Community Health

Nursing Roles
Unit 2
Community Health Nursing
 Home care nursing (home health nursing)
 Parish nursing
 Public health nursing
 Corrections nursing
 Outreach nursing
 Primary Care networks/family care nursing
 Other community health nurses

◦ Forensic nursing
Community Health Nursing ‘CHN’ – review

 Umbrella term
 CHN Practice settings vary
 Roles & functions become more consistent
 Focus can be more toward individuals, groups

or populations
BUT

ALL WORK WITH COMMUNITIES

 Roles

Client Diverse
Settings

Areas of specialty
Chapter 3, Stanhope 2011 – CH nursing components
Home Health Nursing
Purpose & Goals
 Originally created to provide care after

discharge from hospital

 Goals are always related to

◦ Health promotion
◦ Health maintenance
◦ Health restoration

 Main overall goal is rehabilitation &

restoration to maximum health function
Expansion of Home Health is Due to:
 Increased demand for cost effectiveness
 Decreased hospital stays (early discharge)
 Consumer preference
 Technological advances becoming user

friendly
 Proven quality of service
 Hospital bed closures
Home Health Nursing Defined
 Includes disease prevention, health
promotion, episodic illness related services
 Care provided in the place of residence
 Main focus is primary prevention
 Work with family-family caregiving
 Family is defined individually
 Meet basic care needs
Home Health Nursing
Practice Setting:
 In the home or wherever the resident resides

Client Population:
 Elders are the most frequent users
 All ages can use services

Note:
 Fastest growing section is palliative care
Functions & Roles of Home Health
Nurses
 Helps prevent the occurrence of illness & promote
client well-being
 Client’s have control over and determine their own
health care needs
 Need active involvement of the client
 It is often intermittent health care & therefore we
want to facilitate self-care:
 activities that individuals initiate and perform on their own
behalf in maintaining life, health and well-being (Orem, 1995)
 Contracting
 Direct and indirect functions
Functions
Involved in direct & indirect care
 Direct

◦ Physical care
◦ Supervision
◦ Assessing & teaching
◦ Reporting to physician
 Indirect
◦ Consulting with others
◦ Advocating
◦ Documenting
◦ Obtaining test results
Home Health Nurse
Care Co-ordinator
 client conferences
 increase coordination between services
 continuity of care
 optimal client care & use of resources

Case Manager
 not always a nurse (physical therapist)
 enhance continuity
 provide appropriate care
Role of the Practical Nurse in Home
Health Care
Nurse must be
 Self directed
 Flexible
 Adaptable
 Good critical thinking & assessment skills
 Generalist nurse, clinician, educator,

consultant

Effectiveness depends on client’s involvement

in & understanding of plans
Home Health Nursing: Discharge
Planning
 Definition:
◦ A process that connects clients and services, to
ensure continuity of care between hospital and
community
 Goal:
◦ To prevent health problems from arising
following discharge to prevent unnecessary
hospital readmission.
Referral Process
 Referral process:
◦ Directing a client to another source of assistance
when the client or CHN is unable to address the
client’s issue
 Interdisciplinary Collaboration
Professional: Non-professional:
RN’s (Unregulated)
LPN’s Health care aides
Rehab - PT, OT, Personal care aides
Speech Housekeeping
Respiratory Home mgmt.
Social work
Consult services:
Nutritionists, Enterostomal/ Wound Therapists, Nurse Practitioners,
Registered Dieticians, Pharmacists, Mental health, Palliative team
Public Health Nurse
 Takes a population health approach to
protect and promote health and prevent
disease
 Work within and external to health unit
 Involves

◦ Coordinating care, planning services or programs,

collaboration
 Important to have good communication skills
Practice Setting For Public Health
Nursing
 Health unit
 Funded by province/territory
 Work in client homes (e.g., healthy

beginnings program)
 Work in schools (e.g., collaborate with school

staff, parents and students to promote

health)
 Provide services such as influenza prevention,

travel health, immunizations, communicable

disease follow up
Public Health Nursing
 Prevention
 Health surveillance
 At risk population

Client is defined as the population, community,

aggregate group, family & individual
Public Health
 Community approach to maintain health,

prevent disease & protect the population

 Goal is to achieve a healthy environment
Roles & Functions of Public Health
Nursing
 Depends on the needs & resources of the
community
Roles
 Advocate (for required services)

 Manager (assess, plan, implement, evaluate)

 Major referral resource
 Direct primary care giver

 Emergency (disaster) nursing

 Controlling communicable disease
 School health & safety
Clarification
Public Health Nursing
 Merges knowledge from public health sciences with
professional nursing theories
Community Health Nursing
 Promotes & protects health of individuals, families,
groups, communities, populations
 Includes
◦ Public Health nursing
◦ Community mental health nursing
◦ Home health nursing
◦ Occupational health nursing
◦ School nursing
◦ Correctional nursing
Other Community Health Nursing
 Parish Nurse-nurse with specialized
knowledge and who is called to ministry
 Guidelines for practice=RN, spiritual maturity,
personal/interpersonal skills, teaching, worship

 Forensic Nurse-new specialty; in Edmonton

work in emergency departments
Other Community Health Nurses
 Outreach Nurse-street nurse

 Corrections Nurse-work in correctional

facilities providing care to inmates

 Telenurse-providing nursing care through the

use of a variety of technologies. Could be via
telephone, skype

 Primary care network/Family care nurse

Community Health Nursing
in Rural Settings
 Rural is generally defined in terms of either
the geographic location and population
density, or the distance from (e.g., 40 km)
or time needed to commute to (e.g., 30
minutes) an urban centre.
 Approximately one fifth of the Canadian
population resides in rural settings.
Community Health Nursing
in Rural Settings
 Peoplein rural areas may experience
increased health risks such as the
following:
Janssen, I. (2013). The Public Health Burden of
Being overweight or obeseJournal of
Obesity in Canada. Canadian
Higher Diabetes, 37(2),
rates of smoking90–96. doi:
Higher 10.1016/j.jcjd.2013.02.059
prevalence of heart disease
Higher-than-average likelihood of mental illness
(especially depression)
Higher-than-average incidence of hypertension
and arthritis
Community Health Nursing
in Rural Settings

 Rural health care providers usually live and

practise in a particular community for
decades.
 A limited number of CHNs (e.g., PHNs or

nurse practitioners) may offer a full range

of services for residents in a specified area
that may span more than 150 km.
Community Health Nursing
in Rural Settings
 CHNs need to have an accurate
understanding of rural clients in order to
design community health programs that are
available, accessible, and appropriate.

 Whatmight be some of these

understandings?
Community Health Nursing
in Rural Settings
 Barriers to health care in rural settings:
Accessibility (lack of existing health care services,
and lack of the necessary personnel to provide
those services)
Affordability (services may not come at a
reasonable cost, or a family may have insufficient
resources to purchase them when needed)
Acceptability (a service may be inappropriate or
may not be offered in a manner that corresponds
with the values of the target population)
Community Health Nursing
in Rural Settings
 Challenges for CHNs in rural settings:
◦ Boundaries between CHNs’ home and work roles
may blur

◦ Expectation that CHN will know something about

everything (practice can therefore be demanding)

◦ Heavy workloads

◦ Professional isolation
Role of Practical Nurse

 Performing skills as set up by agency

 Documenting care given
 Observing & Reporting client changes to

agency supervisor
 Calling appropriate persons in emergency

situations
 Validating & Evaluation of Services
Role of Practical Nurse
 Assisting with ADL’s for home based
clients
 Assisting with transfers and bathing (self-
care deficits)
 Skill examples:
◦ Dressing changes
◦ Medication Administration
◦ Insulin injections
◦ Catheter insertion
◦ Ostomy care
◦ Pressure ulcer treatment
 Role of Practical Nurse

 Nutritional counseling
 Exercise/mobility programs
 Stress management
 Assist with Case Management (complex

conditions)
Home Care Case Study
 Client: Mr. V, 72, diagnosed with terminal
(Stage 4) lung cancer 2 weeks ago. He has
expressed a desire to receive palliative care
services at home. He has left-sided weakness
due to a brain tumour that was diagnosed 2
weeks ago. The family is aware that his
condition is terminal and that he will likely
only live a few more months.
Case study continued

 Health History:
 Immunizations – up to date.
 Allergies – NKA
 Medications – Metformin 500 mg PO TID,

gliclazide 40 mg PO BID, Altace 10 mg PO

daily, Lasix 40 mg PO daily, Lipitor 40 mg
PO daily, Colace 100 mg PO BID, Senokot 2
tabs PO daily, ASA 80 mg PO daily,
gabapentin 300 mg PO QID.
 Accidents/injuries – none recent.
Case Study continued
 Serious/chronic illnesses – DM, hx of acute
MI, CHF, peripheral vascular disease, diabetic
retinopathy, diabetic foot ulcers, recent
diagnosis of lung cancer with metastases to
brain.
 Childhood illnesses – measles, mumps,

rubella, chickenpox.
 Hospitalizations – hospitalized for MI 18

months ago; hospitalized 16 months ago for

CHF; recently in hospital for 5 days due to
lung cancer diagnosis.
 Operations – double heart bypass 18 months

ago; previous eye surgery

Case Study continued

 Social history:
 Married x 43 years, ten children, 31 grandchildren. 3 sons

and their families live in the same city. Smoked 3 ppd x 38

years; quit after MI. Some exercise – walks 2x/week, has not
been able to walk recently due to weakness from brain
tumour. Occupation – retired. Travel – born in Holland;
emigrated to Canada 45 years ago. No history of recent
travel outside Canada.
 
 ADLs:
 Eating – independent.
 Toileting – requires some assistance from wife due to brain

tumour. Remains continent.

 Hygiene – able to perform daily hygiene independently;

difficulty with showering/bathing due to brain tumour.

 Dressing – requires assistance from wife due to left-sided

weakness.
Evidence-Informed
Practice in Nursing
 Evidence-informed practice has become
central to daily nursing practice.

 It provides guidance to nurses to help them

make the most relevant and individualized
nursing care decisions in their practice.

 Underlying principle: High-quality care is

based on evidence rather than on tradition or
intuition.
Evidence-Informed Practice
 Definition:
◦ Combining the best evidence derived from
research with clinical practice, knowledge
and expertise, and unique client
expectations, preferences, or choices
when making clinical decisions

◦ The application of the best available

evidence to improve practice (best
practices)
Evidence-Informed Practice Process
 Community Health Nurses need to use best
available evidence to make policy
recommendations
 CHNs make clinical observations
 Develop hypotheses of what is happening
 Develop a clinical/community question
 Look at various sources of information
 What changes do we make, how will we

implement the changes

Clinical Practice Guidelines
 Clinical practice guidelines are developed by
a team (often interdisciplinary) of experts
who find and appraise the evidence, draw
conclusions, and make recommendations
about best practices.
Implementing
Evidence-Informed Practice
 When applying evidence-informed practice
to clients, CHNs must
Recognize the importance of assisting the client
with decision making.
Ensure that the evidence is at an appropriate
literacy level for each client.
Advise the client of the benefits and risks of an
intervention.
Consider client preferences and values in
practice decisions.
Ethics-definitions
 a branch of philosophy that includes a body
of knowledge about the moral life & a process
of reflection for determining what persons
ought to do, or be, regarding this life
CHN
 ethical principles of doing good & preventing

harm
 struggle with the rights of the individual &

families vs the rights of local groups within

the community
Ethics-definitions
Ethics
 examines ideal human behaviour
 Standards of ethical behaviour differ from

culture to culture & depend on the value of

the culture & its individuals
Terms
Ethical Issues
 moral challenges facing our profession – how

to prepare an adequate & competent

workforce for the future
Ethical Dilemma
 puzzling moral issue in which a person takes

or chooses not to take a course of action

Ethical Decision Making
 process of how ethical decisions are made
Terms
Morals
 shared, generational societal norms about

what constitutes right/wrong

Values
 beliefs about shared worth or importance of

what is desired or esteemed within society

Code of Ethics
 framework nurses use to guide their

professional obligations & actions within the

profession
Ethics-Veracity
 telling the truth
 promotes trust in a therapeutic relationship
 May be exceptions – where telling the truth

may bring about more harm than good –

Ethical Judgment
 concerned with values
 best ethical resolution of issue
 choice of action feels right for resolution of

ethical issue
Ethics-theories and principles
Consequentialism (teleology)
 the right action is the one that produces the

greatest amount of good or the least amount of

evil in a given situation
Utilitarianism
 maximizing of good & minimizing of harm for

the greatest number of people

Deontology (also called deontic or duty-based)
 the action is right or wrong in itself regardless

of the good that might come from it (a “duty” to

do something or not do something)
Principles
Respect for Autonomy
 dignity & respect for individuals, choice of actions

unless results in harm

Non-malificence
 do no harm

Beneficence
 “we do good” – professionals have an obligation to

“do good” for clients

Distributive Justice
 fair distribution benefits/burdens in society based

on needs/contributions of members
Ethical Theories of Distributive Justice
Egalitarian
 everyone is entitled to equal rights & equal

treatment in society
Libertarian
 totally individualistic
 the right to private property is most

important
Liberal Democratic
 a theory that values both liberty & equality
Communitarianism
 maintains that abstract, universal principles are
not an adequate basis for moral decision
making
1. Virtue ethics
◦ to enable persons to flourish as human beings E.g.,
benevolence, compassion, trustworthy, integrity
2. Ethic of care
◦ a belief in the morality of responsibility in
relationships that emphasize connection & caring
3. Feminist Ethics
◦ equal rights, etc.
Practical Nurse Code of Ethics
Measurement Criteria:
 adheres to the CLPNA code of ethics
 delivers care in a manner that preserves & protects

client autonomy, dignity & rights

 maintains client confidentiality within policy
 serves as an advocate & assists clients to advocate

for themselves
 maintains a therapeutic & professional relationship
 identifies & reports ethical issues
 reports illegal, incompetent or impaired practices
Code of Ethics
1. Safe, competent, ethical care
2. Health & well being
3. Choice – respect & promote autonomy
4. Dignity of all persons
5. Confidentiality of all information
6. Justice – equity & fairness for all clients
7. Accountability – answerable to practice
8. Quality practice environments – safe,
supportive & respectful
Steps for Ethical Reasoning
 Identify the issue
 Clarify your values
 Identify all alternatives
 Determine outcome
 Place on scale of 1-10
 Plan of action
 Evaluate
Advocacy
Definition
 Community Health

◦ address quality of life of individual

◦ application of information & resources (finances, effort,
votes) to effect systemic changes that shape the way
people in the community live
 Public Health
◦ address quality of life for aggregates
◦ intended to reduce death or disability in groups of
people
◦ involves the use of information & resources to reduce
the occurrence or severity of public health problems
Advocacy For LPN’s
 Principle 2: Responsibility to clients:
◦ 2.2 Advocate for the client to receive fair and
equitable access to needed and reasonably
available health services and resources
◦ 2.3 Respect and protect client privacy and hold in
confidence information disclosed except in certain
narrowly defined exceptions
Conceptual Framework for Advocacy
3 stages
1. Information stage
◦ gathering information
2. Strategy stage
◦ tactics to disseminate information, identify
objectives, build coalitions
3. Action stage
◦ focus is on implementing the strategies by
lobbying, testifying, issuing press releases,
passing laws & voting
Ethical Principles for Effective
Advocacy
 Act in the client’s (individual, group,
community) best interest
 Act in accordance with the client’s wishes &

instructions
 Keep the client properly informed
 Carry out instructions with diligence &

competence
 Act impartially & offer frank, independent

advice
 Maintain client confidentiality
Advocacy Relating to Social Justice
Advocacy is a nursing responsibility
 minimize unnecessary/unwanted procedures that

may increase suffering

 health & social conditions that allow persons to

live/die with dignity

 protect communities’ privacy

 help individuals gain access to appropriate health

services
 policies/procedures should be consistent with current

knowledge/practice
 fairness & inclusiveness in health resource allocations