Just as the health care system is continually evolving, commu- nity health nursing practice evolves to remain effective with the clients it serves. Over time, the role of the community health nurse has broadened. This breadth is reflected in the description of public health nursing from the American Public Health Association, Public Health Nursing Section (1996):
Public health nurses integrate community involvement and knowledge about the entire population with personal, clini- cal understandings of the health and illness experiences of individuals and families within the population. They trans- late and articulate the health and illness experiences of diverse, often vulnerable individuals and families in the population to health planners and policy makers, and assist members of the community to voice their problems and aspirations. Public health nurses are knowledgeable about multiple strategies for intervention, from those applicable to the entire population, to those for the family, and the individual. Public health nurses translate knowledge from the health and social sciences to individuals and
population groups through targeted interventions, programs, and advocacy.
Public health nursing may be practiced by one public health nurse or by a group of public health nurses working collaboratively. In both instances, public health nurses are directly engaged in the interdisciplinary activities of the core public health functions of assessment, assurance, and policy development. Interventions or strategies may be targeted to multiple levels depending on where the most effective outcomes are possible. They include strategies aimed at entire population groups, families, or
individuals. In any setting, the role of public health nurses focuses on the prevention of illness, injury or disability, the promotion of health, and maintenance of the health of populations.
Community health nurses wear many hats while con- ducting day-to-day practice. At any given time, however, one role is primary. This is especially true for specialized roles, such as that of full-time manager. This chapter examines seven major roles: clinician, educator, advocate, manager, collaborator, leader, and researcher. It also describes the factors that influence the selection and performance of those roles.
Clinician Role
The most familiar role of the community health nurse is that of clinician or care provider. The provision of nursing care, however, takes on new meaning in the context of community health practice. The clinician role in community health means that the nurse ensures health services are provided not just to individuals and families, but also to groups and populations. Nursing service is still designed for the special needs of clients, however, when those clients comprise a group or population, clinical practice takes different forms.
It requires different skills to assess collective needs and tai- lor service accordingly. For instance, one community health nurse might visit elderly residents in a seniors’ high-rise apartment building. Another might serve as the clinic nurse in a rural prenatal clinic that serves migrant farm workers.
These are opportunities to assess the needs of entire aggre- gates and design appropriate services.
For community health nurses, the clinician role involves certain emphases that are different from those of basic nursing.
Three clinician emphases, in particular, are useful to consider here: holism, health promotion, and skill expansion.
Holistic Practice
Most clinical nursing seeks to be broad and holistic. In com- munity health, however, a holistic approach means considering the broad range of interacting needs that affect the collective health of the “client” as a larger system (Dossey, Keegan, & Guzzetta, 2005). Holistic nursing care encompasses the comprehensive and total care of the client in all areas, such as physical, emotional, social, spiritual, and economic. All are considered and cared for when the client is a large system, just as they should be with individual clients.
The client is a composite of people whose relationships and interactions with each other must be considered in totality.
Holistic practice must emerge from this systems perspective.
For example, when working with a group of pregnant teenagers living in a juvenile detention center, the nurse would consider the girls’ relationships with one another, their parents, the fathers of their unborn children, and the detention center staff. The nurse would evaluate their ages, developmental needs, and peer influence, as well as their knowledge of preg- nancy, delivery, and issues related to the choice of keeping or giving up their babies. The girls’ reentry into the community and their future plans for school or employment would also be considered. Holistic service would go far beyond the physical condition of pregnancy and childbirth. It would incorporate consideration of pregnant adolescents in this community as a population at risk. What factors contributed to these girls’ sit- uations, and what preventive efforts could be instituted to pro- tect other teenagers or these teens from future pregnancies?
The clinician role of the community health nurse involves holistic practice from an aggregate perspective.
Focus on Wellness
The clinician role in community health also is characterized by its focus on promoting wellness. As discussed in Chapter 1, the community health nurse provides service along the entire range of the health continuum, but especially emphasizes pro- motion of health and prevention of illness. Effective services CHAPTER 3 Setting the Stage for Community Health Nursing
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include seeking out clients who are at risk for poor health and offering preventive and health-promoting services, rather than waiting for them to come for help after problems arise. The community health nurse identifies people, programs, and agencies interested in achieving a higher level of health, and works with them to accomplish that goal and to sustain the expected changed behavior (Pender, Murdaugh, & Parsons, 2005). The nurse may help employees of a business learn how to live healthier lives or work with a group of people who want to quit smoking. The community health nurse may hold seminars with a men’s group on enhancing fathering skills or assist a corporation with the implementation of a health pro- motion program. Groups and populations are identified that may be vulnerable to certain health threats, and preventive and health-promoting programs can be designed in collabora- tion with the community (Pender et al., 2005). Examples include immunization of preschoolers, family planning pro- grams, cholesterol screening, and prevention of behavioral problems in adolescents. Protecting and promoting the health of vulnerable populations is an important component of the clinician role and is addressed extensively in the chapters in Unit VII on vulnerable aggregates.
Expanded Skills
Many different skills are used in the role of the community health clinician. In the early years of community health nursing, emphasis was placed on physical care skills. With time, skills in observation, listening, communication, and counseling became integral to the clinician role as it grew to encompass psychological and sociocultural factors. Recently, environmental and community-wide considerations—such as problems caused by pollution, violence and crime, drug abuse, unemployment, poverty, homelessness, and limited funding for health programs—have created a need for stronger skills in assessing the needs of groups and popula- tions and intervening at the community level. The clinician role in population-based nursing also requires skills in col- laboration with consumers and other professionals, use of epidemiology and biostatistics, community organization and development, research, program evaluation, administration, leadership, and effecting change (ANA, 2000; ANA, 2006).
These skills are addressed in greater detail in later chapters.
Educator Role
A second important role of the community health nurse is that of educator or health teacher. Health teaching, a widely recognized part of nursing practice, is legislated through nurse practice acts in a number of states and is one of the major functions of the community health nurse (ANA, 2004;
ANA, 2007c).
The educator role is especially useful in promoting the public’s health for at least two reasons. First, community clients usually are not acutely ill and can absorb and act on health information. For example, a class of expectant parents, unhampered by significant health problems, can grasp the relationship of diet to fetal development. They understand the value of specific exercises to the childbirth process, are motivated to learn, and are more likely to perform those exercises. Thus, the educator role has the potential for finding greater receptivity and providing higher-yield results.
Second, the educator role in community health nursing is significant because a wider audience can be reached. With an emphasis on populations and aggregates, the educational efforts of community health nursing are appropriately tar- geted to reach many people. Instead of limiting teaching to one-on-one or small groups, the nurse has the opportunity and mandate to develop educational programs based on community needs that seek a community-wide impact.
Community-wide antidrug campaigns, dietary improvement programs, and improved handwashing efforts among children provide useful models for implementation of the educator role at the population level and demonstrate its effectiveness in reaching a wide audience (Redman, 2007).
One factor that enhances the educator role is the public’s higher level of health consciousness. Through plans ranging from the President’s Council on Physical Fitness and Sports to local antismoking campaigns, people are recognizing the value of health and are increasingly motivated to achieve higher levels of wellness. When a middle-aged man, for example, is discharged from the hospital after a heart attack, he is likely to be more interested than before the attack in learning how to prevent another. He can learn how to reduce stress, develop an appropriate and gradual exercise program, and alter his eating habits. Families with young children often are interested in learning about children’s growth and development; most parents are committed to raising happy, healthy children. Health education can affect the health status of people of all ages (Bastable, 2006; Pender et al., 2005).
Today, in more businesses and industries, nurses promote the health of employees through active wellness-education and injury-prevention programs. The companies recognize that improving the health of their workers, which includes earning a living wage, means less absenteeism and higher production levels, in addition to other benefits (Halls &
Rhodes, 2004). Some companies even provide exercise areas and equipment for employees to use and pay for the cost of their participation or allow paid time off for exercise.
Whereas nurses in acute care teach patients with a one- on-one focus about issues related to their hospitalization, community health nurses go beyond these topics to educate people in many areas. Community-living clients need and want to know about a wide variety of issues, such as family planning, weight control, smoking cessation, and stress reduction. Aggregate-level concerns also include such topics as environmental safety, sexual discrimination and harass- ment at school or work, violence, and drugs. What foods and additives are safe to eat? How can people organize the com- munity to work for reduction of violence on television?
What are health consumers’ rights? Topics taught by com- munity health nurses extend from personal and family health to environmental health and community organization.
As educators, community health nurses seek to facili- tate client learning. Information is shared with clients both formally and informally. Nurses act as consultants to indi- viduals or groups. Formal classes may be held to increase people’s understanding of health and health care. Estab- lished community groups may be used in the nurse’s teach- ing practice. For example, a nurse may teach parents and teachers at a parent–teacher meeting about signs of mood- modifying drug and alcohol abuse, discuss safety practices with a group of industrial workers, or give a presentation on the importance of early detection of child abuse to a health 48
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planning committee considering funding a new program. At times, the community health nurse facilitates client learning through referrals to more knowledgeable sources or through use of experts on special topics. Client self-education is facilitated by the nurse; in keeping with the concept of self- care, clients are encouraged and helped to use appropriate health resources and to seek out health information for themselves. The emphasis throughout the health teaching process continues to be placed on illness prevention and health promotion. Health teaching as a tool for community health nursing practice is discussed in detail in Chapter 11.
Advocate Role
The issue of clients’ rights is important in health care. Every patient or client has the right to receive just, equal, and humane treatment. The role of the nurse includes client advocacy, which is highlighted in the ANA Code of Ethics for Nurses with Interpretive Statements (2001) and Nursing’s Social Pol- icy Statement (2003). Our current health care system is often characterized by fragmented and depersonalized services, and many clients—especially the poor, the disadvantaged, those without health insurance, and people with language barriers—
frequently are denied their rights. They become frustrated, confused, degraded, and unable to cope with the system on their own. The community health nurse often acts as an advo- catefor clients, pleading their cause or acting on their behalf.
Clients may need someone to explain which services to expect and which services they ought to receive, to make referrals as needed, and to write letters to agencies or health care providers for them. They need someone to guide them through the com- plexities of the system, and assure the satisfaction of their needs. This is particularly true for minorities and disadvan- taged groups (Sequist, Cullen, & Ayanian, 2005; Traeger, Thompson, Dickson, & Provencio, 2006).
Advocacy Goals
Client advocacy has two underlying goals. One is to help clients gain greater independence or self-determination.
Until they can research the needed information and access health and social services for themselves, the community health nurse acts as an advocate for the clients by showing them what services are available, those to which they are entitled, and how to obtain them. A second goal is to make the system more responsive and relevant to the needs of clients. By calling attention to inadequate, inaccessible, or unjust care, community health nurses can influence change.
Consider the experience of the Merrill family. Gloria Merrill has three small children. Early one Tuesday morn- ing, the baby, Tony, suddenly started to cry. Nothing would comfort him. Gloria went to a neighbor’s apartment, called the local clinic, and was told to come in the next day. The clinic did not take appointments and was too busy to see any more patients that day. Gloria’s neighbor reassured her that
“sometimes babies just cry.” For the rest of the day and night, Tony cried almost incessantly. On Wednesday, Gloria and her children made the 45-minute bus ride to the clinic, and waited 3.5 hours in the crowded reception room; the wait was punctuated by interrogations from clinic workers.
Gloria’s other children were restless, and the baby was crying.
Finally, they saw the physician. Tony had an inguinal hernia
that could have strangulated and become gangrenous. The doctor admonished Gloria for waiting so long to bring in the baby. Immediate surgery was necessary. Someone at the clinic told Gloria that Medicaid would pay for it. Someone else told her that she was ineligible because she was not a registered clinic patient. At this point, all of her children were crying. Gloria had been up most of the night. She was frantic, confused, and felt that no one cared. This family needed an advocate.
Advocacy Actions
The advocate role incorporates four characteristic actions:
being assertive, taking risks, communicating and negotiating well, and identifying resources and obtaining results.
First, advocates must be assertive. Fortunately, in the Merrills’ dilemma, the clinic had a working relationship with the City Health Department and contacted Tracy Lee, a com- munity health nurse liaison with the clinic, when Gloria broke down and cried. Tracy took the initiative to identify the Merrills’ needs and find appropriate solutions. She contacted the Department of Social Services and helped the Merrills to establish eligibility for coverage of surgery and hospitaliza- tion costs. She helped Gloria to make arrangements for the baby’s hospitalization and the other children’s care.
Second, advocates must take risks—go “out on a limb”
if need be—for the client. The community health nurse was outraged by the kind of treatment received by the Merrills:
the delays in service, the impersonal care, and the surgery that could have been planned as elective rather than as an emergency. She wrote a letter describing the details of the Merrills’ experience to the clinic director, the chairman of the clinic board, and the nursing director. This action resulted in better care for the Merrills and a series of meetings aimed at changing clinic procedures and providing better telephone screening.
Third, advocates must communicate and negotiate well by bargaining thoroughly and convincingly. The community health nurse helping the Merrill family stated the problem clearly and argued for its solution.
Finally, advocates must identify and obtain resources for the client’s benefit. By contacting the most influential people in the clinic and appealing to their desire for quality service, the nurse caring for the Merrill family was able to facilitate change.
Advocacy at the population level incorporates the same goals and actions. Whether the population is homeless people, battered women, or migrant workers, the community health nurse in the advocate role speaks and acts on their behalf.
The goals remain the same: to promote clients’ self- determination and to shape a more responsive system.
Advocacy for large aggregates, such as the millions with inadequate health care coverage, means changing national policies and laws (see Chapter 13). Advocacy may take the form of presenting public health nursing data to ensure that providers deliver quality services. It may mean conducting a needs assessment to demonstrate the necessity for a shelter and multiservice program for the homeless. It may mean tes- tifying before the legislature to create awareness of the prob- lems of battered women and the need for more protective laws. It may mean organizing a lobbying effort to require employers of migrant workers to provide proper housing and CHAPTER 3 Setting the Stage for Community Health Nursing
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working conditions. In each case, the community health nurse works with representatives of the population to gain their understanding of the situation and to ensure their input.
Manager Role
Community health nurses, like all nurses, engage in the role of managing health services. As a manager, the nurse exer- cises administrative direction toward the accomplishment of specified goals by assessing clients’ needs, planning and organizing to meet those needs, directing and leading to achieve results, and controlling and evaluating the progress to ensure that goals are met. The nurse serves as a manager when overseeing client care as a case manager, supervising ancillary staff, managing caseloads, running clinics, or con- ducting community health needs assessment projects. In each instance, the nurse engages in four basic functions that make up the management process. The management process, like the nursing process, incorporates a series of problem-solving activities or functions: planning, organizing, leading, and controlling and evaluating. These activities are sequential, yet also occur simultaneously for managing serv- ice objectives (Cherry & Jacob, 2005). While performing these functions, community health nurses most often are participative managers; that is, they participate with clients, other professionals, or both to plan and implement services.
Nurse as Planner
The first function in the management process is planning. A planner sets the goals and direction for the organization or project and determines the means to achieve them. Specifi- cally, planning includes defining goals and objectives, deter- mining the strategy for reaching them, and designing a coor- dinated set of activities for implementing and evaluating them. Planning may be strategic, which tends to include broader, more long-range goals (Cherry & Jacob, 2005;
USDHHS, 2000). An example of strategic planning is setting 2-year agency goals to reduce teenage pregnancies in the county by 50%. Planning may be operational, which focuses more on short-term planning needs. An example of opera- tional planning is setting 6-month objectives to implement a new computer system for client record keeping.
The community health nurse engages in planning as a part of the manager role when supervising a group of home health aides working with home care clients. Plans of care must be designed to include setting short-term and long-term objectives, describe actions to carry out the objectives, and design a plan for evaluating the care given. With larger groups, such as a program for a homeless mentally ill popu- lation, the planning function is used in collaboration with other professionals in the community to determine appropri- ate goals for shelter and treatment, and to develop an action plan to carry out and evaluate the program (Burke, 2005).
The concepts of planning with communities and families are discussed further in Chapters 15 and 19, respectively.
Nurse as Organizer
The second function of the manager role is that of organizer.
This involves designing a structure within which people and tasks function to reach the desired objectives. A manager
must arrange matters so that the job can be done. People, activities, and relationships have to be assembled to put the plan into effect. Organizing includes deciding on the tasks to be done, who will do them, how to group the tasks, who reports to whom, and where decisions will be made (Cherry
& Jacob, 2005). In the process of organizing, the nurse man- ager provides a framework for the various aspects of service, so that each runs smoothly and accomplishes its purpose.
The framework is a part of service preparation. When a community health nurse manages a well-child clinic, for instance, the organizing function involves making certain that all equipment and supplies are present, required staff are hired and are on duty, and that staff responsibilities are clearly designated. The final responsibility as an organizer is to evaluate the effectiveness of the clinic. Is it providing the needed services? Are the clients satisfied? Do the services remain cost-effective? All of these questions must be addressed by the organizer.
Nurse as Leader
In the manager role, the community health nurse also must act as a leader. As a leader, the nurse directs, influences, or persuades others to effect change that will positively impact people’s health and move them toward a goal. The leading function includes persuading and motivating people, direct- ing activities, ensuring effective two-way communication, resolving conflicts, and coordinating the plan. Coordination means bringing people and activities together, so that they function in harmony while pursuing desired objectives.
Community health nurses act as leaders when they direct and coordinate the functioning of a hypertension screening clinic, a weight control group, or a three-county mobile health assessment unit. In each case, the leading function requires motivating the people involved, keeping open clear channels of communication, negotiating con- flicts, and directing and coordinating the activities estab- lished during planning, so that the desired objectives can be accomplished.
Nurse as Controller and Evaluator
The fourth management function is to control and evaluate projects or programs. A controller monitors the plan and ensures that it stays on course. In this function, the commu- nity health nurse must realize that plans may not proceed as intended and may need adjustments or corrections to reach the desired results or goals. Monitoring, comparing, and adjusting make up the controlling part of this function. At the same time, the nurse must compare and judge performance and outcomes against previously set goals and standards—a process that forms the evaluator aspect of this management function.
An example of the controlling and evaluating function was evident in a program started in several preschool day care centers in a city in the Midwest. The goal of the project was to reduce the incidence of illness among the children through intensive physical and emotional preventive health education with staff, parents, and children. The two commu- nity health nurses managing the project were pleased with the progress of the classes and monitored the application of the prevention principles in day-to-day care. However, staff 50
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