Overview of Community Health Nursing
- Community health nursing (CHN) = population-focused approach to planning, delivering, and evaluating nursing care.
- CHN is broad: nurses practice in many settings; promote health across lifespan and diverse populations.
- NCLEX connections:
- Nurses in the community must understand foundations, guiding principles, health promotion, and disease prevention.
- Historical concepts in public health:
- Care for the poor or displaced shows public health foundations.
- Advances in health knowledge led to provider education and regulation of water and environmental factors.
- Public Health Service (1798) and home nursing in the early 1800s; local health boards emerged to monitor disease, promote health, and collect community statistics.
- Nursing practice in the community is guided by multiple theories and definitions of care.
- Systems thinking: analyzes how individuals or units interact with other organizations/systems; useful for cause-and-effect relationships.
- Upstream thinking: focuses on health-promoting interventions and prevention of illness, not just care after illness.
- Nursing theory provides the basis for care of the community and family; theories guide high-quality care.
- Examples of theories used in CHN:
- Nightingale’s Environmental Theory: relationships between environment and health; health as a continuum; emphasis on preventive care.
- Health Belief Model: predicts/explains health behaviors; preventive actions aimed at avoiding disease; individual-level focus.
- Milio’s framework for prevention: complements Health Belief Model; community-level change; links health deficits to availability of health-promoting resources; behavior changes across many people lead to social change.
- Pender’s Health Promotion Model: similar to Health Belief Model; does not frame health risk as a trigger; focuses on factors affecting individual actions to promote/protect health (biological, psychological, sociocultural factors; self-efficacy).
- Transtheoretical Model (TTM) / Stages of Change (SOC): change over time in six stages: Precontemplation, Contemplation, Preparation, Action, Maintenance, Termination (most clients do not reach termination).
- Precaution Adoption Process Model: similar to TTM/SOC; includes a stage of being unengaged between unaware and contemplating action; no termination stage.
- Determinants of health: client/environmental factors influencing health (nutrition, social support, stress, education, finances, transportation, housing, biology/genetics, personal health practices). (Refer to Chapter 2 – Social Determinants of Health.)
- Health indicators: mortality rates, disease prevalence, levels of physical activity, BMI, tobacco/substance use; describe community health status and guide improvement targets.
- Quality Improvement (QI): nurses assess whether a community’s health needs are identified and met.
- Community defined: a group of people and institutions sharing geographic, civic, and/or social parameters; communities vary in characteristics and health needs.
- CHN = synthesis of nursing and public health theory.
- Goals of CHN (also called community-oriented nursing): promote, preserve, maintain the health of populations; deliver health services to individuals, families, and groups to influence community health.
- Practice settings: CH nurses are community-based and usually have a facility (clinic, county health department) but practice is not limited to institutional settings; care is often delivered where clients live/work (home, school, workplace) but focused on the community population.
- The client in CHN = the community or a population (aggregate sharing one or more characteristics).
- QPCC: Community-based nurses can develop relationships with clients while working with individuals with acute and chronic conditions and their families.
- Public health nursing (PHN): population-focused; combines nursing knowledge with social/public health sciences; goal = promoting health and preventing disease.
- The 10 essential public health services, organized under three core public health functions (CDC):
- Assessment: monitor health status, identify health problems, diagnose/investigate health problems and hazards.
- Policy development: inform/educate/empower; mobilize partnerships; develop policies/plans; enforce laws/regulations to promote equity, protect health, ensure safety.
- Assurance: ensure access to personal health services; ensure a competent workforce; evaluate effectiveness, accessibility, and quality of health services.
- For more PHN info: Chapter 5 – Practice settings and nursing roles in the community.
- Core function mapping exercise: Determine to which core function (Assessment, Policy Development, Assurance) each essential service belongs.
- Community health nursing focus: aggregates, communities, populations (public health).
- Can include at-risk or unserved individuals and families; individuals and families; population-focused scope.
- Primary goal: health promotion and disease prevention; management of acute or chronic conditions; population-level outcomes.
- Nursing activities: usually indirect (program management) for some services; direct care for at-risk individuals and populations in others.
Population-Focused Nursing
- Population-focused nursing involves assessing needs, intervening to protect/promote health, and preventing disease within a specific population (e.g., individuals at risk for hypertension, uninsured individuals, those with knowledge deficits).
- Public Health Intervention Wheel: model for the 10 essential public health services; access via Minnesota Department of Health and CDC.
- Community partnership: active participation of community members, agencies, and businesses in health promotion and disease prevention; critical for strategy success.
- Key principles of PHN:
- Emphasize primary prevention.
- Strive for the greatest good for the largest number.
- Recognize the client as a partner in health.
- Use resources wisely to promote the best outcomes.
Practice Roles and Orientation
- A nurse manager developing orientation content to differentiate community-based vs community-oriented activities.
- Basic distinctions (examples):
- Community-based: direct care to individuals or families in the community; focus on acute/chronic conditions in local settings.
- Community-oriented: emphasis on population-level health outcomes; integrates prevention and health promotion for communities.
- Community health nursing: broad umbrella including PHN principles; focus on population health within the community.
- Ethics
- Advocacy
- Evidence-based practice
- Quality
- Professional collaboration and communication
Ethics in Public Health
- Public Health Code of Ethics: prevent harm, do no harm, promote good, respect autonomy and diversity, confidentiality, competency, trustworthiness, advocacy.
- CHN aims to protect/promote health and prevent disease; balancing individual rights with community rights is a challenge.
- Client rights in CHN: information disclosure, privacy, informed consent, confidentiality, participation in decision-making.
- Researchers in the community must use ethical decision-making to protect client rights.
Application of Ethical Principles
- Respect for autonomy: individuals choose actions aligned with personal goals (e.g., choosing not to pursue chemotherapy).
- Nonmaleficence: no harm when applying care standards; include monitoring/outcome evaluation in plans.
- Beneficence: maximize benefits and minimize harms; evaluate costs/risks/benefits when planning interventions.
- Distributive justice: fair distribution of benefits/burdens; allocate resources based on need.
- PHN core functions can reflect ethics in practice (assessment, policy development, assurance).
Advocacy
- Client advocate roles: informer, supporter, mediator; clients are autonomous, with rights to trustworthy nurse-client relationships; clients are responsible for their own health; nurses advocate for resources/services to meet needs.
- Nurses advocate for communities/populations by influencing health care systems and improving quality of life.
- Example: advocating for rural clinics to improve access to care.
Evidence-Based Practice (EBP)
- Definition: use of best practices, expert opinion, and client preferences to improve outcomes.
- Data appraisal in EBP:
- Assess bias (quality), study quantity (number of studies/participants/effect size), and consistency (repeatability).
- Seek highest level of evidence validated by systematic peer review.
- In community settings, EBP improves public health by informing assessment, policy development, and assurance.
- Examples: using high-level evidence to support immunization media campaigns; CPSTF (Community Preventive Services Task Force) reviews guidelines to determine sufficiency/strength of evidence and which interventions are recommended.
- When applying evidence: consider cost, benefit, client satisfaction, safety, and client-specific factors (culture, demographics).
- Community-Based Participatory Research (CPBR/CBPR): partners (professionals and community residents) involve communities in identifying issues and interventions; fosters support, leadership, and collaboration with health professionals.
- QA, QI, and QM are strategies to improve health care quality.
- Quality promotion mechanisms: licensure/credentialing, adherence to policies, professional development, and legal compliance; specialty certification available for many CH roles.
- Quality reporting: quality report cards for managed care and PH organizations; may include health profiles, needs assessments, QoL, health status.
- Use of data from quality reports to revise community care strategies (e.g., diabetes care and HbA1c testing guidance).
- Total Quality Management (TQM): an approach to meet or exceed expectations.
- Continuous Quality Improvement (CQI): focuses on organization, processes, and systems with objective data to improve processes; PHN uses CQI in assessment, assurance, and policy development ongoing.
- Quality evaluation criteria (six domains):
- Effectiveness: services benefit those who will benefit.
- Timeliness: reduce waits/ delays in care.
- Client-centered: client values guide decisions.
- Equity: equal care regardless of gender, race, SES, etc.
- Safety: avoid injuries from care.
- Efficiency: avoid waste of resources.
Levels of Prevention
- Public health nurse evaluates outcomes of community interventions across prevention levels.
- Primary prevention: prevent initial occurrence of disease/injury; examples include nutrition education, family planning/sex education, smoking cessation education, communicable disease prevention education, safety education (seat belts, helmets), prenatal classes, immunizations, advocating for access to care and healthy environments.
- Secondary prevention: early disease detection and treatment to limit severity; examples include community assessments, disease surveillance, screenings; specific disease targets include cancer (breast, cervical, testicular, prostate, colorectal), diabetes, hypertension, hypercholesterolemia, sensory impairments, TB, lead exposure, genetic/metabolic disorders in newborns; control of outbreaks of communicable diseases.
- Tertiary prevention: reduce disability and promote rehabilitation after health alterations; examples include recovery maximization after injury/illness (rehabilitation), nutrition counseling for Crohn’s disease, exercise rehabilitation, case management for chronic/mental illness, physical/occupational therapy, support groups, and exercise for conditions like hypertension.
- Distinction: health promotion vs disease prevention are terms often used interchangeably; both aim to promote health, reduce overall disease risk, and prevent specific conditions.
- National health goals guide nurses in health promotion strategies and population health improvement.
- Three levels of prevention applied to communities and individuals:
- Primary prevention: prevent disease before it occurs.
- Secondary prevention: screen and treat early to prevent progression.
- Tertiary prevention: reduce complications and maximize functioning after disease onset.
Healthy People and National Health Goals
- Healthy People = national health goals/ objectives derived from data/trends; established since 1979 and updated every 10 years.
- Transitioned to Healthy People 2030 (August 2020).
- Healthy People serves as a quality measure and guide for health promotion strategies.
- Focus areas include: access to health services, adolescent health, chronic kidney disease, disability, genomics, global health, QoL, hearing/communication disorders, nutrition/weight, older adults, oral health, preparedness, family planning, food safety, mental health, medical product safety, LGBTQ health, substance abuse, sleep health, and additional areas.
- PHN helps people adopt healthier lifestyles toward optimal physical and psychosocial health.
- Preventive services include education/counseling based on evidence, immunizations, preventive medications, lifestyle changes, and other actions to prevent disease or disability.
- PHN provides preventive services across multiple community settings and plans/implements screening programs for at-risk populations.
- Successful screening programs:
- Produce accurate and reliable results.
- Are inexpensive and quick to administer to large groups.
- Produce minimal adverse effects.
- Evaluation criteria for a screening method: reliability (consistency), validity (accuracy of measurement), and predictive value (effectiveness in identifying individuals with a condition).
Disease Prevention Highlights by Level
- Primary prevention examples: nutrition education; family planning/sex education; smoking cessation; communicable disease prevention education; health/hygiene education for specific groups (day care workers, restaurant workers); safety education (seat belt/helmet use); prenatal classes; immunizations; advocating access to care; healthy environments.
- Secondary prevention examples: community assessments; disease surveillance (communicable diseases); screenings; cancer (breast, cervical, testicular, prostate, colorectal); diabetes; hypertension; hypercholesterolemia; sensory impairments; TB; lead exposure; genetic/metabolic newborn disorders; outbreak control.
- Tertiary prevention examples: rehabilitation-focused activities (nutrition for Crohn’s, exercise rehab, case management for chronic/mental illness, physical/occupational therapy, support groups); exercise for hypertension; other rehab-oriented interventions.
- Public Health Intervention Wheel: widely used model for the 10 essential public health services; available via Minnesota Dept. of Health and CDC.
- Community partnerships: essential when communities, agencies, and businesses actively participate in health promotion and disease prevention strategies.
- KeyPHN Principles (recap): emphasis on primary prevention; maximize benefits for the greatest number; client as partner; efficient resource use.
- Ethics, Advocacy, EBP, Quality, Collaboration/Communication form the core professional competencies in CHN.
- Professional Collaboration and Communication:
- CHN uses clear, respectful language in written, electronic, and face-to-face communication.
- Account for variations in verbal/nonverbal communication, literacy, and client preferences.
- Protect privacy and confidentiality in all communications.
- Benefits of professional communication:
- Improved client adherence; reduced hospital admissions; cost reductions; shared decision-making; reduced medication errors.
Ethical Principles in Practice (Continued)
- Distributive justice: fair distribution of resources; eligibility decisions based on need and resources.
- Fidelity, Respect for autonomy, Veracity, Beneficence, Nonmaleficence, Privacy/confidentiality.
- Scenarios illustrating ethical principles in CHN (e.g., resource allocation to underserved areas; ensuring informed consent in community interventions).
- EBP process includes: recognizing best available evidence, client preferences, and resources; applying to practice with consideration of context (cost, benefits, safety, cultural factors).
- CPSTF guides recommendations by evaluating strength/quality of evidence and identifying interventions with sufficient evidence.
- CBPR/community-led research engages community members in issue identification and intervention development; fosters leadership and sustainable collaboration with health professionals.
Quality Improvement in Public Health Nursing
- CQI approach emphasizes organizational processes, data-driven analysis, and ongoing improvement.
- PHN CQI responsibilities: assessment, assurance, policy development with ongoing improvement.
- Quality evaluation criteria (quality indicators):
- Effectiveness, Timeliness, Client-centered, Equity, Safety, Efficiency.
Practice Question (Level of Prevention Example)
- A public health nurse reviews outcomes of an exercise program at various locations in a community.
- Which aspect of care is this evaluating?
- Options: a) Timeliness b) Client-centered c) Equity d) Safety
- Correct answer: c) Equity (evaluating whether benefits are distributed across locations/populations equally)
Professional Ethics and Legal Considerations
- Privacy and confidentiality laws apply to all community communications; nurses must safeguard client information in all formats.
- Client advocacy involves informing, supporting, and mediating for clients, while respecting autonomy and collaborative decision-making.
- Nurses advocate for communities by influencing policies and health system changes to improve access and quality of life.
Summary Connections
- CHN integrates public health science and nursing theory to address population health.
- Upstream and preventive approaches are central to CHN, with emphasis on primary prevention and health promotion.
- Ethical practice, advocacy, EBP, and CQI are essential to advancing community health.
- Health goals (Healthy People 2030) guide strategies, with measurement via health indicators and public health reporting.
- Skills in communication, collaboration, and culturally competent care are critical to success in CHN settings.