Sue Chilton, Senior Lecturer/Academic Course Leader at the School of Health and Social Care, University of Gloucestershire, Gloucester, UK. It is excellent to see a focus on the principles of long-term condition management within the current policy context and the central role of the nurse in the community.
INTRODUCTION
Sue Chilton and Heather Bain
A variety of topics related to professional issues in community nursing are addressed within the book. Community nursing is seen in the context of not only political, but also social and environmental influences.
ACKNOWLEDGEMENT
This chapter examines the complex environment within which community nurses practice and provides some definitions of "community" and the ways in which the term is used. It explores the wide range of factors that influence the services that community nurses provide to patients and discusses ways of adapting care to meet local needs.
DEFINITIONS OF ‘COMMUNITY’
CHAPTER
Laverack (2009) offers four key characteristics of "community" that help summarize the many definitions found in the literature. Uncertainty about the true meaning of the word 'community' also applies to community nursing (Hickey and Hardyman, 2000).
FACTORS INFLUENCING THE DELIVERY OF COMMUNITY HEALTHCARE SERVICES
The authors address the contention that community nurses are still dependent on others to present the public image of community nursing that is portrayed. According to Blake (2013), community is a "fluid, chaotic thing" and the definition of the concept is not essential, adding that "it is important to do something together".
MEETING THE NEEDS OF THE LOCAL POPULATION
Which information sources can help you understand the specific needs of your customer group/population? Each locality will have its own individualized local public health objectives, tailored to the specific needs of the local population.
THE COMPLEX NATURE OF THE ENVIRONMENT OF COMMUNITY HEALTHCARE
List the identified health and social care needs of all people involved. Information that helps you understand the experience can be obtained in several ways.
COMMUNITY NURSES: KEEPING THE FOCUS ON PERSON-CENTRED CARE
Three main aspects of the role are first contact, public health and long-term management of the condition (Sines et al., 2013a). The role of the district nurse has evolved over time in response to political influences.
THE FUTURE VISION
Many community nurses fear that care will be compromised if person-centred approaches are replaced by task allocation models of care. Many community nurses are concerned that this situation will worsen if community nurses are not adequately prepared for their demanding and challenging roles and more collaborative relationships are not established between professionals, patients, carers and communities.
FURTHER RESOURCES
Mafuba, K and Gates, B (2015), Investigating the public health roles of community learning disability nurses. Royal College of Nursing (RCN) (2017) Nursing at Work. Accessed 23 January 2017) https://www.rcn.org.uk/clinical-topics/public-health/specialist-areas/.
HEALTH AND WELL-BEING
This chapter examines public health, identifies the relationship between health and well-being, and discusses its relevance to community nursing. When reading the WHO definition of health above, it is notable that the concept of well-being is integral.
SOCIAL DETERMINANTS OF HEALTH
In the UK there are inequalities and health gaps between sectors of the population. Within health care, the importance of broader determinants of health and health inequalities is recognized and understood.
PUBLIC HEALTH
They continue to build on these in recent policies in each of the four British nations, while remaining true to the idea that the promotion of health and well-being through the prevention of disease is achievable through the collective efforts of society. The idea of health and well-being has been embedded in government policy for many years and continues to be.
INFLUENCING FACTORS
There are three main approaches to needs assessment in public health, characterized as epidemiological, comparative and corporate. This approach gathers the knowledge and views of the stakeholders on the issues addressed in the needs assessment.
PROMOTING HEALTH AND WELL-BEING
Other theories that contribute to understanding the effect of health promotion interventions on the client and why people seek help are psychological theories of behavior change, which aim to explain why and how people can change their behavior. Social change • Sometimes called radical health promotion; recognizes the importance of the socio-economic environment in determining health.
SCREENING
CULTURAL AWARENESS
Examples of where cultural dimensions may arise include an individual's belief systems about health and well-being; how they perceive illness, diseases and their causes; the behavior of individuals seeking health care and their attitudes toward health care providers; and importantly the views and values of those providing health care. As Szczepura (2005) states, improved openness and understanding of individuals' health beliefs, practices and cultural needs are essential to ensuring equitable and effective access to health services for all populations beyond service provision.
APPLYING THEORY TO PRACTICE
Although health promotion is often defined in terms of working with populations, and working with individuals is defined as health education, any intervention that aims to enable people to take control of their own health on an individual or population basis is considered health promotion stakes. (Whitehead and Irvine, 2010).
CONCLUSION
FURTHER READING
I Coles L og Porter E (red) (2008) Public Health Skills: A Practical Guide for Nurses and Public Health Practitioners. I Coles L og Porter E (red) Public Health Skills: A Practical Guide for Nurses and Public Health Practitioners.
THE TRADITIONAL MODEL OF PROFESSIONAL PRACTICE
Box 3.2 Features of the medical health model Focus on the disease process and healing. Box 3.3 Features of the social model of health Health is holistic and not just the absence of disease.
PRINCIPLES INFORMING PROFESSIONAL PRACTICE
In order to do what is right in the specific circumstances, different stakeholders will have different views that need to be taken into account when making decisions. In the community this can be challenging as there will be inequities and resources that affect the quality of care, for example housing, access to family support or respite.
INFORMED CONSENT
In the case of community mental health nursing, where a service user declines treatment but the nurse is aware of the potential harm if the patient does not take their medication, the principle of autonomy is contrary to beneficence unless the patient is considered unable to use such medications. a decision under the Mental Capacity Act (DH, 2005). Having considered Miss Davies' case in relation to her autonomy, she may refuse permission for alternative accommodation or rehabilitation, which she is fully entitled to do, provided she is deemed capable of making such decisions.
PROFESSIONAL VALUES
Values must be shared; at an abstract level they are less problematic, but the context in which they apply is where conflict can arise (Dominelli research showed that despite shared values of caring, compassion and holism between general practitioners and community nurses, these values are shared by both professions were perceived differently. that have fueled communication problems. 2006) argue that what appears to be a moral dilemma is more likely to be due to insufficient information or a breakdown in communication. Conversely, the learning disability hospital passport identifies the individual's needs and preferences in advance and is crucially owned by them; it has proven to be an essential document that has saved lives (Skinner, 2011).
PROFESSIONAL CODES OF PRACTICE
Although confidentiality is a shared value, this does not mean that service users' information can be automatically shared. Although professionals need to understand the law to ensure it is implemented correctly, it is essential that health and social care professionals share information in the interests of service users.
TOWARDS A NEW PARTNERSHIP MODEL OF PROFESSIONAL PRACTICE
Service users are generally less dependent on professionals as sole experts or holders of professional knowledge. The new model for professional practice is a partnership between service users and professionals and interprofessional work.
INFLUENCE OF SERVICE USER INVOLVEMENT ON PROFESSIONAL PRACTICE
ROLE OF SERVICE USERS IN PROFESSIONAL EDUCATION
Partnership with service users and healthcare providers can now play an important role in the professionalisation of healthcare and social care providers. DH (2006) A stronger local voice: a framework for creating a stronger local voice in the development of health and social care services.
RISK ASSESSMENT IN RELATION TO COMMUNITY NURSES Personal safety
PREPARATION FOR HOME VISITING
It's the patient's or client's space that you're invading – you don't know what's going on or what's happened recently in that person's home. It may not be convenient for the patient or client to allow you into a certain room.
CAR SAFETY
ORGANISATIONAL SUPPORT
PRINCIPLES OF RISK MANAGEMENT
IDENTIFY THE HAZARDS
Senior nurses will carry out a risk assessment with evidence input from the team. Documentation must be comprehensive and accurate and must include a full account of the intervention and assessment of the condition (NMC, 2015).
RISK ASSESSMENT IN RELATION TO PATIENT CARE Raising concerns
It suggests that working in a supportive and nurturing environment should support those individuals who wish to raise concerns. It is therefore obvious that organizations must clearly enable nurses to raise concerns, which should then be investigated quickly and thoroughly (RCN, 2015).
IDENTIFYING PATIENTS AT RISK OF READMISSION AND ADMISSION
Some of the predictive models currently used in England are the Patients at Risk of Readmission (PARR 30) (Billings et al., 2012) and the combined model (Lewis et al., 2011). Scottish Patients at Risk of Readmission (SPARRA) have also been successfully used, Wales has used the Prism (predictive risk model) model (Hutchings et al., 2013) and Northern Ireland has used PARR models (Lupari, 2010).
ADULTS AT RISK
Predictive models identify patients at highest risk for hospitalization and allow physicians to engage with high-risk patients to induce behavioral or treatment changes and introduce preventive measures to reduce risk (Billings et al., 2012). However, few prediction models have been validated and evidence on their effects on patient care is limited (Hutchings et al., 2013).
PEOPLE WITH MENTAL HEALTH ISSUES
Adults with long-term conditions are more likely to develop mental health problems, such as depression and anxiety (Naylor et al., 2012). Anxiety is one of the most common mental health problems in the UK and it is on the rise.
CARING FOR OLDER PEOPLE
This is partly attributed to the insufficient recognition of the problem by health professionals (Lazarou et al., 2011). To improve the recognition of mental health problems, it is imperative that nurses, and especially those working in community settings, recognize the importance of rapid diagnosis, which presupposes both understanding and knowledge of the basic aspects of the problem, and an understanding of their role in there. coping with depression (Lazarou et al., 2011).
FALLS
Community nurses may come into contact with individuals who have sustained injuries, or who have lost mobility or suffered a loss of function and are therefore at high risk of falling. NICE (2015) recommends that older people who have had recurrent falls or who are assessed to be at high risk of falling should be offered an individualised, multifactorial risk assessment.
SAFEGUARDING ADULTS, CHILDREN AND YOUNG PEOPLE
In the longer term, compared to their peers, "looked after children" generally have poorer outcomes in terms of education and mental health. Joint Commissioning Panel for Mental Health (2013) Guidance for commissioners of older people's mental health services.
THE FEATURES OF A THERAPEUTIC RELATIONSHIP
It is recognized as central to promoting the best interests and outcomes for the person and families (Porr et al., 2012; Canning et al., 2007). The characteristics of a therapeutic relationship regarding the person's state of health and encouraging active participation in the decision-making process (Foot et al., 2014).
CHALLENGES OF DEVELOPING THERAPEUTIC RELATIONSHIPS IN COMMUNITY SETTINGS
Expectations of the nurse and local nurses can also affect the therapeutic relationship. Therefore, the nurse who 'does for' the individual rather than enabling them to self-care is contrary to current perspectives on best practice (Wilson et al., 2007).
WHEN THE BALANCE IS NOT MAINTAINED: FAILURES IN THERAPEUTIC RELATIONSHIPS
The results of under-involvement are the nurse's lack of understanding of the person's perspective, conflict and standardized rather than context-sensitive care (Milton, 2008). When the balance is not maintained: Failures in the therapeutic relationship are often considered one of the most desirable qualities in a nurse.
INFLUENCE OF THE CURRENT AND FUTURE CONTEXT ON THERAPEUTIC RELATIONSHIPS
Trade Union Congress (TUC) (2015) Good Practice in the Workplace Mental Health; TUC Workshop Report February 2015. Accessed 1 September 2015) https://www.tuc.org.uk/sites/default/files/GoodPracticeMentalHealth_0.pdf. Wilson PM (2001) An analysis of expert patient policies in the United Kingdom: Self-care as an expression of pastoral power.
THEORIES OF GROWTH AND DEVELOPMENT
The importance of developing a broad perspective and an awareness of all aspects of the life expectancy continuum should support the provision of effective care. It is useful to consider some of the theories that support growth and development and a life span approach.
BIOMEDICAL INFLUENCES
Margaret Clay 78 years Lives in 3 bedroom semi-detached house urban area suburbs of the city Type 2 diabetes diagnosed 10 years ago, diet controlled Jack Clay (deceased) 79 years married 58 years Died 6 months ago after a heart attack. Although critical to healthcare delivery, it is important to recognize that biomedical factors will be overshadowed by psychosocial influences.
PSYCHOSOCIAL INFLUENCES
The effects of aging can be a new concern. 2004) emphasize the concept of a "midlife crisis" as a period of uncertainty and change that may be perceived as the last chance to achieve some life goals. It is important to know that a long-term illness can challenge and change the expected norms throughout life.
EXPLORING THE MEANING OF ASSESSMENT
The purpose of this chapter is to explore community nursing assessment by defining terminology and identifying what constitutes a holistic assessment. Decision-making and its essential alignment with community nursing assessment will then be discussed, with opportunities to guide reflection on current practice.
DEFINING ASSESSMENT
PATIENT-CENTRED CARE
In addition, the principles of patient-centered care are associated with holistic assessment, identification of needs, and shared decision-making. Regardless, person-centred care can present complex challenges for community nurses, as sharing evidence-based information to enable authentic shared decision-making can be time-consuming.
HOLISM
NURSING MODELS
Perhaps unsurprisingly, the current literature promoting the use of nursing models in contemporary community nursing practice is sparse, which may reflect a lack of interest among both educators and practitioners. Regardless, it is likely that finding a perfect community nursing assessment tool is not realistic; However, various theories and concepts are available in the literature to help nurses develop holistic approaches for their field of practice.
DISCUSSION OF ASSESSMENT FRAMEWORKS
Of course in some cases a validated assessment tool will be included in the documentation, and as practitioners you should be able to clearly identify this. Unfortunately, if the whole model is not used, the activities of life become a checklist and as a result the information gathered can often become superficial and lack crucial detail.
EXPLORING THE CONCEPT OF NEED
ANALYZING CONCEPTUAL ASPECTS OF ASSESSMENT
ADOPTING NEW ROLES
Gough's (2008) holistic assessment tool, which can be viewed in Box 7.3, was developed with a prescriptive focus in mind. The tool provides community nurses with guidance in carrying out a holistic assessment. Although not every aspect can be assessed on the first visit, the assessment tool allows community nurses to respond to the needs identified by both the patient and the nurse, implementing a partnership approach.
CRITICAL REFLECTION ON DECISION MAKING
CONTEXT OF DECISION MAKING
For community nurses, insight into the relationship between physical and mental health is important. Source: Naylor C, Parsonage M, McDaid D et al., (2012) Long-term conditions and mental health The costs of comorbidities.
WHO IS A CARER?
In Scotland, the Carer Strategy (Scottish Government, 2010) calls for early intervention and a preventative approach to prevent crises. These tools are used to assess the caregiver's experience, his/her ability or willingness to cope, and the caregiver's quality of life.
THE IMPACT OF CARING
Community care assessments look at the carer's role and the help the carer provides. Most carers who live with the person they care for find the constant need to be present and on call the most stressful feature of the role.
SUPPORTING CARERS
The literature review shows that professional, voluntary services and family carers need to work together effectively, with a clear role for nurses in undertaking assessments, providing information and providing other support (Zwaanswijk et al., 2010; O'Brien et al., al., 2012). District and community nurses express concerns about their confidence to provide appropriate support to carers and this clearly shows that they have their own educational needs (Jack and O'Brien, 2010; Whitehead et al., 2012).
LITERATURE REVIEW AND RESEARCH
This chapter is about the concept of spirituality in the care provided by nurses. Finally, the competence of nurses to deal with the spiritual aspects of care is considered, together with the importance of observation skills and communication, essential tools in the repertoire of all nurses.