Community Nursing Practice

Theory, skills and issues

Winsome St John

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000256611
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Community practice is a stimulating and diverse field of nursing. Community nurses often work without direct support from other health professionals and need, not only excellent clinical skills, but also skills in communication, research and health promotion. Community Nursing Practice offers a thorough introduction to the role of the community nurse. Based on principles of primary health care, it outlines the theory, knowledge and skills required to make a difference to the health and wellbeing of individuals, families, groups, and even whole communities.The contributors make a point of articulating knowledge that is often taken for granted among experienced practitioners. Community Nursing Practice is based on the premise that community nursing is a specialist field of nursing practice in its own right, and nurses require a specific body of knowledge to work effectively in a community setting - no matter what their clinical focus or location. Contributors outline the foundations of community practice, including principles of disease prevention and wellness promotion, as well as a social model of health. Together with the skills required for work with different population groups, the contribution of research is explored. Professional skills including program management, advocacy, teamwork, home visiting and self management are also covered.With contributions from leading nurse educators and researchers, Community Nursing Practice is richly illustrated with case studies and examples from a variety of practice settings. It is an essential student text and valuable professional reference.

PART I
THEORETICAL FOUNDATIONS FOR COMMUNITY NURSING PRACTICE

1
CONTEXT AND ROLES IN COMMUNITY NURSING PRACTICE

Winsome St John

Overview

This chapter introduces and explores the nature of community nursing roles and the context of community nurses’ work. It also presents a theoretical overview that will provide a foundation for the areas explored in more detail throughout this book.

Objectives

When you have read this chapter, you should be able to:

• describe the nature of community nursing practice;
• review the roles and characteristics of the community nurse;
• describe the context of community nursing practice;
• identify underpinning theoretical and conceptual bases for community nursing.

Key terms

community, community nurse, community health nurse, community-based nursing, community practice

Introduction

Practice in the community is diverse, stimulating and challenging. Although community nurses usually work for health agencies, they are often required to be independent practitioners, working and making decisions about their practice alone. Community practice requires nurses to use many clinical, communication, research, teaching and people skills to make a difference to the health and well-being of individuals, families, groups, and sometimes whole communities.

Community nursing is characterised by responsiveness, challenges and opportunities. Community nurses work within a milieu of political, social and environmental change. Societal changes have affected the nature and management of community health organisations. Governments, health services, communities and individuals are focused on quality of life, prevention of ill-health, promotion of health and well-being, consumer participation, the needs of an ageing population and fiscal responsibility. Health care providers must demonstrate the effectiveness of their work, and clearly identify the purpose, focus and outcomes of their services.

Recent changes in the Australian health system have been aimed at reducing reliance on tertiary care, improving management of chronic diseases and increasing community care, with strategies such as earlier discharge, day surgery, hospital out-reach programs, developing the primary health care role of general practices, increasing the use of medical technology at home, development of the hospice movement, fiscal restraints on hospitals, privatisation of health services, and de-institutionalisation of mental health services. These changes have resulted in greater attention and focus on primary care and support in the community, disease prevention, health and well-being. Community nurses’ practice is keenly affected by political and organisational decision-making, and has always responded to local changes and the prevailing social issues of the day (Cowley, 1991; St John, 1997), such as an increase in the number of refugees in a community, a local disaster or community concern about youth suicide. Thus the nature of community nursing practice makes it a specialty that is suited to nurses who enjoy change, independent decision-making, diversity and an opportunity to use their initiative.

What is community nursing?

The simplest understanding of community nursing is nursing that takes place outside a hospital or institutional setting. However, closer examination of these roles reveals that, even though these nurses all come under the umbrella of ‘community nursing’, they are doing many different sorts of jobs with many different client types, goals, underlying philosophies, service foci, activities and approaches to practice. While some community nursing roles have clear labels or titles (such as ‘child health nurse’, ‘community health nurse’ or ‘domiciliary nurse’), many do not. Dunt et al. (1991) found in a survey of 689 nurses employed outside hospitals and nursing homes in Victoria that 281 separate job titles were used for their roles. Thus community nursing roles are defined not only by their community setting, but by the aims of the services provided and the underpinning philosophies that guide practice.

One way of understanding differences in community nursing roles is described by Hunt (2005), who differentiates between community-based nursing and community health nursing.

Community-based nursing

Community-based nursing practice focuses on promoting and maintaining the health of individuals and families, preventing and minimising the progression of disease, and improving quality of life (Ayers et al., 1999; Hunt, 2005). Care is provided to individuals and families who are living and working in the community, and is aimed at managing acute or chronic conditions and promoting self-care; it may also include case management. Care can be provided in place of hospital/institutional care, on discharge from hospital, as a follow-up, or to maintain people in their homes. The main concepts of community-based nursing care are self-care, preventive care, rehabilitative care, continuity of care, family-centred care and collaboration within a community context (Hunt, 2005). The immediate environment and community resources are considered in relation to their impact on the individual and family. Although some nursing activities may contribute to improving the health of a whole community, the individual or family unit remains the main focus.

Community-based nursing interventions are comprised of primary care activities. Although community-based nurses may engage in primary prevention activities, such as health screening and health risk appraisal, their major focus is on secondary and tertiary prevention. Their primary prevention activities are aimed at promoting health and preventing illness or disease for individuals and families, including interventions such as health education, screening and immunisation. Secondary prevention activities centre on health maintenance and early detection, as well as timely intervention to prevent complications or minimise loss of function and independence. Tertiary prevention focuses on assisting people to optimise well-being, minimise deterioration and improve quality of life. Tertiary care may include rehabilitation to assist individuals in achieving their maximum potential by working through clients’ physical or psychological challenges.

Examples of community-based nursing include domiciliary nursing, palliative care in the home, home-based mental health, drug and alcohol services, home-based renal dialysis nursing, and flying doctor services. Some community-based nursing fields have become specialties in their own right, such as women’s health, sexual health, diabetes education and domiciliary nursing. In addition to traditional clinical specialty expertise, community-based nurses require the skills to work in new ways in a community setting.

Community health nursing

By contrast, community health nursing is a specialty that, in addition to providing care for individuals and families, also focuses on groups, communities and populations. The aims of a community health nursing role were clarified in a classic article by Williams (1977), who suggested that community health nursing is not defined by the setting, but rather by a focus on high-risk or vulnerable populations and the whole community. Although community health nurses may provide care to individuals or families, their central focus remains health promotion and prevention of disease in groups and/or the entire community. This involves community nurses not just in disease prevention and primary care, but also in lifestyle and behavioural approaches (such as health education, empowerment and skill development) and socio-ecological approaches (such as community development and engagement, policy and organisational change and community action). These approaches are explored further in Chapters 2 and 8. In Australia, the roles and practice of community nurses have been shown to focus on individuals, families, groups and sometimes whole communities; attending to at-risk groups within communities; and practice that is based on the principles of primary health care (St John, 1999).

While some community health nurses may provide direct care to individuals and families, they also engage in health development or upstream health promotion activities (Butterfield, 1990) such as political advocacy to secure resources for aggregate populations, community development projects, community action and policy development. The community health nurse may function as a researcher, a case manager for a group of clients, or a coordinator of services provided to an aggregate of clients. For example, in addition to providing services to individual school students and teachers, a school nurse would view the whole school as his/her community, and identify the major health problems experienced within the school community. Based on an assessment of health needs in the school, the nurse could develop programs aimed at sub-groups or the whole school community. For instance, the school nurse may implement community-focused programs aimed at changing policies in the school related to nutrition, healthy breakfasts, sexual health, whole-of-school first-aid up-skilling, raising awareness of diabetes, or asthma prevention and management. Other community health nursing approaches include health promotion, public health or group work. The common thread in these various roles is that the nurse maintains a population focus on community needs, while they may or may not attend to more specific individual and family needs.

Conceptualising community nursing

While these approaches to thinking about community nursing are helpful, community nursing roles do not always fit neatly into either community-based or community health nursing categories. To clarify the nature of a community nursing role, it is useful to consider roles in relation to two intersecting practice focus continua: the wellness–illness continuum and the individual/family–group/population/aggregate continuum (see Figure 1.1). The vertical continuum, the health/wellness–illness continuum, identifies the extent to which a community nurse focuses on illness or health/wellness. Although all community nurses are interested in illness/disease as well as health/wellness, their role will usually have a predominant focus at some point along this continuum, with ‘hospital in the home’ nursing demonstrating an illness focus, while at the other end of the continuum a health promotion nurse’s major focus is on health and wellness.

Figure 1.1 The wellness–illness continuum and the individual/family–group/population/aggregate continuum

The horizontal continuum in Figure 1.1 identifies the level of client being served. Community nurses’ roles may range along a continuum from attending to individual and family needs (such as in domiciliary nursing) to a role which addresses the needs of a group, population or aggregate (such as policy development, school nursing or community development projects). Figure 1.1 provides a loose identification of community nursing roles along these two continua. The exact position of roles along these two continua will obviously vary according to the philosophy, approach and practices of a particular health agency and the individual nurse in relation to health/illness and an individual or group focus.

Community nursing: generalist or specialist?

It has often been debated whether community nursing is a specialty. One school of thought posits that, because community nurses require generalist skills to address needs as they arise in the community, they are generalist health workers. Another perspective is that community nursing itself is a specialty practice area because community nurses require specific knowledge and skills to work effectively in a community setting, and that these are distinctly different from those required in institutional settings. This perspective is illustrated by professional community nursing organisations and the development of specific competencies for community nurses (Community Health Nurses and the Health Department of Western Australia, 2001). To complicate the debate further, many community nurses have additional areas of clinical specialty expertise, such as diabetes education, women’s health, adolescent health, palliative care, mental health, child health or occupational health. These specialty areas may relate to a client sub-group (such as children or the elderly), the setting (such as occupational health, school or domiciliary nursing), or a medical condition (such as diabetes education). Many of these specialty areas may overlap with noncommunity based specialties within nursing.

An underlying principle of this book is a belief that community nursing has a distinct body of knowledge and skills and is a specialist area of nursing that builds on the foundations laid down in general nursing practice. While it is acknowledged that many community nurses have additional expertise in other specialty areas that contributes to their community practice roles, this book addresses specific knowledge and skills that a...

Table of contents

• Cover
• Half Title
• Dedication Page
• Title Page
• Copyright Page
• Contents
• Tables and figures
• About the authors
• Preface
• Part I Theoretical foundations for community nursing practice
• Part II Approaches in community nursing practice
• Part III Practice in the community
• Part IV Issues in community nursing practice
• References
• Index