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COMMUNITY HEALTH NURSING

OBJECTIVES: 1. Describe the historical stages of nursing. 2. Analyze the impact of societal influences on community health nursing. 3. Explain conceptual models and theoretical framework of community health nursing practice. 4. Identify the roles of various community nursing personel. 5. Identify the components of various community nursing service. 6. Describe the characteristics of various community nursing services. 7. Discuss roles of setting of community health nursing practice. 8. Critique the structure and function of community health services nationally, regionally and internationally. 9. Discuss policies pertaining to community health nursing care. 10.Discuss the roles of various health organizations in the delivery of community health nursing.

HISTORICAL STAGES OF NURSING

Community Health Nursing is the product of responsiveness and growth, its practice has adapted to accommodate the needs of a changing society, it has maintained its goal of improved community health. Community Health Nursing development which has been influenced by changes in nursing, public health and society can be traced through several ways. Four stages of public health nursing: 1. 2. 3. 4. The early home care stage (For many centuries the sick was nursed at home) The District Nursing stage The Public Health Nursing stage The Community Health Nursing stage

*Kalish and Kalish 1986- stated that the focus of this care was to reduce suffering and promote healing.

HOME CARE The early roots of home care nursing began with religious and charitable roots, mid-evil times saw the development of various institutions devoted to the sick including hospitals and nursing orders. In 1601 Elizabethan Poor Law stated: that it provided medical and nursing care to the poor and disabled. E.g. a friendly visitor volunteers organized by St. Francis de Sales in the early 1600 in france this association was directed by madame de Chantel and assisted by wealthy woman who was cared for the sick poor at home. St. Vincent de Paul in Paris, started the sister charity in1617, an organisation composed of lay-women and nuns, dedicated to serve the poor and needy.

DISTRICT NURSING District Nursing mid 1800-1900, this is the second stage of Community Health Nursing and was a formal organisation of District nursing. William Rathbone- became convinced of the value of home nursing as a result of valued home care given to his wife in 1986. He employed Mary Robinson the nurse who cared for his wife. He then opened a nursing school, which was connected to Liverpool, as the service grew, nurses were assigned to districts in the city, hence the name District Nursing. E.g. the Nurses Training Institute for District Nurses developed by the British privately financed the nurses dispensing food and medication to the sick and the poor in their homes and was supervised by various middle and upper class women who collected the necessary supplies. Although District Nurses primarily cared for the sick they also taught cleaniness and wholesome living to their patients and Florence Nightingale refered to them as Health Nurses. The work of District Nurses focused almost exclusively on the care of individuals, they recorded: 1. 2. 3. 4. The temperature of the individuals The pulses Gave simple treatment under the direction of a physician They instructed family members on diet, personal hygiene and living habits and in the care of the sick.

PUBLIC HEALTH NURSING Public Health nursing- 1900-1970 Robert Koch- by the turn of the century District Health Nursing has broaden it focus to welfare and care of the general public. Robert Kochs has demonstrated that TB was communicable which lead to John Hobkins Hospital hiring a nurse Reba Thalin in 1903 to visit the homes of patients with TB. Her job was to ensure that the patient followed the regimen of: fresh air, rest, proper diet and to prevent possible infection.

Specialized programmes such as infant welfare, TB clinics and vinerial disease control wer developed causing nurses to work in these areas.

COMMUNITY HEALTH NURSING 1970 Present Emergance of the term Community Health Nursing herald in a new era, while Public Health Nurses continue their work by the late 1960s to early 1970s, many other nurses not necessarily practicing Public Health were placed in the community. Their practice setting included: community based clinics, doctors offices, work sires, schools and more. Nursing education recognizing the importance of public health content, now required course work in public health for all baccalaureate schools, this change meant that graduates where expected to incorporate public health principle such as health promotion and disease prevention, and was regarded as the sphere of service. Another source of confusion arose, around the issue of community health being a generalized vs a specialized practice. Yet another area of confusion lay in distingushing Public Health Nursing and Community Health Nursing, the terns where being used interchangeably and yet held different meaning for many in the field. Finally, confusion arose around the changing roles and functions of Community Nursing. Accelerated changes in health care organization and financing; technology and social issues made increasing demands on Community Health Nurses to adapt to new practice of nursing.

THE SOCIETAL INFLUENCE ON DEVELOPMENT OF COMMUNITY HEALTH NURSING

Many factors influence the growth of Community Health Nursing. There are six (6) factors that one needs to understand in the nature of this field: 1. 2. 3. 4. 5. 6. Advanced technology Progress in casual thinking Changes in education The changing role of women The consumer movement Economic factors

Advanced Technology Technology has contributed in many ways to shape the practice of Community Health Nursing. For e.g.: technological inovation has greatly improved health care, nutrition and lifestyle, and cause concomitant increase in life expectency. Consequently Community Health Nursing direct an increasing share of their effort towards meeting the needs of the elderly population and addressing chronic conditions. This has also been a strong force behind industrialization, large scale employment and urbanisation. Community Health Nurses are learning how to combat these urban health problems caused by population density. In addition changes in transportation and a high job morbidity have affected the health scene, as people travel and relocate they are separated from family and support systems. Community Health Nursing designs programmes to help the urban population to cope with accompaning stress. New products, equipment, methods and energy resources has also increased environmental polution. Community Health Nursing has become invovled in related research, occupational health and preventative education.

Technological innovation has helped promote medical complex diagnostic and treatment procedures thus making it more costly. Community Health Nursing face a challenge to demonstrate the physical and economic value of wellness oriented care. Inovation of communication and computer technology has shifted American from an industrial to an information society. The Community Health Nurses now more than ever are in the business of information distribution and use new computer technology to enhance their efficiency and effectiveness in their service.

Progress in Causal Thinking Casual thinking particularly in epidemiology, has significantly affected the nature of Community Health Nursing. The Germ Theory of disease causation established in the 1800 was the first real break through in communicable diseases. A second advance in caused thinking was initated by the tripartite view, that called attention to the interaction between a causative agent, a suseptable host and th environment, this thinking offers Community Health Nurses new ways to control and prevent health disorders. Community Health Nurses can avoid/ control health problems by examing all possible causes and the attaching stratigic casual points.

Changes in Education Changes in education especially in nursing education have had an important influence on Community Health Nursing practice, it is now considered a basic right and necessity for a vital society. When understanding of environment grows an increased understanding of health is usually involved. Education has lead to much more responsibility, so now nurses have now moved from going to collaborating with the clients. Community Health Nursing has always required a fear measure of independent thinking a self reliance, now Community Health Nurses need skills in such areas as population assessment, policy making, political advacy, research, management, collaborative functioning and fundrasing.

Changing role of women Women are moving out of the traditional roles to more challanging career in which they created a gap so therefore and then men have picked up the role in being nurses.

Consumer movement and changing Demographics Consumers have become more aggressive/ demanding quality, services and goods, they assert their rights to participate in decision that affect them regardless to their race, sex, colour and socio-economic levels. Health care comsumers are viewed as active members of the health team rather than passive recipient of care and are very active members, they may contract with the Community Health Nurses for family care or group services, represent the community on the health board or act as ombudsman by serving as representive or advocates for their community. Such as shifting pattern in immigration, number of birth and deaths and a rapidly increasing population of elderly persons affect community health nursing planning and efforts, monitoring these changes is essential for relevant and effective nursing services.

Economic Forces Unemployment and rising cost of living combine with mounting health care costs has spauned great numbers of individuals who are unable to care for themselves, with limited or no access to needed health services, these populations are vunerable to health problems and further economic stress and global economic forces also influence Community Health Nursing practice. Unemployment and poverty posses a serious threat, Community Health Nursing has responded to these forces in several ways: - By assuming new roles, e.g.: Health Educator - Directly competing with other Community Health Nursing providers, e.g.: Home care - By developing new programmes and services emphasis

THEORETICAL BASIS FOR COMMUNITY HEALTH NURSING

Theory- is a set of systematically inter-related or hypothesis that seek to explain a phenomena. Concept- ia a generalized idea about an abstract or concreate set of objects. Combining concepts and theories in to relivant wholes provide Community Health Nurses with great understanding of human environmental interaction and guides practice decisions. A clustering of concepts with a set of explainations that describe their relationship is called a conceptial framework. The same is true for a theoretical framework. Stevens and Hall argue that: We need theoretical framework that can guide our community practice in the face of serious public health challenges. For Community Health Nursing the issues we must address are: (1) inequitable health care access and (2) the effects of poverty or the distruction of the environment, require a broader more comprehensive view of health. We can no longer be satisfied with the exclusive focus on individuals and their immediate millius that characterises traditional nursing theories Stevens and Hall, the future of Community Health Nursing depends on two (2) things: 1. Our daily ability to recognize social-economic and political aspects of the environment, as they affect health. 2. Our williness to interven at the community level for structural change, critical theories that draw from both reflection and action that are grounded in real life circumstances, will enpower Community Health Nurses and the communities they serve to affect health enhancing cahnges.

SYSTEMS THEORY AND COMMUNITY HEALTH NURSING Proves to be one of the most pivotable. Systems theory states that every living system is whole and its wholeness is made up of inter-dependant parts in interaction and it provides the foundation for understanding how communities function as living systems. Systems theory as it applies to Community Health Nursing, includes the following attributes: a system is a regularly interacting and interdependant group of parts forming a unified whole. Community Health Nursing practice must address many sizes of systems ranging from individual and family to population and larger aggregates, each is a whole that functions as such virtue of a relationship between its parts. Living systems such as animals, plants, or groups of people are known as an open systems because they exchange matter, energy and information with the environment. A closed system such as rock does not have such an exchange, and remains self contained, isolated and relatively unaffected by its environment. Open systems experience heirarchial ordering with other systems from simple to complex, from large to small, such order is interlocking and interacting, for example various human cells make up a large system such as the respiratory system, muscular system, circulatory system that inturn make up the body as a system. Similarly people organize themselves into groups such as the health system and the legal system, which are sub- units of a large community, communities themselves are a part of a larger system in the same way as a school of fish is a part of a under sea life. Living systems form boundaries or lines of demarkation that distinguish themselves from other systems and their environment, boundaries may be visible such as the human skin or a country line or may be visible or they may be understood. A system boundaries services as a mean of identifying a systems, an acts as a filter for exchanging energies in the form of materials and information with its environment. Energy exchange is a critical attribute of living things or systems.

Since the input-output phenomenom enables the system to function towards the purpose to which it exists, energy exchange occurs at varying rates, depending on the ability of the system to absorb energy from and release energy into the environment. Through energy absorption all living systems may potentially increase their order or complexity. The reverse is also true. A boundary may contract or expand depending on the systems goals and needs, thus establishing one of the system function tht of boundary maintenance. System needs to maintain adequate function with the environment. All systems have structure, which is the way the component parts are arranged e.g(leaders and followers). A community structure is much more complex than a group and consist of some kind of overall governance by any authority such as a president, mayor or governor. The community structure will always coexist with education and other subsystems. Systems may be stable or adaptive as a system grows and learns its ability to adapt and grow increases. A living system seeks homeostasis a relatively stable state of equillibrium between its independent part to which it returns to its normal state. Although living systems are different from each other they often share similar components. This attribute known as isomorphism enables nurses to use knowledge of one system as a basis for understanding another.

THE ADAPTATION THEORY AND COMMUNITY HEALTH NURSING

This draws in large measures form systems theory and states that human beings whether individuals or groups are adaptive systems (Roy 1984). Every living system whether an individual, family or nation must cope with internally and externally impossed condition these are called input or stimuli. The control process by which people deal with various stimuli are coping mechanism. The ability for people to cope at any given time is called their adaptation level, a level that is constantly flutuating (Helson 1964). When people cope or respond to stimuli, in a health manner that is in a way that promotes growth and new levels of mastery it is called adaptive. If not the response is mal-adaptive, these effective or ineffective responces becomes the output in the adaptive process. The ability of people to cope at any given point in time is called the adaption level, a level that is constantly fluctuating. HANS SELYELS STRESS THEORY 1956 Stress is a physical and emotional state which is always present in people which increases in the presents of internal and external environment changes or threats that require additional response. Humans have built in or aquired self regulatory mechanism that assist them in this response and adaptation process. When stressors cant be handled locally then a larger system had to respond to ensure survival. If you can handle a stressor, or tension producing stimuli, could be handled local, the body fighting off a local infection , or a local police apprehending a drug dealer each system would respond positively. Adaptation theory has many useful applications for Community Health Nursing. It forms a basis for understanding how the human system functions It provides a mean for assessing clients coping abilities and designing nursing actions to facilitate positive adaptation.

CONCEPTUAL FRAMEWORK FOR COMMUNITY HEALTH NURSING

Community Health Nursing combines theories, concepts and principles; from nursing, public health and other sciences to form its practice. A set of concept integrated into a meaningful configuration called a conceptual framework, helps one determine behaviour and situation. Concepts underlying Community Health Nursing developed by White (1982), these are viewed into five (5) variables: 1. 2. 3. 4. 5. Practice Priorities Practice interventions Scope of practice Health determinance Community Health Nursing dynamics

1) Practice Priorities Prevention, Promotion and Health Protection, these are the three (3) underlying forms of public health. Prevention Prevention includes three (3) levels of activities: 1. Primary Prevention- seeks to avoid the occurance of illness or injury. For example: vaccination and seat belts. 2. Secondary prevention- aims to find a threat of existing health problems at the earliest stage possible. For example: physical examination, mamogram and pap smear. 3. Tertiary prevention- seeks to reduce or minimize the effects of illness as much as possible. For example: chemo-therapy for cancer.

Health protection This is the second fundamental concepts involves efforts to sheild the public of harmful health effects of elements in the environment. Heath Promotion This is the third concept that refer to activities that maintain the communities level of wellness.

2) Practice Interventions To accomplish the practice intervention the Community Health Nurse uses three levels of practice interventions. Which include: Education, Engineering, and Enforcement. These levels provide varying degrees of persuadation for enhancing these accomplishment of public health goals. Education The nursing action of providing information is to encourage people to voluntarily modify their behaviour in health promotion ways. For example: exercise and diet. Engineering It is a strong form of persuation, value nursing actions directly or indirectly, manage variables in the environment to reduce health risk. For example: immunization. Enforcement This uses more cohersive measures such as laws prohibiting child abuse or intake of harmful chemical. Community Health Nurse employs all three interventions to protect the public, to prevent illness or disability and to promote health.

3) Scope of Practice Refers to the extent or range of nursing activities and influence . What it encompasses? What is practiced?- This focuses on protection from health endangering agents, prevention of illness and disabilies, and promotion of wellness. From whom?- In community health nursing practice involves a broad range from individuals to worldwide aggregates, but always maintains a concious aggregate commitment. It is the goal of the public health to reduce premature death, disease, disablities and discomfort, to protect, restore and promote people health for the good of the community.

4) Health Determinance Another set of valuables that is conceptual framework. There are four (4) determance: Human biological determinance - those physiological defences and vulnabilities that influences who is at risk. E.g. genetic pre-disposition to certain diseases. Environmental an external agents and conditions such as persons living in an earthquake zone and poverty capable of enhancing or inhabiting health. Adequances and inadequances the medical techniological organizational determinance. E.g. include inadequate acess to services in rural areas and the expense of high tech equipments in the hospitals. Psycho-social cultural determinance such as lifestyle and racially determined practices that influences health.

5) Community Health Nursing Dynamics There are two processes, the nursing process and the valuing process are the driving forces that energize nursing practice ( White 1982 ). 1. Nursing process these elements of the nursing process provides the means of analyzing health needs and solving health problems of communities and population at risk. 2. Valuing process guides community health nursing actions, to value something is to hold it dearly. Public health holds to several significant values. E.g. public health subscribes for the greatest good, for the greatest number, a concept that conflicts with our society emphasis on individualism. Public health bases its practice on collaboration and co-operation and believes in advocacy for the under served and disadvantaged (Pickett and Halon 1990). Values aslo influence consumers attitude and behaviour and dictate their response to health care interventions.

NURSING MODELS FOR COMMUNITY HEALTH NURSING PRACTICE

A model is a description or an analogy used as a pattern to enhance understanding of some reality: Newmans Model enhances the understanding of systems functioning. Rogers Model - emphasizes the science of unitary man. Penders Model reinforces health promotion Roys Model focuses on adaption. Orems Model self care

Four variables : 1. 2. 3. 4. Physiological Psychological Socio-cultural Development

Given the four variables : Clients have a unique responces to stressors, a client response to stressors is depicted as a series of concentric circles, in the center is a core of basic survival abilities, such as an individual genetic responses and normal system function or a communitys ability to make the best use of its natural recources. The first or inner most boundary is a sat flexible lines of resistance, these are the clients defence machanism against stress such as an individual immunes responses or a communitys collective sense of responsibility. The second boundary is the normal line of defence. The third boundary is a dynamic outer ring called the flexible line of defence, a protective buffer that prevents stressors from entering the normal line of defence.

Newman Theory Newman describes people as open system, which constanty interact with their environment, influenced or been influenced by it, people response to environmental stressors by either adapting to the environment or changing their environment. People are health according to (Newman 1982) when they have achieved a state pf harmony between themselves and the environment, when they have succesfully adapted or change their environment to meet their needs. Nursing interventions in this model focus on assisting clients to remain stable in their environment (Newman 1983). Corresponding to our conceptual framework nurses goals include : Prevention help clients to remove or minimize environmental stressors. Health promotion strenghting clients defences. Protection promote recovery An adaptation to Newmans model provides a useful means for applying the nursing process to population focus practice.

Rogers model Rogers developed a conceptual model in 1970 based on systems theory and emphasizes that the whole is greater than the sum of its parts. Rogers developed her model around four (4) components: 1. Universe of open systems refers to constant interaction between people and their environment. 2. Energy fields refers to the wave pattern of energy given of by people and their environment. 3. Pattern and organization refers to the way these energy fields take shape. 4. Dimentionality refers to the energy fields transcending time and space. Using this model one can focus on client environment interaction, and see the client as functioning interdependantly with others and the environment.

Community health nursing goal is to promote holistic health and client environment interaction in order to minimize client health potential.

Penders model Penders defines health promotion as action directed toward increasing the level of well being and self actualization of a given individual or group (1987). This is in contrast to health protection, another important vatiable in our conceptual framework which pender describes as actions directed towards decreasing illness by active protection of the system against pathological stressor or detection of illness in the asymptomatic stage. While Penders model is with individuals one can make application to families and communities. Community Health Nursing can encourage health promoting behaviors among their clients by careful assessment of the models variables to determine perceptions and the modifying factors that might influence the likely hood of clients engaging in health promoting behaviours. Clients should be involved in the entire process of assessing, planning, implementing and evaluating health promotion efforts.

Roys Adaptation Model In Roys adaptation model she describes two (2) processes that influence peoples responces to stimuli: 1. Regulator 2. Cognator The Regulator - receives stimuli from the external environment and from within the system and then processes this combination of information together to produce a response. For an individual, Roy describes the regulator process as going through neural-chemical- endocrine channels, by some unknown the neural input are transformed into concious perception in the brain eventually, eventually these perceptions leads to psychomotor choices of response which activates a whole body response. A sample example: Hunger sensation (stimuli) that promotes the

appetite (regulator) leading to nutritional intake (response), seldom does the regulator mechanism work on its own but is most often intractive with other human control response. The Cognator using the cognator mechanism people apply perception, learning, judgement, and emotion to process intenal and external stimuli and arrive at a response. E.g.: with an individual, might be when a woman learns she is pregnant unexpectedly. She applys she perception about this information and her previous learning about what being pregnant will mean to her physically, emotionally, and economically, she also apply judgement (her ability to solve problems and make decisions) and emotion (her effective assessments) to arrive at a response which may be adaptive or maladaptive. A community similarly may apply the cognator process to the stimulus of a potential flood using these four (4) channels: 1. 2. 3. 4. Perception Learning Judgement Emotion

Roy explains that cognator and regulator processes act in relation to four effector models: 1. 2. 3. 4. Physiological function Self concept Role function Interdependance

These further shape the nature of people coping and help them to determine whether their response will be adaptive or maladaptive. When a nurse applys Roys model to Community Health Nursing it is important to remember people as systems are wholes made up of many parts and are influenced by many variables. Roys also points out that people adaptive levels are constantly changing influenced by all these factors.

Orems Self Care Model This model of nursing practice focuses on the concept of self care, it draws from the development and systems theory. She defines self care as the actions people take to preserve and promote their health, life and state of wellbeing, the ability of people to engage in these actions or to care for themselves, she calls self care agency. The total set of self care actions that a person might need at a given point in time, she called that persons therapeutic self care demand. Orem further describes self care in terms of three type of requirements that influence people self care ability: 1. Universal requirement- self care activities required to meet physiological needs. 2. Development requirement- self activities necessary to help people process develop mentally. 3. Health deviation requirement- self care activities needed to help people deal with a diminished level of wellness. Orem apply her model primarly to individuals as systems but families and communities can draw from this thoery. Using this model one can define Comminity HealthNursing goal in assisting people until they can take care of themselves.

CHARACTERISTICS OF COMMUNITY HEALTH NURSING

There are six (6) characteristics of Community Health Nursing are particularly salient to the practice of this speciality: 1. 2. 3. 4. 5. 6. Its a field of nursing Its combines public health with nursing It is population focused It emphasises wellness It involves disciplinary collaboration Promotes client self care and responcibility

1) Field of Nursing Its basic knowledge and skills are those of professional nursing practice. It seeks to give humanistic, accessable, and holistic care. Community Health Nursing is a nursing speciality,nursing theories undergurd its practice and the nursing process is one of its basic tools, but Community Health Nursing synthesizes concepts, knowledge and skills from public health to become a distinct practice. 2) It combines public health with nursing Knowledge of the following elements is essential to public health nursing: 1. History and philosophy of public health including emphasis on the greatest good for the greatest number of persons. 2. The concept of aggrigates- assessing needs, planning, providing and evaluating services impact on population growth 3. Priority of preventative,protective and health promoting stratergies over curative stratergies. 4. The means for measurement and analysis of community health problems including epidemiological concepts and biostatics. 5. Influence of environmental factors and aggregate health 6. Principles underlying management and organization for community health since the goal of public health is organized through community efforts. 7. Public policy analysis and development 8. Health accuracy and the political process.

3) It is population focused It means that it is concerned for the health status of population groups and their environment. A population oriented focus requires the assessment of relationship. When working in groups the nurse does not consider them separately but rather in context, that is with the rest of the community. A population oriented focus involves a whole new outlook and set of attitudes individualized care is important but prevention of aggrigates problems in community health nursing practice reflects more accurately its philosophy and benefits a larger group of people. The community or population at risk is the client.

4) Emphasizes wellness Community has a primary charge to prevent health problems from occuring and to promote a higher level of health. Community health nursing concentrates on the wellness end of the wellness illness continum in a variety of ways; they teach proper nutrition or family planning, promotes immunization among pre school children, encourage regular physical and dental check up, assisting with starting exercise classes or physical fitness programs and promote healthy interpersonal relationships, their goal is to help the community reach its optimal level of wellness. A wellness emphasis requires taking initative and making sound judgements which are characteristics of effective community health nursing.

5) It involves disciplinary collaboration Community health nursing must work in cooperation with other members of the health team, coordinating services and addressing the needs of population groups. The interdisciplinary collaboration among health workers and professionals is essential to establishing effective programs. Individual efforts and specialized programs when planned in isolation can lead to fragmentation and gaps in health services. Effective collaboration requires team members who are strong individuals with various areas of experties and who can make a commitment to team goals. Inappropiate situations community health nurses also function autonomously, making independent judgements, collaboration involves working with members of

other disciplines, on community advisory boards, health planning board, need assessment surveys, policy developmental efforts and many more. Interdisciplinary collaboration requires clarification of each team members role, a primary reason for community health nurses to understand the nature of the practice.

6) Promote client responsibility and self care The goal of public health is to protect, promote, and restore peoples health requires a partnership effort. Just as learning cannot take place in a school without students participations, the goals of public health cannot be realised without consumers participation. Client health status and behaviour will not change unless people accept and apply the proposal of the community health nurse. Community health nurses can encourage individuals participation by promoting the autonomy rather than allowing dependency to occur. A characteristics of community health nursing that is sometimes overlooked is encouraging clients to take responsibility for their own health. When people believe their health and that of the community is their responsibility and not that of the health professional they will take an interest in their own health. The process of taking responsibility for developing ones own health potential is called self -care. When people maintain their own life, health and well being they are engaging in self care. When peoples ability to continue self care activities drop below their needs, they experience a self-care deficit. However, nurses goal is to assist clients to return to or reach a level of functioning, where they can obtain optimal health and assume responsibility for maintaining it. To this end community health nurses fuster their clients sense of responsibility by treating them as adults capable of maintaining their own affairs. Nurses can encourage people to negotiate health care goals and practices, develop their own programs; contact their own resources, identify and implement lifestyle changes that promote wellness and learn ways to monitor their own health. Client participation is promoted when people serve as partners on the health care team. An aim of community health nurses is to collaborate with people rather than doing things for them. Community health nurses encourage the involvement of

health care consumers, by giving their ideas and opinions, by inviting them to prticipate on health boards and commities and by finding ways to promote the participating in their decisions of community health.

CHARACTERISTICS OF COMMUNITY HEALTH PRACTICE

1. Community health practice is population focused, it is concerned with the health status of people, who form a distinct population, these groups and community in turn are multiple and overlapping. Thus community health must deal with a complex set of interacting physical, psychological, socioeconomic, cultural and biological variables that influence human behavior and affect aggrigate health. Community health as a part of public health is fundamental concern with the collective good. It focuses on the community and on the valves of life, health and security shared by the community. 2. Promotion of health and the prevention of illness- these include services to mothers and infants, prevention of environment polution, school health programmes, seniors citizens fitness classes. 3. Measurement and analysis- analysis of health states, environment factors, health related services, economic patterns and social policy are among the focus of community health evaluation and research. 4. Management and organization theory- public health has been long defined as the protection and improvement of community health, through organized and community efforts it is the organization and administration of such services that enables practioners to ultimately address community needs.

SETTINGS FOR COMMUNITY HEALTH NURSING PRACTICE

Home The home is a setting for health promotion, many Community Health Nursing visit focus on assisting families to understand and practice healthier living. For example: they may include instruction in parenting, infant care, child discipline, diet, exercise, coping with stress, or managing grief and loss. The character of the home setting is as varied as the client of whom the Community Health Nurse serves. In one day the nurse may visit an elderly, wellto-do widow in her luxury home, a middle income family in their modest bungalo and a transcient in his one room 5th story walker. In each situation Community Health Nurse can view their clients in perspective and therefore better understand their limitation, capitalize on their resources and tailor health services to meet their needs. In the home clients are on their own turf, they feel comfortable and secure in family surroundings and are often better able to understand and apply health information. Clients self respect can be promoted, since the client is a host while the nurse is the guest. The increased demand for high tech care in the home requires specialized skills, best delivered by nurses with this expertice. Community Health Nurses with skills in population based practice serves the public health best by focusing on sites, where they can have the greatest impact at the same time, they can collaborate with various types of home care providers including hospitals, other nurses, physicans, rehabilitation therapist, to ensure continuous and holistic service. They continue to supervise home care services and involve in case management.

Ambulatory services This includes a variety of places for Community Health Nurses practice, in which clients come for day or evening service but they do not include overnight stays. Community health clinics are an example of an ambulatory setting. Sometimes multiple clinics offering comprehensive services are community based or located in out-patient department, hospitals or medical centers. They may also be based in comprehensive neighbourhood health centers. A single clinic such as a Family Planning Clinic or a Well Child Conference may be found in a location more convevient for clients, perhaps a church basement or a empty storeroom. Some kinds of daycare centers such asthose for physically handicaped or emotionally disturbed adults utilize the community nursing service. Other ambulatory settings are some health departments, Community Health Nursing agencies where clients would come for assessment and counselling. Some other ambulatory care settings are providing service in conjunction with a medical practice, include places where services are offered to selected groups.

School Schools of all levels make up a major group of settings for Community Health Nurses practice. Nurse from Community Health Nurses agencies frequently serve private school, primary and secondary schools. Public schools are served by the same agencies or by Community Health Nurses hired through the public school system. Specialized schools such as those for the handicaped are another setting for community health nursing practice. Community Health Nurses roles in school settings are changing. School nurse whos primary role was initiallt that of a clinician are widening. Their practice include more health education, collaboration and client advocacy. Community Health Nurses in school settings are also beginning to assume mangerial and leadership roles and to recognize that the researcher role should be an integral part of their practice.

Occupational Health Business and industry provides another group of setting for the community health nurse practice. Employ health has long been recognized as making a vital contribution to individual life, productivity of business and the well-being of the entire nation. Organizations are expected to provide a safe and health work environment, in addition to offering insurance for health care. An increasing number of companies recognize the contribution of health employees, go beyond offering the traditional health benefits to support health promotion efforts. Community Health Nurses in occupational health settings practice a variety of roles, they also act as employee advocate ensuring appropriate job assignments for workers and adiquate treatment for job related illness or injury. They collabrate with other health care providers and company management to offer best services to there clients. They act as leaders and managers in developing new health services, in the work setting, endorcing programmes such as hypertension screening or weight control. Occupational health settings range from industies and factories to business corporation and large department stores.

Residential Instutions This can include a half way house in which clients live temporarly, while recovering from a drug addiction or an inpatient hospice programme in which terminally ill clients live. Community Health Nurses based in a community agency maintain continuity of care for there clients by collaborating with hospital personel, visiting clients in the hospital and helping plan care during and following hospitalization. A long term care facility is another example of a residental site providing health care that may use Community Health Nursing services. Community Health Nurses also practice in settings where residents are gathered for the purpose other than receiving care. Residential institutions provide unique setting for Community Health Nurses to practice health promotion. There clients are a captive audience whos needs can be readily assessed and whos interest can be stimulated. These setting offer Community Health Nurses the opportunity to generate an environment of caring and optimal services.

Community at large On like the five (5) settings already discussed the 6th setting to Community Health Nursing practice is not confined to a specific setting or location. When nurses work in group, population or the total community they may practice in different places. It is important to remember that Community Health Nursing practice is not limited to a specific site. Community Health Nursing is a speciality of nursing defined by the nature if its practice not its locatiom, it can be practiced anywhere.

ROLES OF THE COMMUNITY HEALTH NURSE

1. 2. 3. 4. 5. 6. 7.

Clinician Educator Advocate Manager Collaborator Leader Researcher