Week 2: Community Health Nursing | Core Functions, Roles, Models, and Practice Settings

Core Functions of Public Health

Public health relies on three foundational core functions to protect and improve the health of communities:

• Assessment: The regular collection, analysis, and sharing of information about health conditions, risks, and resources in a community.

• Policy Development: The strategic use of assessment data to develop health policies and direct community resources toward those policies.

• Assurance: Ensuring the availability and accessibility of necessary health services throughout the community.

The 10 Essential Public Health Services

The core functions encompass ten essential public health services organized around system management and research:

• Assessment Services:

  • Monitor health status to identify and solve community health problems.

  • Diagnose and investigate health problems and health hazards in the community.

• Policy Development Services:

  • Inform, educate, and empower people about health issues.

  • Mobilize community partnerships and action to identify and solve health problems.

  • Develop policies and plans that support individual and community health efforts.

• Assurance Services:

  • Enforce laws and regulations that protect health and ensure safety.

  • Link people to needed personal health services and assure the provision of healthcare when otherwise unavailable.

  • Assure a competent public and personal healthcare workforce.

  • Evaluate effectiveness, accessibility, and quality of personal and population-based health services.

• System Steering Core:

  • Research for new insights and innovative solutions to health problems.

Major Roles of Community Health Nurses

Community Health Nurses (CHNs) fulfill seven major interconnected roles to positively influence individual and population health outcomes:

• Clinician:

  • Delivers holistic healthcare services across the entire continuum (from individual clients to families and aggregate groups).

  • Applies expanded clinical skills to address environmental, economic, and social concerns, directly targeting the Determinants of Health.

• Educator:

  • Focuses on community-wide health planning and education.

  • Spends approximately $3\times$ as many hours in the educator and communicator role compared to an acute care nurse.

  • Adheres to federal mandates regarding Culturally and Linguistically Appropriate Services (CLAS) in Health Care.

  • Identifies and addresses individual learning barriers while tailoring instruction to distinct learning styles (visual, auditory, and kinesthetic).

• Advocate:

  • Applies the nursing process as an informer and supporter of patient self-determination.

  • Functions as a mediator to address systemic inadequacies within responsive healthcare systems.

  • Engages in political action and lobbying for progressive public health policies.

• Manager:

  • Utilizes a participative approach when working with community groups.

    • Together as a community/team, comes up with a plan of care.

  • Operates within multidisciplinary teams, practicing collegiality and collaborative leadership.

• Leader:

  • Serves as an active change agent to initiate and sustain health improvements.

• Researcher:

  • Conducts systematic investigation, collection, and analysis of data to solve community-based problems.

  • Translates evidence-based research findings directly into community practice settings.

Theoretical Frameworks and Models

Nightingale's Theory of Environment

• Core Focus: Examines the direct relationship between the environment and an individual's health status.

• Preventative Health Care: Emphasizes that health is maintained and promoted through key environmental factors, including:

  • Proper ventilation

  • Pure water

  • Warmth

  • Light

  • Cleanliness and hygiene

• Community Service Evaluation Criteria: When evaluating community health services, nurses must analyze:

  • Why were these services created?

  • Who benefits from these services?

  • Who pays for the services?

  • What is the direct cost to the individuals using the services?

  • What is the public's perception of the services?

Pender's Health Promotion Model

• Core Focus: Identifies actions that increase the level of well-being and self-actualization in individuals or groups.

• Proactive Orientation: Unlike reactive models that respond to environmental stressors, Pender's model represents a proactive set of behaviors where individuals actively transform their environment.

• Theoretical Basis: Grounded in Social Learning Theory, emphasizing that individual thoughts and perceptions directly motivate the initiation and maintenance of health-promoting behaviors.

• Key Determinants of Health Action:

  • Personal factors (biological, psychological, and sociocultural characteristics).

  • Prior related behaviors, abilities, and perceived self-efficacy.

  • Perceived benefits, barriers, and feelings associated with a health action.

  • Interpersonal influences (attitudes and expectations of others), alongside competing demands and preferences.

• Five Modifying Factors:

  • Demographic Factors: Age, income, race, and ethnicity.

  • Biologic Characteristics: Physical attributes such as height and weight.

  • Interpersonal Influences: Expectations and social support from family, peers, or healthcare providers.

  • Situational Factors: Environmental contexts, such as the local availability of healthful food choices.

  • Behavioral Factors: Prior personal experiences, including established stress-coping patterns.

    • Different beliefs about whether the COVID-19 vaccination was going to help or not.

• Application: Frequently serves as a research framework for studying health promotion strategies across diverse populations.

Community Practice Settings and Specialized Nursing Roles

Community health nurses practice across a wide range of domestic and international environments, including homes, ambulatory clinics (walk-ins), schools, occupational sites, residential institutions, faith communities, and the broader community.

Ambulatory Service Nursing

• Definition: Clinical settings where clients receive day or evening healthcare services without requiring overnight facility stays.

• Focus: Outpatient diagnostics, preventive screenings, minor procedures, and wellness counseling.

School Nursing

• ANA Definition: A specialized practice that advances the well-being, academic success, and lifelong achievement of students.

• Practice Settings: Ranges from infant daycare centers to elementary, middle, and high schools, up to university campuses.

• Role Characteristics: Highly autonomous and diverse; includes the direct supervision of Licensed Practical Nurses (LPNs) and health room aides.

• Framework: Aligns health promotion programs with Healthy People 2030 objectives and national initiatives.

  • SDOH and health literacy are the top priorities of Healthy People 2030!*

• Standards & Staffing:

  • Governed by professional Scope & Standards of Practice.

  • Requires Certified School Nurse (CSN) credentials in many school districts.

  • Recommended Nurse-to-Student Ratio: $1:750$.

• Implementation of Levels of Prevention:

  • Primary Prevention: Assesses children's baseline health knowledge; mandated by law to maintain accurate, up-to-date immunization records.

  • Secondary Prevention: Assesses ill or injured students and faculty; provides acute care (e.g., managing nosebleeds or evaluating head injuries); performs triage during emergencies and disasters; conducts mandated screenings for vision, hearing, scoliosis, mental health issues, and child abuse or neglect.

    • All nurses are mandated reporters for abuse!

  • Tertiary Prevention: Participates in developing Individualized Education Plans (IEPs) for children with disabilities; coordinates ongoing care for students with long-term chronic medical conditions.

Camp Nursing

• Clinical Scope: Varies depending on the camp's target population and clinical focus.

• Specialized Camps: Camps serving populations with specific chronic illnesses or physical disabilities require specialized direct care clinical skills (e.g., oncology, pulmonology, pediatrics, diabetes care).

• Traditional Camps: Focus on well-child health maintenance, wellness promotion, and acute first aid.

• Essential First Aid Competencies: Assessment and treatment of human/animal/insect bites, poison ivy exposure, minor burn care, and acute dermatological conditions such as acne.

Faith-Based Community Nursing (Parish Nursing)

• Historical Background: Established in 1984 as a specialty where Registered Nurses partner with faith communities to deliver health promotion services in either paid or volunteer capacities.

• Primary Activity: Providing pastoral care through the intentional integration of faith and health practices.

  • Not providing direct care, but aiding individuals in understanding their health needs and navigating healthcare resources by fostering a supportive environment that promotes overall well-being.

• Standards: In 1998, the American Nurses Association (ANA) officially recognized and adopted the Scope & Standards of Parish Nursing developed by the Health Ministries Association, Inc.

• Practice Dynamics:

  • Operates within the specific tenets of the religious group; the nurse is usually an active member of the faith community.

  • Key Roles: Health educator, personal lifestyle counselor, referral agent to congregational and community resources, support group developer, volunteer coordinator, and general troubleshooter.

  • Non-Duplication Rule: Does not duplicate existing professional nursing services in the community (e.g., instead of performing daily prescribed wound care directly, the parish nurse refers the patient to a visiting nurse agency).

Occupational Health Nursing

Occupational Health Nurses (OHNs) and Employee Health Nurses focus on conserving and enhancing worker health and productivity by maintaining safe occupational environments.

• Professional Governance: Guided by the American Association of Occupational Health Nurses (AAOHN) Standards of Practice.

• Educational Requirements: Requires a Bachelor of Science in Nursing (BSN); specialized board certification is available.

  

  
  

Total Worker Health Domains (NIOSH / CDC Framework)

• Control of Hazards and Exposures:

  • Chemical agents

  • Physical agents

  • Biological agents

  • Psychosocial factors

  • Human factors

  • Risk assessment and risk management

• Organization of Work:

  • Fatigue and stress prevention

  • Work intensification prevention

  • Safe staffing ratios

  • Overtime management

  • Healthier shift work scheduling

  • Reduction of health risks from extended work hours

  • Flexible work arrangements

  • Adequate meal and rest breaks

• Built Environment Supports:

  • Healthy indoor air quality

  • Access to healthy, affordable food options

  • Safe and clean restroom facilities

  • Safe, clean, and equipped eating facilities

  • Safe physical access to the workplace

  • Environments designed to accommodate worker diversity

• Leadership:

  • Shared organizational commitment to safety, health, and well-being

  • Supportive managers, supervisors, and executives

  • Responsible business decision-making

  • Meaningful work and employee engagement

  • Worker recognition and respect

• Compensation and Benefits:

  • Adequate wages and prevention of wage theft

  • Equitable performance appraisals and promotion opportunities

  • Comprehensive work-life programs

  • Paid time off (sick, vacation, caregiving leave)

  • Short-term and long-term disability insurance

  • Workers' compensation benefits

  • Affordable, comprehensive healthcare and life insurance

  • Prevention of cost shifting between payers (Workers' Compensation vs. Health Insurance)

  • Retirement planning and benefits

  • Chronic disease prevention and disease management programs

  • Access to confidential, quality healthcare services

  • Career and professional skills development

• Community Supports:

  • Healthy community design

  • Safe, healthy, and affordable housing options

  • Safe and clean local environment (air/water quality, noise control, tobacco-free policies)

  • Access to safe green spaces and non-motorized pathways

  • Access to affordable, quality healthcare and well-being resources

• Changing Workforce Demographics:

  • Multigenerational and diverse workforce integration

  • Aging workforce and support for older workers

  • Protection for vulnerable worker populations

  • Accommodations for workers with disabilities

  • Elimination of occupational health disparities

  • Support for small employer workplaces

  • Managing global and multinational workforces

• Policy Issues:

  • Health information privacy

  • Reasonable job accommodations

  • Structured return-to-work programs

  • Equal employment opportunity compliance

  • Family and Medical Leave Act (FMLA) implementation

  • Elimination of workplace bullying, violence, harassment, and discrimination

  • Prevention of stressful job monitoring practices

  • Worker-centered organizational policies

  • Promotion of productive aging strategies

• New Employment Patterns:

  • Managing contracting and subcontracting dynamics

  • Addressing precarious and contingent employment risks

  • Multi-employer worksite safety protocols

  • Organizational restructuring, downsizing, and merger management

  • Promoting financial and job security

Forensic and Correctional Nursing

• Scope of Practice: Provides comprehensive primary care to incarcerated individuals from initial intake entry through inter-facility transfers and final community release.

• Practice Environments: Jails, state/federal prisons, juvenile detention centers, and secure forensic psychiatric facilities (serving populations ranging from adolescents to older adults).

• Primary Focus: Primary prevention, health education, and preventing the transmission of communicable diseases—specifically addressing high rates of HIV and Tuberculosis (TB).

• Population Risk Factors: Incarcerated individuals demonstrate elevated baseline risks for violence, low educational attainment, substance use disorders, and socio-economic poverty.

• Occupational Safety: Nurses face an elevated personal risk of workplace violence and high exposure rates to infectious pathogens, mandating strict adherence to standard/universal precautions.

Hospice and Palliative Care

Residential Institutions

Community health nursing services are delivered across various specialized residential living environments:

• Halfway houses: facilities that provide temporary housing and support for individuals in recovery from substance abuse or mental health issues, offering a structured environment to assist with reintegration into the community.

• Group homes: usually where people with mental illnesses live.

• Continuing Care Retirement Communities (CCRCs)

• Inpatient hospice facilities

Hospice Philosophy and Regulations

• Philosophy: A specialized care model focused on palliative end-of-life care for terminally ill individuals. Hospice represents a philosophy of compassionate care rather than a specific physical location.

• Core Objectives: Enhances quality of remaining life; supports clients, families, and primary social circles through the dying process; provides structured bereavement services to surviving family members after death.

• Care Approach: Focuses on holistic, family-centered care rather than curative treatment.

• Eligibility Criteria:

  • Clinical prognosis of an expected lifespan of $6\text{ months}$ or less.

  • Disease process advanced to a stage where curative interventions are no longer effective or desired.

  • Patient chooses to formally discontinue active curative treatment.

• Medicare & Insurance Guidelines:

  • Care delivered through Medicare-approved or commercial hospice providers.

  • Requires formal physician recertification of terminal status every $6\text{ months}$.

  • Patients may revoke hospice benefits if disease remission occurs, retaining the option to re-certify at a later date if health declines.

• Common Diagnoses: Advanced oncological malignancies and end-stage organ system failure diseases.

• Cultural & Respite Considerations: Requires advanced understanding of diverse cultural death rituals. Agencies frequently offer short-term respite care to prevent family caregiver burnout.

Interdisciplinary Hospice Team Structure

• Governance: Medically directed by physicians and coordinated by Registered Nurses.

• Team Composition:

  • Registered Nurses (RNs/typically the care coordinator) and Certified Nursing Assistants (CNAs)

  • Hospice Physicians

  • Trained Volunteers

  • Chaplains and Spiritual Bereavement Counselors

  • Expressive Therapists (Art and Music Therapy)

  • Respite Care Staff: Provide temporary relief to primary caregivers, allowing them to take breaks while ensuring the comfort and safety of individuals receiving care.

  • Social Workers and Financial Advisors

• Coverage: All interdisciplinary clinical services are on call $24\text{ hours/day}$.

Psychological Frameworks of Dying and Grief

• The Seven Primary Fears of Dying:

  1. Pain

  2. Loss of control

  3. Loss of loved ones

  4. Other people's emotional reactions

  5. Isolation and abandonment

  6. Fear of the unknown

  7. Having lived a meaningless life

• Kübler-Ross Five Stages of Dying (Patient):

  1. Denial & Isolation

  2. Anger

  3. Bargaining

  4. Depression

  5. Acceptance

• Four Stages of Grief for Significant Others:

  1. Shock and numbness

  2. Searching and yearning

  3. Disorganization

  4. Reorganization

Clinical Indicators of Impending Death

• Reduced level of consciousness (LOC)

• Zero fluid intake and anuria (absence of urine output)

• Distinct mottling (purple coloring of the skin) of lower and upper extremities

• Labored respiratory patterns characterized by prolonged apnea spells

• Terminal respiratory secretions ("gurgling")

• Alternating disorientation and lucid reorientation

• Sudden, transient surge of physical energy

• Fluctuating body temperature (subnormal body temperature or low-grade pyrexia)

• Irregular, weak, or completely unpalpable pulse

• Progressively decreasing or unobtainable blood pressure

• Terminal restlessness and agitation

Targeted Hospice Nursing Interventions

• Pain Management: Aggressive, continuous multi-modal pain control.

• Dyspnea Relief: Administration of supplemental low-flow oxygen, low-dose opioids (e.g., morphine), meticulous oral care, ice chips, and topical lip balm application.

• Secretion Control: Strategic patient positioning (elevation of head/side-lying), gentle oral suctioning, and administration of anticholinergic medications (hyoscyamine [Levsin] or transdermal scopolamine).

• Restlessness Management: Administration of psychotropic medications (lorazepam [Ativan] or haloperidol [Haldol]), environment modification, and quiet, reassuring touch.

Palliative Care vs. Hospice Care Comparison

• Palliative Care Definition: Specialized clinical care aimed at preventing and relieving physical, emotional, and spiritual suffering for patients diagnosed with complex, serious illnesses. Delivered by interdisciplinary teams (physicians, nurses, social workers, massage therapists, pharmacists, and nutritionists) working alongside curative treatment plans.

Home Health Nursing

• Primary Goal: To assist patients in achieving their maximum level of functional capacity, health, comfort, and independence within their home environment.

• Skilled Nursing (SN) Interventions:

  • Comprehensive physical and psychosocial assessments

  • Advanced wound care and complex dressing changes

  • Diagnostic laboratory blood drawing

  • Medication instruction, reconciliation, and parenteral administration

  • Total Parenteral Nutrition (TPN) management

  • Intravenous (IV) fluid and pharmacological infusions

  • Central venous access device (CVAD) maintenance and dressing care

  • Urinary catheter insertion and long-term maintenance

• Case Management and Care Coordination:

  • Serves as Case Manager to coordinate broad multidisciplinary services.

  • Supervises clinical care and documentation completed by Licensed Practical Nurses (LPNs) and Home Health Aides (HHAs).

  • Maintains detailed clinical documentation of nursing interventions and therapeutic outcomes.

    • This will determine pay and resource allocation for patients, ensuring that all services are delivered effectively and efficiently.

  • Assesses caregiver burden, delivers emotional support, and teaches positive family coping strategies.

• Environmental Assessment & Governance:

  • Conducts home safety evaluations to identify physical and environmental hazards.

  • Prioritizes care plans for post-hospitalization recovery, actively involving the family.

  • Initiates referrals to specialized community resources.

  • Scope of Practice is defined by the American Nurses Association (ANA), the National Association for Home Care & Hospice (NAHC), and the Department of Health and Human Services (HHS).