Part I Introduction and Overview of Community Health Nursing

Mary Ann Rosa MSN, RN, CS, GNP

Queensborough Community College

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Historical Perspective
First written reference to care of the ill at home is found in the New Testament Florence Nightingale, 1860s Opened the Nightingale School of Nursing in 1860 where she stressed good

food, clean air and sanitation

One year of training: promoting self-care and the health of the communities Also involved in developing nursing for the sick poor at home and in

workhouses
Origin of the concept of visiting nurse District public health nursing. Each nurse was assigned a specific geographic

area of London William Rathbone: Promoted the establishment of district nursing Modern concept of visiting nurse
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Historical Perspective
Lillian Wald
Founder of Public Health Nursing The number of poor immigrants who had come to

America from Europe with little resources Lived in communities on the lower east side of Manhattan Resided in tenements Developed many illnesses
.
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Historical Perspective
Lillian Wald continued:
Visiting Nurse Service founded by Lillian Wald and Mary

Brewster in 1893. Venture was funded entirely through private donations Started with a focus on MCH
Henry Street Settlement House, 1895 Founded by Lillian Wald; help by Mary Brewster Nurses lived in the neighborhoods where they worked Coined the term Public Health Nurse Lillian Wald defined public health nursing as seeking to

cure the sick patients as well as trying to alleviate the underlying cause of disease by improving health education and public health standards.
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Historical Perspective

1910: approx. 90% of all nursing care was provided in the home Shift to the Hospital after World War I Technology and complexity Increased Access to Health Insurance An Aging Population and Increased health care needs Injuries from war Development of private insurance & Medicare & Medicaid

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Historical Perspective
Shift Back to the Community in the 1980s
Escalating Health Care Costs

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Historical Perspective
Rising Health Care Costs in the 1980s
Overuse of expensive care & procedures
Failure to promote preventive services Increased number of uninsured people Higher insurance rates for those that can pay Increased Health Care Salaries

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Historical Perspective
Rising Health Care Costs in the 1980s continued:
Aging Population Survival of patients with complex problems Expensive, sometimes, unnecessary tests covered by

insurance Defensive Medicine Long Hospital Stays

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1980s begins the start of Cost Containment

The Tax Equity and Fiscal Responsibility Act

(TEFRA) in 1982
1983 Social Security Amendments Prospective Payment System (PPS) Diagnosis Related Groups (DRGs) for

reimbursement
Development of PPOs, HMOs, and managed MRosa

Managed Care
Through the use of responsible, effective, and cost-efficient care, Managed care refers to a system that for a set fee, assumes responsibility and accountability for the health of a population
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1980s begins the start of Cost Containment

LOS decreased Discharged quicker and sicker Increased need for services in the community Movement of nursing care back to community

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Difference Between Hospital & Community

Factors Hospital Illness Environment Resources Access to Patient Focus Family support Client Role Nursing Role Teaching style of nurse
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Community

Community Based Nursing

Nursing care directed toward specific individuals

and families within a community

Philosophy of care how the nurse practices, not

where the nurse practices

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Community Based Nursing

Assists patients as they move among and

between health care settings The individual & family have primary responsibility for decisions The patient is viewed within the family and social systems Illness is a part of life Purpose of care is to limit disability, improve functional capacity and QOL Treatment effectiveness drives decisions
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Community Health Nursing

Subset of community based nursing

Requires specific knowledge and skill

Care provided for individuals, families, and

groups within a community

CHN defined by its role in promoting publics

health

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NLN
NLN recommends that all nursing education prepare nurses to function in community based settings.
To also understand the business of health care

To have highly developed skills assessment,

interdisciplinary collaboration & working with culturally diverse populations

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National League for Nursings Essential Components of Community Care

Self-care Advance Directives Living Will Management of Illness

Prevention
Consideration of family, culture, and

community
Continuity of care through Collaboration Essential for quality care

Continuity of Care
Coordination of activities involving clients, providers,

and payers to promote the delivery of heath care

Collaboration
Commits two or more persons or

organizations to achieve a common goal through enhancing the capacity of one or more of the members to promote and protect health

Question
Which of the following is an example of how an individuals perceptions of his or her health may improve the way he or she manages self-care? A. Maria believes that illness comes from God as punishment for sin. B. Juan thinks that if he takes his medication and stops smoking, his asthma will improve. C. Kristin states that there is nothing she can do to alter her labile blood sugars.

Critical Thinking Exercises CONTINUITY OF CARE

1. List three examples from your clinical experience
where you believe continuity was interrupted.

2. Indicate the steps that could have been taken to

ensure continuity of care in these examples.

3. Recall three examples from your clinical experience

where continuity of care was evident.
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Community Based Nursing Skills & Competencies

Assessment & Physical Caregiving Critical Thinking & Problem Solving Learner / Teacher Management Documentation Communication

Culturally Sensitive Care

Being an advocate
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Community Based Nursing Skills & Competencies

Interdisciplinary Care Partner with communities Improve access to care Understanding Primary Care / Disease Management Preventative Care Evidenced Based Practice Information Technology Leadership Performance Improvement Ethical Legal
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Health Promotion & Disease Prevention

Health Promotion Disease Prevention Health Protection

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Levels of Prevention
Primary Prevention

prevention of initial occurrence of disease or injury Includes Health Promotion & Health Protection
Secondary Prevention

Early identification of disease / injury with intervention to limit disability

Tertiary Prevention

Limit disease progress / disability

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Match each activity with the appropriate level of prevention

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Immunizations Physical assessment HTN screening Teaching re: lifestyle changes such as diet Smoking cessation Mammography Support groups for caregiver Meals on Wheels for homebound Seat belts Pregnancy testing Alcohol & drug prevention PT after stroke Mental health counseling for rape victims Home management after chronic illness Hygiene teaching

Prevention in Different Settings to Individuals, Families, Groups & Communities

Examples of _________________ Prevention
Counseling and HIV testing to individual

Early prenatal care

TB screening for a family at risk Lead screening of children in a community

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Prevention in Different Settings to Individuals, Families, Groups & Communities

Examples of _________________ Prevention
Nutrition teaching to the patient with AIDS Teaching to a newly diagnosed patient with

diabetes about diet Teaching to a family member about how to follow procedure for a dressing change Support group for children with asthma Shelters for victims of natural disasters
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Prevention in Different Settings to Individuals, Families, Groups & Communities

Examples of _________________ Prevention
Family planning to an individual in the clinic education about infection control in the home prenatal classes to a group of pregnant

adolescents fluoride water supplementation to the community

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Goals of Prevention

Improve Quality of Life Be Cost Effective

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Screening
Identifies individuals with unrecognized health

risk factors or asymptomatic disease conditions in populations

Outreach
Locates populations of interest or populations

at risk and provides information about the nature of the concern, what can be done about it, and how services can be obtained

Question
Which public health nursing intervention is seen in the following example? Student nurses go into a neighborhood door-todoor. They identify individuals who have not had flu shots and direct them to the local community centers flu clinics. A. Screening B. Outreach C. Health teaching

Question
Which public health nursing intervention is seen in the following example? A group of student nurses takes blood pressures at a senior center in the community and provides information about hypertension, what follow-up those with high blood pressure require, and how they may secure health care. A. Screening B. Health education C. Outreach

Question
Which public health nursing intervention is seen in the following example? A nurse and a physical therapist meet to plan the care of an elderly woman who is hospitalized with a broken hip and will be discharged from the hospital today. A. B. C. Collaboration Consultation Care management

Question
Which public health nursing intervention is seen in the following example? A nurse meets with Edna, an elderly woman who has been hospitalized with a broken hip, and her family. They discuss what self-care Edna can manage on her own and how the family may be able to assist her once she goes home, and determine the community resources available to assist with her care.

A. B. C.

Health teaching Case management Collaboration

Infant Mortality
Death Rate of infants < 1 year per 1000 births An international measure of health status US Infant Mortality Rate = 6.9 International Ranking = 27

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Infant Mortality Leading Causes of Infant Death

Congenital ailments Pre-term / LBW Sudden Infant Death Syndrome Problems Due to Pregnancy

Respiratory Distress Syndrome

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The Community

Group of people with common characteristics

Geographic Political Race / Ethnicity Age Problem Based

Knowledge of the community increases quality care What makes a healthy community?
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The Community & Health, Health Care Needs Influenced by:

Vital Statistics & Demographics

Resources & Support Services

Community Leadership Culture Composition of Families Socioeconomic Status Community Boundaries Social Systems
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Social Systems & Health in the Community

Economy

Education
Religion Welfare

Recreation
Health Care Government

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Health
Defined by the World Health Organization as a state of physical, mental & social wellbeing and not merely absence of diseases Health Illness Continuum Continuum from optimal health to total disability
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What is Health?
Acute Care Nursing Focus
Fix the problem Eliminate disease

Community Nursing Focus

Facilitate Self Care Improve functional ability Enhance QOL

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Healthy People 2020

Provide information & knowledge about how to

improve health in a format that enables diverse groups to work together

Provides science-based, 10-year national objectives

for improving the health of all Americans; Framework for improving health of nation.
Road map to better health for all Can be used by many different people, communities,

groups, professional organizations whose concern is a particular population or threat to health

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Healthy People 2020

The Office of Disease Prevention & Health Promotion U.S. Department of Health and Human Services
coordinates Healthy People 2020 www.health.gov/healthypeople 1-800-367-4725

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Healthy People 2020

Vision A society in which all people live long, healthy lives. Mission: Healthy People 2020 strives to: Identify nationwide health improvement priorities. Increase public awareness and understanding Provide measurable objectives and goals Engage multiple sectors Utilize evidence based practice MRosa

Determinants of Health
What makes some people healthy and others

unhealthy?
How can we create a society in which everyone

has a chance to live long healthy lives?

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Healthy People 2020

Addressing All Hazards Preparedness as a

Public Health Issue

The Role of Health Information Technology and

Health Communication

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What Does Healthy People 2020 Say About Cultural Care?

Elimination of disparity among groups in access to

quality health care

Increase in community-based programs that are

culturally and linguistically appropriate

Healthy People 2020: Focus Areas 1. Access to Quality Health Services

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Arthritis, Osteoporosis, and Chronic Back Conditions Cancer Chronic Kidney Disease Diabetes Disability and Secondary Conditions Educational and Community-Based Programs Environmental Health Family Planning Food Safety Health Communication Heart Disease and Stroke Immunization and Infectious Diseases HIV
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Healthy People 2020: Focus Areas

15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28.

Injury and Violence Prevention Maternal, Infant, and Child Health Medical Product Safety Mental Health and Mental Disorders Nutrition and Overweight Occupational Safety and Health Oral Health Physical Activity and Fitness Public Health Infrastructure Respiratory Diseases Sexually Transmitted Diseases Substance Abuse Tobacco Use Vision and Hearing MRosa

Healthy People 2020 Eliminate Health Disparities Examples of Health Disparities

Effect of income on health status Effect of education on income The lower the household income, the poorer the health The higher the education, the more income

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Question
What can nurses do to address disparity in their own
community? A. B. C. Educate themselves regarding issues of disparity Use evidence-based decision making Identify vulnerable populations in their communities

D.
E.

Advocate for vulnerable populations

All of the above

Life Expectancy at Birth, 19302002

Healthy People 2020 Increase Quality & Years of Healthy Life

2002 2000 1995 1990 1980 1970 1960 1930 MRosa 77.3 77.0 75.8 75.4 73.7 70.8 69.7 59.7

National Center for Health Statistics, National Vital Statistics Reports, vol. 52, no. 3

Case Study 1
.

Harold is a 61-year-old bachelor who lives alone on a farm in a rural area. His diabetes has been well controlled for 40 years. Harold had lived with his mother, who cooked for him and administered his insulin. After his mothers death last year, he went to the clinic three times in 3 months for problems with his diabetes. Harold stated, Every time I went to the clinic I saw someone different. I would tell them the same story three times. Dont they ever talk to each other? He was admitted for a large ulcer on his ankle and uncontrolled diabetes last week.

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Case Study 1 continued

This morning you interviewed him in preparation for his discharge. He told you that he has never cooked and doesnt plan to learn now. He would rather go to the bakery and get doughnuts and caramel rolls for breakfast and lunch and eat cake and ice cream for dinner. He has refused to participate in any care related to his wound or even look at his wound. Harold seems very attached to his niece, who lives on a farm half a mile from him. She visits him every evening and has offered to help with his care. Your first plan was to have a home health aide provide homemaking care for Harold. When you suggested this he said, No one is going to come into my house and cook in my mothers kitchen! Thats what family is for!
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Case Study 1
a. What are the problems identified?
1. 2. 3. 4.

5.

Physical Psychosocial Family dynamics Environmental Lifestyle

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Case Study 1
b. How will you use the elements of community based nursing to plan for Harolds discharge?
self-care in the context of the family and community preventive focus continuity

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Case Study 1
c. List one goal for each problem identified.
1. 2. 3. 4.

5.

Physical Psychosocial Family dynamics Environmental Lifestyle

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Case Study 1
d. What nursing actions would you take to help achieve these goals?

e. Specify community resources you can suggest to this client.

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Case Study 2
Anna is 85 years old and suffers from congestive heart failure. She is not taking her medication. Her hemoglobin is 9.0 g/dL and she complains about constant fatigue. Her weight has remained constant, but she states my legs have gotten so swollen and I am so short of breath. a. Determine the primary nursing role.
b. State two likely basic or physical needs and psychosocial needs MRosa

Case Study 3
Mrs. Nguyen is a 45-year-old woman admitted to the hospital for spinal fusion of C5-6 & C6-7 vertebrae. She is from Vietnam & has lived in the U.S. for 15 years. She has been suffering from degenerative disk disease & osteoarthritis for the last 4 years & has lost some of the function in her right arm. Her plan of care was developed around the critical pathways for cervical fusion, with an expected length of stay in the hospital from 3 to 5 days. The surgical procedure was uneventful, but Mrs. Nguyen suffered from nausea & vomiting until the middle of postoperative day (POD) 1. Today is POD 2. She is able to get to the bathroom by herself but cannot dress herself, bathe herself, or pick up anything weighing over 3 or 4 lb. Her physician is recommending that she be discharged tomorrow, POD 3. She will be in a Philadelphia collar for 6 weeks, during which time she will be unable to drive. Mrs. Nguyen lives with her husband & 2 teenage sons, ages 14 & 16. Her husband owns a restaurant & works 12 to 14 hours a day. He will not be taking off any work time to care for her when she gets home.
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Case Study 3
a. List four reasons why the nurse is the best person on the interdisciplinary team to be involved in coordination of disciplines.

b. Identify goals of discharge planning for this patient

c. Discuss potential blocks to successful discharge planning and possible nursing interventions. d. Describe strategies to reduce cultural barriers MRosa to discharge planning for Mrs. Nguyen.

Question
Who said the nurse, through her peculiar introduction to the patient and her organic relationship with the neighborhood could be the starting point for wider service in the community? A. Mary Brewster B. William Rathbone C. Lillian Wald D. Florence Nightingale

The Principles of Community Care

Advocating self-care
Focusing on prevention Family, culture, and community Health and Social Systems are interactive Continuity of care Collaborative care