Origins of Community Health Nursing

Pre-Contact Era

Indigenous medicine and healing practices served the health of communities in Canada before settlers arrived.
Women were the primary caregivers, providing healthcare and midwifery services in their homes and to others.
They used medicines passed down through generations and were respected for their skills and herbal remedies.
Healthcare was mainly left to the individual, with little government involvement.
In some cases, Indigenous women cared for settlers using their herbal medicines.

17th and 18th Centuries - New France

Nurses, rather than physicians, provided and administered healthcare in New France.
Community Health Nursing (CHN) was the earliest form of nursing in New France.
Much of the early care was provided by religious orders.
Religious Augustinian nuns were the first CHN order, establishing essential healthcare and working in homes, hospitals, and communities, providing outreach.
They provided access to health services, food, shelter, and education for the most vulnerable, addressing health inequity and social determinants of health (DoH).
Marie Rollet Hebert immigrated in 1617 with her surgeon husband and was the first laywoman to provide care to settlers and Indigenous people. She understood the value of evergreen trees as a source of Vitamin C during winter months.
Hotel Dieu de Montreal was established in 1644-45 by Jeanne Mance, Canada's first nurse and co-founder of Montreal. She worked with religious orders to build and run the hospital.
Female religious orders played a prominent role in building the hospital system in Canada and emerged as leaders when women had few employment options.

18th to Late 19th Century

Immigration to Canada increased with a focus on the fur trade.
Communicable disease epidemics of infectious diseases such as smallpox, tuberculosis (TB), measles, cholera, and typhus were brought by immigrants.
Cities saw an increase in death rates due to unsanitary conditions among the poor, inadequate nutrition, and contaminated food and water.

Nightingale Era

Social unrest created by industrial capitalism, immigration, urbanization, and harsh weather led to an increase in vulnerable populations.
From 1830-1850s medicine dominated health care.
Florence Nightingale, considered a community health nurse, believed in the uniqueness of nursing care.
As an epidemiologist and environmentalist, she strongly believed in Social Determinants of Health (SDoH) such as water, air, drainage, cleanliness, and light.
In 1860, the First Nightingale School of Nursing opened in St. Thomas Hospital, London.
Nightingale was the first person to promote nursing education using an apprentice model.
She raised the status of nursing, suggesting it was a respectable profession for women, distinct from untrained caregiving work.
Her vision emphasized environmental conditions of fresh air and water, stating the nurse should put the patient in the best possible position for nature to act upon them.
In 1874, the first nursing schools in Canada were established but lacked financial support, requiring students to provide nursing service to the hospital in return for education and living expenses.

BNA Act 1867 and Governmental Roles

Provincial governments assumed responsibility for health and social welfare, including hospitals, public health, asylums, and charities. This was assumed by default as it was not clearly stated in the Act.
In the early years, provinces did not organize healthcare, so municipal governments organized some health services through public welfare, charitable organizations, and churches.
The BNA Act of 1867 addressed healthcare responsibilities, assigning the federal government to establish and maintain marine hospitals, care for Indigenous peoples, and manage quarantine.
At the time of enactment, the government regularly imposed quarantines to prevent outbreaks of tuberculosis, influenza, and cholera, similar to measures during COVID-19.

Late 19th and Early 20th Century (early 1900s)

During this period, nursing had three distinct sectors:
1. Hospital nurses
2. Private-duty nurses
3. Community health nurses (CHNs): public health and home visiting/district nurses.
CHNs were considered among the profession’s elite and were driven by a sense of adventure, independence, and humanitarianism, leading them to work in the poorest urban districts and isolated rural communities.
They enjoyed more financial stability, paid by charitable organizations (Red Cross) and some local government funds.
Early practice of public health and visiting nurses overlapped, working in rural/poor communities to provide direct bedside care, midwifery services, and health and prevention education to individuals and families.
The focus was on working-class and lower-middle-class families who could not afford services.
Their work was supported at the local level by Maternal Feminists, Women’s Institute, and United Farm Women, who lobbied local officials to prioritize healthcare services.

Distinction Between Direct Care and Community Health Nurses

A distinction grew between direct care nurses and those focused on the health of the community.
In 1897, Lady Aberdeen started the Victorian Order of Nurses (VON) to address the needs of rural communities, marking the evolution of district and home nursing in Canada.
Her view was that home helpers had to be trained in midwifery and basic care to reach women in rural areas.
In Canada, public health nursing became more organized in the early 20th century due to precipitating factors such as the TB outbreak and 1918 Spanish Flu.
Public health departments established health education and preventive programs to address communicable diseases and reduce infant mortality and morbidity in school-age children.
Nurses were considered the best choice to deliver programs and engage with women and families in their homes and schools.
Their work included TB control programs and school health programs (child hygiene/sanitation).
They focused on growth and development, the importance of immunization, and nutrition.
The earliest maternal programs were well-baby clinics established by the Red Cross, carried out at milk depots, clinics, and homes, supported by women volunteers and visiting nurses.
Some public health officials believed mothers were ignorant, and the establishment of public health programs had limited success in rural and isolated areas that wanted visiting nurses to do the teaching.

By the Beginning of WWII

Essential elements of CHN services were in place across the country.
Provincial health departments had been organized, and local public health departments were in the majority of Canadian cities.
Public Health Nurses (PHNs) worked in health education and disease prevention, including:
- Mental health
- Control of 'venereal' diseases (STIs)
- Preschool health
- Prenatal education
VON continued to flourish in urban areas.

Post-WWII and Medicalization

VON continued after the war, but public health departments started taking over health programs provided by VON.
In 1945, penicillin was approved for treatment.
Medical approaches to health increased.
Hospital admissions became the norm, leading to the medicalization of the healthcare system.
VON caseloads then focused on convalescent and chronic care.
There was an erosion of charitable donations, which had previously offset the cost of care for the poor, so care was more likely to go to individuals with money (directly or through third party).

1940s, 50s, 60s

Public health departments shifted emphasis from child health, immunizations, and communicable disease (prevention-promotion) to reduction in morbidity and mortality (epidemiology) from chronic illnesses and injuries =medical focus.

1970s

Healthcare focused on medical services, but costs were rising.
Patients were discharged earlier from hospitals.
There was deinstitutionalization of patients from various institutions.
Communities were not well prepared and did not always have the resources to effectively support individuals.

1980s

Rising healthcare costs led to a loss of nursing jobs, most evident in hospitals.
Nurse leadership in clinical practice was replaced by managers who were not clinical experts.
Governments replaced hospital care with community care, yet there was little to no funding increase for community nurses.
Home health nurses continued to provide care in homes and educate families.

Late 20th Century

The number of PHNs did not increase, but they still had a mandate to focus on communicable diseases, healthy childhood development, and prevention of chronic diseases.
Decreased funding in the 80s and 90s affected public health and home health nurses (↓ staff, ↓ programs) = ↓ monitoring of communicable diseases.
There was a resurgence of TB and an ↑ in communicable diseases like SARS and COVID-19.
Documents such as Alma Ata on Primary Health Care and the Ottawa Charter on Health Promotion refocused practice on SDoH and health promotion (more than disease prevention) as the foundation of CHN practice and education.
In 1987, the Community Health Nurses Association of Canada was formed.
Today, it is the Community Health Nurses of Canada (CHNC) and has created several editions of the CHNC Standards of Practice.

21st Century

The Public Health Agency of Canada (PHAC) was formed in 2004 after the SARS crisis.
PHNs focus on SDoH and look at the root causes of poor health (social inequities).
They work to redefine their roles in schools, homes, and communities.
CHNs continue to:
- Work with marginalized communities (street and outreach nurses)
- Work to promote health
- Advocate for equity in their work organizations to receive sufficient money.
Collectively, public health and community health nurses respond to, advocate for, and address Indigenous healthcare.
All community nurses must:
- Redefine how healthcare is delivered in society
- Continue to advocate for policies that create equity in health
- Policies must address the social and living conditions of vulnerable populations.