unit or department community health nursing setting

school community health practice setting

faith congregation community health practice setting

work community health practice setting

prison community health practice setting

• public health unit or department
• school
• faith congregation
• work
• prison
• home health/hospice

home health/hospice community health practice setting

The focus of care by home health nurses is an individual recovering from an acute disease or illness, or an individual learning how to live with and manage a chronic or long-term disease.

• Hospice nurses work with individuals with a terminal disease who are not expected to live longer than six months.
• The focus of care is on comfort measures and ensuring the patient has a peaceful death.
• The family of the individual is also considered to be the client in both home health and hospice care.
• Family members are often the recipients of teaching or instruction in how to care for the recovering or terminally ill patient.

• “Public health nursing is the practice of promoting and protecting
• the health of populations using knowledge from nursing, social, and public health sciences.”

• It is anticipated that 4 the greatest need for registered nurses in the future will be in community-based settings
• In order to meet society’s need for registered nurses who can practice in both community-based and institutional-based settings, the SLU School of Nursing emphasizes experiences in both settings throughout the curriculum
• Regardless of where you eventually practice nursing, your clients will be part of a larger community, and their health will directly be impacted by issues within that community

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• high incidence of HIV infections within the community
• RN's in Baton Rouge are likely to encounter patients with HIV in any setting they practice in

true

• out of concern with events surrounding birth, death, and illness
• Early humans lived in small tribal units, but as the human population grew, man moved from place to place and interacted with a larger number of people.
• Communal living, both in small and large groups, creates health problems. Because of this, humans have always had a desire to understand, prevent, and control disease, but this need became more and more pronounced
• as the population grew.
• Simply defined, public health seeks to prevent, eliminate and/or minimize, and treat health problems

• Renaissance Period (14th - 16th centuries).
• During this time period advances in scientific inquiry occurred.
• A greater knowledge of anatomy, physiology, and other scientific processes greatly bolstered the understanding of disease and illness, as well as prevention and treatment

• advances in medicine and technology
• Data collection and analysis is critical to public health practice, and computers make working with data more efficient

• 1). the promotion of health,
• 2). the prevention of disease
• 3). the provision of health care services, 4). Rehabilitation from illness and/or disability

• regularly and systematically assessing the community to identify needs
• developing policies to address the
• needs
• assuring that necessary services are available to meet the needs of the community.

Following are several historical milestones that have lead to our practice of modern public/community health.

• In 400 B.C. Hippocrates wrote about the influence of the environment, diet, and work, on health and disease.
• He is credited with being one of the earliest people to clearly document
• these relationships.
• Another early source of information on the link between cleanliness 6
• (hygiene) and diet on health is the Hebrew writings on dietary and hygiene laws found in the Old Testament.
• The Greeks contributed much to the early development of public health.
• In 500 B.C. the Greeks documented the first communicable disease on record - malaria.
• The Greek culture promoted cleanliness and sanitation, and these values were reflected in Greek
• mythology.
• Hygeia was the goddess of health and Panacea was the restorer of health. The Egyptians were also important in the early development of public health and by 1000 B.C. had developed pharmaceuticals and public sewer systems.

• The Romans are given credit for the early development of public sewers and aqueducts, both of which contributed to environmental
• cleanliness and hygiene.
• The Romans were also the first to write about worker's health, specifically miners and the quality of air in mines.
• The Romans eventually adopted the Christian religion, and Christianity promoted a caring social/community perspective that evolved from the Christian doctrine of "love thy
• neighbor."
• This belief is reflected in the Christian parable of "the good Samaritan."
• The Romans were also the first to developed hospitals and homes for the sick.
• Two Christian women in Rome, Fabiola and Paula, both established hospitals

• During the middle ages the Roman Empire declined, as well as its values of health and hygiene.
• Poor sanitation and hygiene practices developed, and epidemics such as influenza, smallpox, and the bubonic plague spread across the European continent.
• However, a connection between religion and health remained, and monasteries and convents began
• providing care for the sick.
• Military nursing orders (which by the way were primarily composed of men – not women) developed during The Crusades (or “Holy Wars” – so much
• 7 for that kind, compassionate, Christian perspective of love they neighbor!!!)

• During the Renaissance there was a return to the values of human dignity and worth.
• Scientific inquiry expanded, universities were established, and dissection of the dead became
• accepted.
• Statistical data began to be collected on the causes of death, and this was the beginning of the fields of public health and epidemiology.
• Towns also began adopting
• cleanliness or sanitation rules, and formal training programs were developed for physicians

• Edward Jenner (1749-1823) discovered the smallpox vaccination, and in 1853 inoculation for smallpox became compulsory in England.
• This was the first required mass vaccination for an infectious disease.
• Louis Pasteur (1822-1895) introduced the "germ theory" of disease.
• Joseph Lister instituted surgical asepsis techniques using carbolic acid (phenol) to spray the surgery room, clean the surgical instruments and wash the hands of the surgeon.
• Prior to this (and even after for quite some time) cleaning the surgical room, table and instruments between patients was not a common practice! The surgeon washing his hands between patients was unthinkable – too much valuable time would be wasted

Edward Jenner

the smallpox vaccine discovered by Edward Jenner

Louis Pasteur

Joseph Lister

• Florence Nightingale
• Clara Barton
• Frances Root
• Lillian Wald and Mary Brewster
• Henry Street Settlement
• Met Life Insurace Company

• "Mother of Modern Nursing"
• first nurse epidemiologist
• kept meticulous statistics and notes on the # of patients cared for, her interventions, and the outcomes
• influenced by Pasteur's writtings and many of her nursing interventions was based on the premise that germs cause disease
• after her successes during the Crimean War, William Rathbone, provided funding for her to establish the district nursing association in Liverpool, England in 1859

This was the first formal group of public health nurses to visit the sick in their homes and work within the community

• Clara Barton
• Barton was not a trained nurse (although she is often mistakenly given credit for being the U.S. equivalent of Florence Nightingale).
• However, the Red Cross made early attempts at providing community-based care in America

Frances Root

• Lillian Wald and Mary Brewster
• provided nursing care for the poor immigrant residents of New York City
• Nurses operated a walk-in clinic at the Henry Street Settlement House, but would also go into homes and out into the community to provide visiting nursing service

Lillian Wald

Lillian Wald

it was the first time in history that an insurance company paid for nursing services

• advances in science, technology, and education during the 1900s
• shift from commuity-based nursing care to institutional-based care
• Many of the early visiting nurse programs were replaced by the building of hospitals, and hospitals became the place were people would go for care when they became ill
• labor union of the 1920s and 30s
• better record keeping of vital statistics and health data due to computers
• discovery of antibiotics in the 40s
• improved workplace safety-mainly due to labor union movement
• increased use of seatbelts and safer designed automobiles
• decline in cause of death from heart disease and stroke
• inspection and regulation of meats and produce lead to healthier food sources, and the fluoridation of water decreased dental diseases

growth of the health care insurance industry

• health insurance
• as more and more people became insured, more and more hospitals were built

true

true

• discover of antibiotics in 1940s
• Widespread use of immunizations to prevent diseases was also a major public health success of the twentieth century.
• Both of these helped contribute to the control of infectious diseases

• due to improved medical management through the use of new medicines and technologically improved cardiovascular surgical techniques
• improvements in diet and exercise
• recognition of tobacco as a health hazard
• better family planning and pre-natal care

• health care delivery system
• demographics
• globalization
• poverty and growing disparities
• primary health care
• violence and bioterrorism

• cost containment
• More and more health care services will be provided outside of costly institutional settings in the future.
• Technology will continue to make community-based care possible.
• Technology will enable community health nurses to assess and manage clients from remote locations.
• Such technology is already being used in pilot projects throughout the world

• aging population due to better health care has added at least 25 years to the average life expectancy
• increasing cultural diversity-nurses need to expand their knowledge on various cultural groups and how their beliefs and values may influence individual health

• we are all interconnected with our families, work, school and communities
• "global village" created due to the growing economic, political and technological intergration

• estimated that 1.3 billion people live in poverty around the world
• The trend in the United States has been to decrease welfare support and encourage more people to return to work
• However, with the new era of globalization, many entry level jobs in the United States have been moved to third world countries where labor is cheap.
• This creates a cycle of poverty for people in the United States who no longer qualify for welfare but cannot find entry level or minimum wage jobs. Those living in poverty in all parts of the world suffer from poor environmental and living conditions, as well as inadequate nutrition
• estimated that worldwide 40,000 children die yearly from hunger-related diseases

• In 1978, at Alma Ata, the World Health Organization (WHO) challenged every nation to provide a basic level of health for all its citizens
• era of "health for all"

Primary health care is essential health care; based on practical, scientifically sound, and socially acceptable methods and technology; universally accessible to all in the community through their full participation; at an affordable cost; and geared toward self-reliance and selfdetermination

• 1. Education for the identification and prevention/control of prevailing health problems
• 2. Proper food supplies and nutrition
• 3. Adequate supply of safe water and basic sanitation
• 4. Maternal and child care, including family planning
• 5. Immunization against the major infectious disease; prevention and control of locally endemic diseases
• 6. Appropriate treatment of common diseases using appropriate technology
• 7. Promotion of mental health
• 8. Provision of essential drugs

Healthy People program continues to be one tool used in the United States to address the essential elements of primary health care

• increasing around the world
• increase in gang related violence-especially from gun shootings
• the influence of the media and entertainment on the increase in violence is unknown
• increase in domestic violence-estimated that 25-30% of all women

bioterrorism

nursing model

model

• establishing a partnership or contract with a community
• determing that the community's perceived needs are and what role the nurse will plan in meeting those needs

• the nruse assesses the community through data collection
• data may be collected through interviews (subjective) or observations and public databases (objective data)

• data must be analyzed to determine the problem(s) within the community
• called nursing diagnosis or community health diagnosis

• plan includes goals and interventions
• the goals identify the outcomes or what the community desires to achieve
• interventions are those activities that the nurse will do to help the community achieve its goals (i.e. health screenings or educational programs)

• person/client
• environment
• health
• nursing

• community-as-a-partner model
• Anderson and McFarland
• provides a framework for assessing a community, analyzing the data collected, identifying community health issues (diagnoses), establishing goals and interventions, and evaluating the effectiveness of the interventions
• based on Betty Neuman's total-persons approach (1972) and follows the nursing process

• assessment wheel
• the center of the wheel is referred to as the "community core"
• surrounding the community core are 8 subsystems of the community

• represents the people that make up the community
• To assess the community core, data about the community's demographics, values, beliefs and history, are collected.
• The people (or core) of the community are affected by, and in turn influence, the eight subsystems of the community

• physical environment
• economics
• health and social services
• communitcation
• education
• politics and government
• safety and transportation
• recreation

• the community's "normal line of defense" or "level of health"
• it represents what the community normally does to maintain health

• the community's "flexible line of defense"
• it creates a "buffer zone" protecting the community and the normal line of defense
• The flexible line of defense represents a dynamic level of health resulting from temporary actions in response to a stressor

• broken lines
• These lines indicate that the eight subsystems are not isolated and separate from one another, but influence, and are influenced by, one another

• "lines of strength" or the strengths of the community
• These lines of resistance are present in all subsystems of the community and represent the defenses the community has in place to fight stressors

• stressor
• i.e. threat of STD's
• Stressors may come from outside a community and penetrate its flexible and normal lines of defense (i.e. air pollution from an industry located in a nearby town)
• stressors may come from within a community (i.e. lack of needed services or access to needed services)

subjective

windshield survey

• the amount of disequilibrium or disruption caused by the stressor.
• The degree of reaction may be reflected in assessment data, such as morbidity and mortality rates, unemployment, or crime statistics, to name a few.
• involved in the diagnosis phase

• no
• as a result of a stressor (a problem or crisis) members of the community may band together and form a group to deal with the stressor.
• After the stressor has passed, or been minimized, the group may continue to function, thus strengthening the overall health of the community and becoming part of its lines of resistance or line of defense

creates a problems list and then from the list formulates a community health diagnosis for each problem identified as a priority for a community

• establishes goals with members of the community
• goals will reflect national health priorities-healthy people 2010
• then the nurse develops interventions that will help the community members achieve their goals

• primary prevention
• focus on prevention
• i.e. immunizations of preschoolers

• secondary prevention
• focus on health screenings
• i.e. breast self-exams, mammography, blood pressure screenings

• tertiary prevention
• aimed at preventing additional disequilibrium and promoting equilibrium
• focus on treatment
• i.e. a team of counselors
• brought in to work with students in shock following a school shooting; support groups

feedback from members of the community

• U.S. Census Report
• Parish Health profile
• Statistics abstracts from LA
• LA Dept. of Public Health
• LA Dept. of Labor
• FBI uniform crime report
• LA Dept. of Education

• housing and zoning
• politics
• media
• health and morbidity
• race
• ethnicity
• transportation
• open space or boundaries
• service centers or stores
• people on the street
• signs of decay
• religion
• common areas in a community

• provides an overview of a particular community
• record objective and observable data
• information collected helps a nurse define a particular community by observing trends and areas that may need change regarding individual's health in the community
• needs to know this information before planning interventions in order to know what issues are affecting individual's health and what is or is not avaiable to members of a community

• about the people and the community
• people's history, beliefs, values, characteristics

• find out about the origin of the community
• how did the community develop?
• prominent leaders and residents?
• major events that shaped the community?
• libraries, historical societies, chamber of commerce

• the people of the community using numbers and statistics
• population by age, sex, race, and family types
• marital status, birth and death rates
• population growth and trends

help us understand what is important to the residents of a community

• first, conduct a windshield survey
• also includes data on the community's vital signs and terrain

• both intra/extracommunity resources
• data is collected on: hospitals, clinics, public health clinics, nursing home, home health agencies, rehab facilities, mental health clinics, and health care practitioners, EMS services

• data is collected on median household income of residents, % of families with income below poverty level, selected industries within the community, the labor force of the community, occupations of the community's residents,community's unemployment rate
• its important to compare the community's unemployment rate to the parish, state and nation

data collection on protective services (police, fire), sanitation, clean water supply, air quality, and transportation infrastructure of the community

structure and function of the commuity's government

• both formal and informal communitcation
• formal-t.v., radio, newspaper, postal service, telephone services and internet service providers
• informal-almost always originates within a community (intracommunity), bulletin boards, posters, hand-delivered fliers, school and church newsletters

years of schools completed by residents, high school drop out rate, current school enrollment, ability of residents to speak english

look at both intra/extracommunity resources within 50 miles of the community

• epidemiology
• -the word is derived from the Greek words "epi" (meaning upon), "demos" (meaning people), and "logos" (meaning the science or study of)
• "what is upon the people" in terms of illness and disease

Valanis (1999)

• 1. the occurrence of disease (descriptive epidemiology)
• 2. the cause of disease (analytic epidemiology)

descriptive epidemiology

analytic epidemiology

• both occurrence and causality data
• this process requires HCP to report cases of infectious disease to the apporpriate agencies

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rates

• incidence
• measured over a span of time

• prevalence
• measured as a one-shot or slice of time
• looks at occurrence of disease on a given point in time

• The formula for calculating rates can be thought of as a fraction, in which the numerator is the total number of
• people experiencing the health problem or disease, and the denominator is the total number of
• persons who have the possibility (risk) of experiencing the health problem or disease.

• morbidity
• both incidence and prevalence are measures of morbidity

mortality

• crude rate
• The population as a whole is used as the denominator (or group at risk) in calculating a crude rate

• specific rate
• A specific subgroup of the population is used as the denominator in calculating a specific rate

• adjusted rate
• Factors that are commonly adjusted for include age, sex, and race, however, statistical adjustments may be made for many other factors as well
• Adjusted rates are useful when comparing two different groups (populations) of people, and answering “What if” type questions
• not real rates so should be interpreted with caution!

endemic level

outbreak

epidemic

pandemic

epidemiology triangle

• the agent
• the host
• the environment

• the agent
• Agents may be physical, chemical, biologic, genetic, or psychological
• Agents are characterized by "infectivity" and "pathogenicity"

infectivity

pathogenicity

• the host
• The host is classified as "susceptible to," "immune to," or "infected by," the agent

• host risk
• there are severla analytical measures that assess risk

relative risk

• risk factor
• Risk factors may include lifestyle, health
• practices, genetics, race, age, sex, etc

• the environment
• External conditions may include the temperature, geography, noise, pollutants, housing, economics, social surroundings, etc

• 1. Escape from the old host
• 2. Travel to the new host
• 3. Entry into the new host

direct transmission

indirect transmission

• demography
• derived from Greek words "demos" (meaning people), and "graphos" (meaning to write)
• Demographic data may include such things as the size of a population, as well as the age, gender, race, etc. of a population, SES

vital statistics

provide information about the characteristics of a population, and are useful in determining potential health care needs based on these characteristics

direct observation

qualitative

quantitative

• 1. categorize the data collected during the assessment phase
• 2. summarize the data collected
• 3. compare the data to parish, state, and nation-look for patterns or themes within the data as well as omissions and incongruiencies
• 4. make inferences and draw conclusions based on the data collected which will help you create a problems list
• -rank the problems in terms of importance or priority

developing a community diagnosis

• 1. describe an actual or potential risk (problem)
• 2. describe the population (group) at risk
• 3. implies at etiology (the cause or contributing factors)
• 4. gives evidence to support the problem or risk (such as statistical data)

risk of ____ among ____ related to ____ as evidenced by ____.

goals

that it is the community's goal, not the nurses goal

• 1. goal must be realistic/achievable
• 2. goal must be measurable
• 3. goal was be time oriented
• 4. goals must be client ("community") focused

interventions

• 1. interventions should incorporate the cultural norms of the community
• 2. interventions must be accessible to the members of the community
• 3. interventions must be affordable
• #3 is the most critical

considering who, what, where, when, and how

• primary interventions
• Educational programs that help prevent a certain behavior or lifestyle is one example of a primary intervention

• secondary interventions
• i.e. conducting a written survey or blood pressure screening

• tertiary interventions
• i.e. organizing a support group for persons already affected by a health issue is one example of a tertiary intervention

• unplanned change
• For example, you may be driving to campus for an 8:00 a.m. class and suddenly encounter a traffic jam on the interstate.
• You have no control over the situation, but you are forced to alter (change)your original plan of getting to class on time

• planned change
• i.e. if you want to lose 10 lbs and join weight watchers, this is a plan to lose the weight

• proposed a theory of planned change:
• 1. unfreezing-becomming aware of a problem and the need for change
• 2. moving-taking action or implementing activities to bring out change
• 3. refreezing-incorporating or maintaining the change

Reinkemyer

• stage 1: I.D. and development of a felt need and desire for change
• 2: development of a change relationship between the community health nurse and the community
• 3: clarification or diagnosis of the community's problem, need, or objective
• 4: examination of alternative routes and tentative goals and intentions of actions (planning)
• 5: transformation of intentions into actual change (intervention)
• 6: stabilization and evaluation
• 7: termination of the relationship b/t the community health nurse and the community

healthy people 2020

• launched by the Department of Health and Human Services in 1979
• focused the needs of improvement on people's health
• emphasis was placed on the importance of setting goals that were based on the health needs of individuals

• eliminate preventable disease, disability, injury, and premature death
• achieve health equality, eliminate disparities, and improve the health of all groups
• create social and physical environments that promote good health for all
• promote healthy development and behaviors across every stage of life