aggregates community
community health
community health nursing disease prevention
health
health promotion population
population-focused nursing primary prevention
public health
public health nursing secondary prevention tertiary prevention
As a result of recent and anticipated changes related to health care reform, community/public health nurses are in a position to assist the U.S. health care system in the transition from a disease-oriented
system to a health-oriented system. Costs of caring for the sick account for the majority of escalating health care dollars, which
increased from 5.7% of the gross domestic product in 1965 to 17.9% in 2010 (National Center for Health Statistics [NCHS], 2013). Alarmingly, national annual health care expenditures reached $2.6 trillion in 2010, or an astonishing $8400 per person.
U.S. health expenditures reflect a focus on the care of the sick. In 2010, $0.31 of each health care dollar supported hospital care, $0.20 supported physician services, and $0.10 was spent on prescription drugs (double the proportion since 1980). The vast majority of these funds were spent providing care for the sick, and only $0.03 of every health care dollar was directed toward preventive public health activities (NCHS, 2013). Despite high hospital and physician expenditures, U.S. health indicators rate considerably below the health indicators of many other countries. This situation reflects a
relatively severe disproportion of funding for preventive services and social and economic opportunities. Furthermore, the health status of the population within the United States varies markedly across areas of the country and among groups. For example, the economically disadvantaged and many cultural and ethnic groups have poorer overall health status compared with middle-class Caucasians.
Nurses constitute the largest group of health care workers;
therefore, they are instrumental in creating a health care delivery system that will meet the health-oriented needs of the people.
According to a survey of registered nurses (RNs) conducted by the Health Resources and Services Administration, about 62% of
approximately 2.6 million employed RNs in the United States worked in hospitals during 2008 (down from 66.5% in 1992). This survey also found that about 14.2%, approximately 400,000, of all RNs worked in home, school, or occupational health settings; 10.5% worked in
ambulatory care settings; and 5.3% worked in nursing homes or other extended care facilities (U.S. Department of Health and Human
Services, Health Resources and Services Administration, Bureau of Health Professions [USDHHS, HRSA, BHP], 2010).
Between 1980 and 2008, the number of nurses employed in
community, health, and ambulatory care settings more than doubled (USDHHS, HRSA, BHP, 2010). The decline in the percentage of nurses employed in hospitals and the subsequent increase in nurses
employed in community settings indicate a shift in focus from illness and institutional-based care to health promotion and preventive care.
This shift will likely continue into the future as alternative delivery systems, such as ambulatory and home care, will employ more nurses (Rosenfeld and Russell, 2012; Way and MacNeil, 2007).
Community/public health nursing is the synthesis of nursing practice and public health practice. The major goal of public health nursing is to preserve the health of the community and surrounding populations by focusing on health promotion and health maintenance of individuals, families, and groups within the community. Thus
community/public health nursing is associated with health and the identification of populations at risk rather than with an episodic
response to patient demand.
The mission of public health is social justice, which entitles all people to basic necessities such as adequate income and health
protection and accepts collective burdens to make it possible. Public health, with its egalitarian tradition and vision, often conflicts with the predominant U.S. model of market justice that largely entitles people to what they have gained through individual efforts. Although market justice respects individual rights, collective action and obligations are minimal. An emphasis on technology and curative medical services within the market justice system has limited the evolution of a health system designed to protect and preserve the health of the population.
Public health assumes that it is society’s responsibility to meet the basic needs of the people. Thus there is a greater need for public
funding of prevention efforts to enhance the health of our population.
Current U.S. health policies advocate changes in personal behaviors that might predispose individuals to chronic disease or accident.
These policies promote exercise, healthy eating, tobacco use cessation, and moderate consumption of alcohol. However, simply encouraging the individual to overcome the effects of unhealthy activities lessens focus on collective behaviors necessary to change the determinants of health stemming from such factors as air and water pollution,
workplace hazards, and unequal access to health care. Because living arrangements, work/school environment, and other sociocultural constraints affect health and well-being, public policy must address societal and environmental changes, in addition to lifestyle changes, that will positively influence the health of the entire population.
With ongoing and very significant changes in the health care system and increased employment in community settings, there will be
greater demands on community and public health nurses to broaden their population health perspective. The Code of Ethics of the
American Nurses Association (ANA) (2001) promotes social reform by focusing on health policy and legislation to positively affect
accessibility, quality, and cost of health care. Community and public health nurses, therefore, must align themselves with public health programs that promote and preserve the health of populations by
influencing sociocultural issues such as human rights, homelessness, violence, disability, and stigma of illness. This principle allows nurses to be positioned to promote the health, welfare, and safety of all
individuals.
This chapter examines health from a population-focused,
community-based perspective. Therefore it requires understanding of how people identify, define, and describe related concepts. The
following section explores six major ideas:
1. Definitions of “health” and “community”
2. Determinants of health and disease 3. Indicators of health and disease
4. Definition and focus of public and community health 5. Description of a preventive approach to health
6. Definition and focus of “public health nursing,” “community health nursing,” and “community-based nursing”