Chapter 5: Practice Settings and Nursing Roles in the Community

Public Health

  • Public health nurses work in diverse settings: as public health nurses, home health nurses, hospice nurses, occupational health nurses, faith community nurses, school nurses, and forensic nurses.
  • 10 essential public health services: the 1010 essential public health services include:
    • Monitoring community health and solving problems
    • Diagnosing and investigating health risks
    • Providing education and empowerment regarding health issues
    • Facilitating community partnerships
    • Developing community health plans and policies
    • Enforcing health regulations
    • Promoting equitable access to health care and services
    • Assuring a competent diverse healthcare workforce
    • Evaluating personal and population-based health services
    • Researching solutions for health problems
  • Specific tasks of public health nurses:
    • Intervening to protect the natural environment
    • Identifying problems for populations at risk
    • Collecting vital statistics and analyzing the impact
    • Providing specific health services to populations in alignment with laws and goals
    • Managing communicable disease through prevention, screening, and treatment
    • Scheduling wellness, screening, and immunization clinics
    • Supervising and ensuring the competency of staff
    • Legislating for policy implementation and revision
    • Partnering with community health agencies
    • Gathering statistics through surveillance, investigations, and monitoring vital statistics
    • Fostering emergency preparedness

Home Health

  • Home health: public health nurses provide health care services to clients where they reside (traditional homes, assisted living facilities, nursing homes).
  • Safety and respect: when visiting a client’s home, the nurse should ensure personal safety and recognize that the nurse is a guest in the client’s home, respecting client and household values.
  • Target population: home health care targets specific at-risk individuals and groups and aids transitions between levels of care.
  • Interprofessional team (QTC): includes nurses, physical therapists, occupational therapists, home health aides, social workers, dietitians, speech and language pathologists, respiratory therapists, psychologists, chaplains.
  • Role of the home health nurse:
    • Primary care provider may prescribe services; the home health nurse coordinates them.
    • Functions as educator, skilled nursing provider, and care coordinator.
    • Daily prioritization and scheduling of client visits; high autonomy requires critical thinking.
  • Skilled services in home health include: assessment, wound care, laboratory draws, medication education and administration, infection prevention, parenteral nutrition, IV fluids and medications, central line care, urinary catheter care, coordination/delegation of other health service participants.

Omaha System and Home Health Processes

  • Omaha System model: used to implement the nursing process in home health and hospice; also used in electronic health records.
  • Steps of the Omaha System (QI):
    • Collecting and assessing data
    • Stating the problem
    • Identifying an admission problem rating using a problem classification scheme
    • Planning and intervening
    • Re-rating problems during care and at discharge
    • Evaluating the end problem outcome

Living Environment and Client Education (Home Health)

  • Living environment safety: evaluate for hazards such as nonsecure rugs, electrical outlets, extension cords, oxygen use, low lighting, bathroom safety devices, and other environmental hazards.
  • Falls risk in older adults; key questions to assess home safety:
    • Does the client have food in the house to eat?
    • Is there help with household activities?
    • Does the client live alone?
    • Who is the client’s support system?
    • Is the client able to set up and dispense their own medication?
    • Does the client have access to health care?
  • Client education (post-acute discharge): home health nurses educate clients and families about complications, adverse reactions, when to contact the agency, emergency room, or provider; provide information and resources to support dealing with illness; education promotes independence and family involvement in care decisions.
  • Hospice focuses on quality of life and palliative care, supporting clients and families through dying, and providing bereavement support to the family. Settings can include home, hospice centers, hospitals, and long-term care facilities.
  • Hospice care is comprehensive for terminal illness; focus on relief of pain and suffering, enhancing quality of life; includes skilled direct services and indirect care coordination.
  • QPCC (questions this content may reference):
    • Hospice uses an interprofessional approach
    • Controlling manifestations of the medical problem and the dying process is a priority
    • The provider directs hospice care services, managed by the nurse
    • Volunteers provide nonmedical care; postmortem bereavement services offered; helping families transition from recovery to acceptance of death
  • Practice question (hospice): Which statement should the nurse make? Options: a) Clients who require skilled nursing care at home qualify for hospice care. b) One function of hospice is to provide teaching about life-sustaining measures. c) Hospice assists clients to develop skills to care for themselves independently. d) A component of hospice care is controlling manifestations of the medical problem. Answer: d

Occupational Health

  • Purpose: address health in all work environments; promote health and prevent occupational illness and injury; reduce costs through fewer sick days, fewer workers’ compensation claims, and lower health coverage use.
  • Roles and collaboration: occupational health nurses work with workplace administration, industrial hygienists, safety specialists, ergonomists, occupational medicine physicians, HR, unions, and insurers to provide cost-effective, high-quality care.
  • Responsibilities (QTS/QS):
    • Primary prevention: teaching good nutrition, health hazards, immunizations, and protective equipment
    • Secondary prevention: identifying hazards, health surveillance and screening, prompt treatment, counseling and referrals, preventing further limitations
    • Tertiary prevention: rehabilitation and limited-duty programs to restore health
  • Risk assessment: susceptibility factors for work-related illness or injury include host factors (job inexperience, age, pregnancy, sex, health status, work practices, ethnicity, lifestyle) and agent factors.
  • Agent factors:
    • Biological agents: viruses, bacteria, fungi, blood-borne and airborne pathogens
    • Chemical agents: asbestos, smoke, lead, mercury, cadmium, nickel, zinc, and antineoplastic drugs
    • Enviromechanical agents: repetitive motions, poor workstation fit, heavy lifting, cluttered/work areas
    • Physical agents: temperature extremes, vibrations, radiation, lighting, noise
    • Psychosocial agents: work-related stress, burnout, violence, interpersonal relationships
  • Environmental factors: physical (temperature, noise, lighting) and social (sanitation, overcrowding) factors; psychological aspects also include addictions, stress
  • Responsibilities and prevention types (more detail):
    • Primary prevention: nutrition, hazard awareness, immunizations, PPE education
    • Secondary prevention: hazard identification, surveillance, early detection, prompt treatment, counseling, referrals
    • Tertiary prevention: rehabilitation and return-to-work strategies
  • Exposure to hazards: occupational health history framework to identify risk agents/host factors, ways to minimize exposure, prevent health problems
    • Information elicited should include current/past jobs, past exposures, relationship of symptoms to work, precipitating factors (underlying illness, prior injuries, health habits)
  • Site walk-through (workplace survey): focus on
    • Work processes and materials
    • Job requirements
    • Actual and potential hazards
    • Employee work practices (hygiene, waste disposal, housekeeping)
    • Incidence/prevalence of work-related illness/injuries
    • Control strategies to eliminate exposures
  • Control strategies: designed to reduce future exposures; may include
    • Engineering controls
    • Altering work practices
    • PPE and education
    • Workplace monitoring
    • Health screening
    • Employee-assistance programs
    • Job-task analysis
    • Design, risk management, and emergency preparedness
  • Protection from violence: identify jobs that are repetitive, boring, or draining to identify workers at risk of fatigue, anger, or inadequacy; refer to employee-assistance programs for counseling and referrals as needed
  • From work-related injuries: analyze injuries from falls, environmental hazards, burns; use research and trend analysis to improve conditions by mitigating hazards
  • Additional strategies: safety/health education, health policy development, strategies to prevent work-related accidents, awareness of OSHA standards, and involvement in legislation for workplace health protection
  • Occupational health legislation
    • Occupational Safety and Health Act of 1970
    • OSHA: develops/enforces workplace health regulations and provides safety education to employers
    • NIOSH (National Institute for Occupational Safety and Health): identifies hazards and conducts prevention research; provides education to safety/health professionals
    • NACOSH (National Advisory Committee on Occupational Safety and Health): 12-member advisory committee representing labor, safety professions, public; advises on policies/programs affecting safety/health
    • Workers’ compensation acts: state-level laws regulating financial compensation for workplace injuries/illnesses
  • Sorting exercise (agent categories): Sort factors into the correct agent categories. Categories: Physical, Psychological, Mechanical

Faith Community

  • Faith community nurses work with individuals, families, and faith communities sharing common religious beliefs and practices relevant to health and healing; religious practices influence health care decisions.
  • Congregational settings include homes, congregational meeting spaces, acute/long-term care facilities, and schools; practice is governed by state nurse practice acts and standards of practice.
  • Nursing interventions address spiritual, physical, emotional, and social dimensions; must be aware of congregants’ faith and belief practices.
  • FICA Spirituality Assessment Tool:
    • F – Faith or belief
    • I – Importance or influence
    • C – Community
    • A – Address (interventions to address)
  • Missionary nursing: promotes health/prevents disease globally; nurses may be career missionaries or short-term volunteers; collaboration and language/cultural sensitivity are essential
  • Faith community nurse roles (FCTCU):
    • Functions of the Faith Community Nurse: personal health counseling (health-risk appraisals, spiritual assessments, support for acute/chronic health problems), health education, liaison with local resources, facilitating support groups, spiritual support (identifying spiritual strengths for coping)
  • Faith community and missionary contexts are connected to the broader aim of holistic care (body, mind, spirit).

School Nursing

  • School nursing encompasses multiple roles:
    • Case manager: coordinates comprehensive services for children with complex health needs
    • Community outreach: collaborates with schools and community agencies to meet needs of all school-age children
    • Consultant: assists students, families, and school personnel with information gathering/decision-making on health needs/resources
    • Counselor: supports students with a wide range of health needs; provides grief counseling
    • Direct caregiver: provides nursing care to ill/injured children at school
    • Health educator: helps students, families, staff, and community make informed health decisions
    • Researcher: contributes to knowledge base for school health and education needs
  • Levels of Prevention (QQI; Levels may be presented as Primary, Secondary, Tertiary):
    • Primary prevention: assess knowledge base; teach health promotion practices (hand hygiene, tooth-brushing, healthy eating, injury prevention, immunizations, disease prevention)
    • Secondary prevention: assess immunization status; maintain current immunization records
    • Tertiary prevention: assess children with disabilities; manage chronic conditions (asthma, diabetes, cystic fibrosis); drug administration per prescription; ensure meds are in original bottle and stored securely; obtain written parental consent for medication administration
  • School health screenings and physicals: vision/hearing, height/weight, oral health, scoliosis, infestations (lice), general physicals; assess for child abuse/neglect and report as required by state law; assess for mental health issues, suicide risk, violence; identify at-risk children; respond to crises and disasters; develop crisis plans; act as first responder; participate in drills; counsel and debrief
  • Tertiary prevention in schools: assess children with disabilities and assist with IEPs; support long-term health needs (chronic conditions); adolescent pregnancy support; parental education
  • Coordinated School Health Program components:
    • Health education in curricula (K-12)
    • Physical education to promote activity
    • Health services provided by qualified professionals
    • Nutrition services (meals meeting health needs)
    • Counseling, psychological, and social services to improve mental, emotional, and social health
    • Promotion of a healthy, safe school environment (drug/tobacco/violence reduction)
    • Health promotion for staff
    • Family/community involvement promotion
    • Safety policy facilitation (policies for fire, disaster, injury)
  • School nurse scenario: Scheduling visits with a physical therapist for a child with cerebral palsy; role is b) Consultant

Forensics

  • Forensic nursing: focuses on injury prevention, care for perpetrators and victims of violence; includes sexual assault, substance-use-related injuries, human trafficking, physical abuse, gang violence, disaster, and accidental injuries
  • Forensic nursing combines nursing knowledge, criminal justice system knowledge, and epidemiology of injuries
  • Settings include: clinics, emergency departments, law enforcement agencies, mental health facilities, and correctional facilities
  • Core principles: safety is paramount; other ethical principles include respect, beneficence, nonmaleficence, caring, justice, and truth; intuition is also valued
  • Credentialing: advanced education and certification often required; SANE (Sexual Assault Nurse Examiner) and advanced practice forensic nurses
  • Roles of SANE: collect detailed medical, physical, and emotional data after sexual assault, manage samples, provide client support, and often testify in legal proceedings
  • Levels of prevention in forensics:
    • Primary prevention: injury prevention programs (e.g., SUID, sexual assault)
    • Secondary prevention: examine crime victims for indicators of intentional injury; provide direct care to clients and perpetrators; collect/preserve evidence
    • Tertiary prevention: treat incarcerated individuals; liaison with medical facilities and legal community to minimize trauma burden; connect clients with community resources (mental health, rehabilitation)