A Textbook of Community Nursing

Sue Chilton, Heather Bain, Sue Chilton, Heather Bain

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781498725415
• Edition: 2
• Topic: Medicine
• Subtopic: Nursing

A Textbook of Community Nursing is a comprehensive and evidence-based introduction covering the full range of professional topics, including professional approaches to care, public health, eHealth, therapeutic relationships and the role of community nursing in mental health. The new edition has been updated throughout, including new guidelines and policies. It also provides a stronger focus on evidence-based practice.

This user-friendly and accessible textbook includes:

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• Current theory, policy, and guidelines for practice. All chapters are underpinned by a strong evidence base;

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• Learning objectives for each chapter, plus exercises and activities to test current understanding, promote reflective practice, and encourage further reading;

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• Case studies and examples from practice which draw on all branches of community nursing to illustrate practical application of theory.

This is an essential text for all pre-registration nursing students, students on specialist community nursing courses, and qualified nurses entering community practice for the first time.

CHAPTER
1

Nursing in a community environment

Sue Chilton

LEARNING OUTCOMES

•Compare and contrast definitions of ‘community’, exploring the contexts in which the term is used and, specifically, how it is interpreted within community nursing.

•Explore the environmental, social, economic, professional and political factors influencing the delivery of community healthcare services and critically appraise ways in which local services aim to be responsive to the specific needs of their population.

•Develop insight into the complex nature of the environment of community healthcare.

•Identify the skills and qualities required of nurses working in community settings.

INTRODUCTION

This chapter considers the complex environment within which community nurses practice and offers some definitions of ‘community’ and ways in which the term is used. It explores the wide range of factors impacting upon the services community nurses provide for patients and discusses ways of tailoring care to respond to local needs. Key skills and qualities currently required by community nurses are identified and discussed.

DEFINITIONS OF ‘COMMUNITY’

Changes in terms of the location and nature of community nursing care provision have occurred over the years in response to a variety of influencing factors. More recently, we have seen a distinct shift of services from the hospital setting to primary care and community locations (Turnbull, 2017; McGarry, 2003). Current health and social care policy directives indicate that still more services will be provided within the community context in the future (Scottish Government, 2013; Welsh Assembly Government, 2013; Scottish Government, 2010; DHSSPSSNI, 2011; NHS England, 2014). In order to provide the required administrative and managerial infrastructure to accommodate these changes, several major organisational reconfigurations have taken place across the United Kingdom in recent years. In England, for example, general practitioner (GP) fundholding was replaced by primary care groups, which then developed into primary care trusts (DH, 1997). Further changes quickly followed with the largest structural reorganisation of the National Health Service (NHS) since its inception in 1948, involving the development of GP consortia (DH, 2010a), which have wide-ranging responsibilities for commissioning services and manage the vast majority of the NHS budget. Over the last few months, there has been the development of ‘Sustainability and Transformation Plans’ (STPs) which involve partners working together in ‘place-based systems of care’ to transform health and social care delivery within local populations. These plans are focused on improving quality and developing new ways of working; improving health and well-being; and improving the efficiency of services in hospitals and the community (Alderwick et al., 2016). Political analysts have recognised the potential value of STPs in supporting new care models and promoting collaboration between key stakeholders but also advise caution and the need for close monitoring and evaluation in testing whether service changes and related financial plans are viable (King’s Fund, 2017).

Although, from an academic perspective, the notion of ‘community’ has been discussed widely across a range of disciplines, including sociology and anthropology (Cohen, 1985), clarity with regard to a definitive definition eludes us.

ACTIVITY 1.1

Reflection point

Compile a list of words that helps to define ‘community’ for you. Identify any recurring themes that emerge when considering different types of communities or different contexts within which the term is used.

Laverack (2009) offers four key characteristics of a ‘community’ which help to summarise many of the definitions found in the literature. These are as follows:

•Spatial dimension – referring to a place or location

•Interests, issues or identities that heterogeneous groups of people share

•Social interactions that are often powerful in nature and tie people into relationships or strong bonds with each other

•Shared needs and concerns that can be addressed by collective and collaborative actions

Although the essence of ‘community’ is difficult to capture within a definition, the word itself largely conveys a positive impression conjuring up feelings of harmony and co-operation. It is unsurprising to find that it is a word used frequently by politicians within government documents to create just that effect.

The uncertainty with regard to the true meaning of the word ‘community’ also applies within community nursing (Hickey and Hardyman, 2000). It is pivotal (Carr, 2001) that the context within which care takes place, including physical and social aspects among many others, is considered alongside the geographical location of care. By attempting to include the wide array of elements involved, the true complexity of nursing within the community begins to emerge. Although some of the challenges, such as interacting with patients and families in their own homes, are acknowledged within the literature (Luker et al., 2000; Quaile, 2016a), the meaning of ‘community’ within community nursing is often assumed and taken for granted (St John, 1998).

St John (1998: 63) interviewed community nurses who explained the nature of the communities they worked within in terms of ‘geography; provision of resources; a network and target groups’. Some nurses described their communities as a ‘client’ or an entity, particularly where members of the community were connected. If a population was not connected, nurses defined community as the next largest connected element such as a group or family.

It would appear, therefore, that definitions of community often include the dimensions of people, geography or space and shared elements, relationships or interests and incorporate some form of interaction. Many of these common themes are captured in the following definition of ‘community’ as

… a social group determined by geographical boundaries and/or common values and interests. Its members know and interact with each other. It functions within a particular social structure and exhibits and creates certain norms, values and social institutions.

(WHO, 1974)

Awareness of the networks that exist within a community helps in identifying opportunities or strategies to engage ‘hidden’ members of the population. ‘Social capital’ is a term used to explain networks and shared norms that form an essential component of effective community development (Wills, 2009). It is proposed that poor health is linked to low social capital and social exclusion where poverty or discrimination exist (Wilkinson, 2005). According to the National Occupational Standards in Community Development Work, the main aim of community development work is

collectively to bring about social change and justice by working with communities to identify their needs, opportunities, rights and responsibilities; plan, organise and take action and evaluate the effectiveness and impact of the action all in ways which challenge oppressions and tackle inequalities.

(Lifelong Learning UK, 2009)

Community development work is inclusive, empowering and collaborative in nature and is underpinned by the principles of equality and anti-discrimination, social justice, collective action, community empowerment and working and learning together.

A study by McGarry (2003) identifies the central position of the home and relationships that take place within it in defining the community nurse’s role. Four key themes emerging from her research are ‘being a guest’ within the home, the maintenance of personal-professional boundaries, notions of holistic care and professional definitions of community. The findings highlight the tensions for nurses in embracing their personal perceptions of community nursing while trying to work effectively within the constraints of organisational and professional boundaries.

Kelly and Symonds (2003), in their exploration of the social construction of community nursing, discuss three key perspectives of the community nurse as carer, the community nurse as an agent of social control and community nursing as a unified discipline. The authors discuss the proposition that community nurses are still reliant on others to present the public image of community nursing that is portrayed. They argue, interestingly, that community nurses may not possess enough autonomy to define their own constructs and articulate these to others.

Community Links is a charitable organisation which, through its national work, shares lessons with government and community groups across the country to achieve social change. The charity’s chief executive, Blake, believes the concept of community has become more complex and that a top-down or narrow definition may not be useful and can, in certain instances, have negative consequences. According to Blake (2013), community is a ‘fluid, chaotic thing’ and defining the concept is not essential and adds that ‘It’s the doing something together that is important’. People can belong to many different communities whether based on geography, ethnicity, religion, interest or other social factors such as disability or refugee status and this notion of multiple communities can strengthen and add value to communities. In addition, communities are not static and can change over time, presenting challenges to service providers who may need to adapt their interventions depending on the expressed needs of a community at any one time (Niven, 2013).

Niven (2013) interviewed five community leaders from different charitable and voluntary organisations and found that, although community identity is difficult to conceptualise, these leaders sensed that a strong desire from the public to be part of a community is returning.

FACTORS INFLUENCING THE DELIVERY OF COMMUNITY HEALTHCARE SERVICES

Community nurses face many challenges within their evolving roles. The transition from working in an institutional setting to working in the community can be somewhat daunting at first (Sines et al., 2013a). As a student on community placement or a newly employed staff nurse, it soon becomes apparent that there is a wide range of factors influencing the planning and delivery of community healthcare services. Within the home/community context, those issues that impact upon an individual’s health are more apparent. People are encountered in their natural habitats rather than being isolated within the hospital setting. Assessment is so much more complex in the community, as the nurse must consider the interconnections between the various elements of a person’s lifestyle. Chapter 7 explores the concept of assessment in more detail. In addition, community nurses are often working independently, making complex clinical decisions without the immediate support of the wider multidisciplinary team or access to a range of equipment and resources as would be the case in a hospital or other institutional healthcare environment. It is recognised, for example, that district nurses are frequently challenged with managing very complex care situations which require advanced clinical skills, sophisticated decision making and expert care planning (Quaile, 2016a). Ford (2016) also acknowledges the need for specialist district nurse practitioners to have expert knowledge and advanced clinical skills as well as highly developed interpersonal skills and a clear understanding of a whole systems approach.

Defining health is complex as it involves multiple factors. According to Blaxter (1990), health can be defined from four different perspectives: an absence of disease, fitness, ability to function and general well-being. The concept of health has many dimensions such as physical, mental, emotional, social, s...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Contents
• Contributors
• Foreword
• Introduction
• Acknowledgement
• 1 Nursing in a community environment
• 2 Public health and the promotion of well-being
• 3 Professional approaches to care
• 4 Managing risk
• 5 Therapeutic relationships
• 6 Care across the lifespan
• 7 Community nursing assessment
• 8 The role of the community nurse in mental health
• 9 Carers: The keystone of communities and families
• 10 Spirituality: A neglected aspect of care
• 11 Collaborative working: Benefits and barriers
• 12 Approaches to acute care in the community
• 13 Emerging issues in long-term conditions
• 14 Providing quality care at the end of life
• 15 Organisation and management of care
• 16 Leading quality, person-centred care in the community
• 17 eHealth
• 18 Development of community nursing in the context of changing times
• Index