Sue Chilton, Senior Lecturer/Academic Course Leader in 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 political context and the central role of the nurse in the community environment.
INTRODUCTION
Sue Chilton and Heather Bain
The book discusses a range of topics related to professional issues in outpatient nursing. Outpatient nursing is discussed in the context of not only political but also social and environmental influences.
ACKNOWLEDGEMENT
This chapter looks at the complex environment in which community nurses work and offers some definitions of the term 'community' and the ways in which the term is used. It explores the wide range of factors that influence the services provided to patients by community nurses and discusses ways of adapting care to respond to local needs.
DEFINITIONS OF ‘COMMUNITY’
CHAPTER
Laverack (2009) offers four key characteristics of a 'community' which help summarize many of the definitions found in the literature. The uncertainty regarding the true meaning of the word 'community' also applies within community nursing (Hickey and Hardyman, 2000).
FACTORS INFLUENCING THE DELIVERY OF COMMUNITY HEALTHCARE SERVICES
The authors discuss the proposition that community nurses are still dependent on others to present the public image of community nursing that is outlined. According to Blake (2013), community is a “liquid, chaotic thing” and defining the concept is not essential. He adds that 'doing something together is important'.
MEETING THE NEEDS OF THE LOCAL POPULATION
What information sources will help inform you about the specific needs of your customer group/population. Each locality will have its own individualized local public health targets tailored to the specific requirements of the local population.
THE COMPLEX NATURE OF THE ENVIRONMENT OF COMMUNITY HEALTHCARE
Make a list of the identified health and social needs of all these people. You can access information to help you understand the experience in a variety of ways.
COMMUNITY NURSES: KEEPING THE FOCUS ON PERSON-CENTRED CARE
The three key aspects of the role are first contact, public health and long-term disease management (Sines et al., 2013a). The role of the community nurse 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-sharing 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), An examination of the public health roles of nurses with learning disabilities. Royal College of Nursing (RCN) (2017) Occupational Health Nursing. 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 United Kingdom, unequal opportunities and healthcare disparities exist between sectors of the population. Within healthcare, there is recognition and understanding of the importance of the broader determinants of health and health inequalities.
PUBLIC HEALTH
They continue to build on these in the latest policies in each of the UK's four Nations, staying true to the idea that promoting health and wellbeing through disease prevention is achievable through the collective efforts of society. The idea of health and wellness has been embedded in government policy for many years and continues to be.
INFLUENCING FACTORS
There are three main approaches to public health needs assessment, labeled epidemiological, comparative and corporate. This approach gathers the knowledge and views of stakeholders on the issues addressed by 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 can occur include a person's health and wellness belief systems; how illness, disease and their causes are perceived; the behavior of individuals seeking health care, and their attitudes toward health care providers; and more importantly the views and values of those who deliver health care. As Szczepura (2005) states, improved openness and understanding of the health beliefs, practices and cultural needs of individuals is essential to provide equitable and effective access to health care services for all populations beyond service provision.
APPLYING THEORY TO PRACTICE
Although health promotion is often defined as work with populations and work with individuals as health education, any intervention that aims to enable people to take control of their own health at the individual or population level is considered a health promotion intervention. (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 Characteristics of the medical health model Focus on the disease process and healing. Box 3.3 Characteristics 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 refuses treatment but the nurse is aware of the potential harm if the patient does not take his medication, the principle of autonomy conflicts with beneficence, unless the patient is considered incapable of to do this. a decision under the Mental Capacity Act (DH, 2005). Having considered Miss Davies's case in relation to her autonomy, she can refuse consent to 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 the abstract level they are less problematic, but the context in which they apply is where conflict can arise (Dominelli research has shown that despite shared values of caring, compassion and holism between GPs and community nurses, these values were perceived differently by both professional groups, which fueled communication problems.2006) states that what appears to be a moral dilemma is more due to insufficient information or a lack of communication. Conversely, the learning disabled hospital passport identifies the individual's needs and preferences in advance and is decisively 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 common 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 best interests of service users.
TOWARDS A NEW PARTNERSHIP MODEL OF PROFESSIONAL PRACTICE
Service users are generally less dependent on professionals as sole experts or as holders of professional knowledge. The new model of professional practice is one of partnership between service users and professionals and interprofessional working.
INFLUENCE OF SERVICE USER INVOLVEMENT ON PROFESSIONAL PRACTICE
ROLE OF SERVICE USERS IN PROFESSIONAL EDUCATION
Partnership with service users and carers can now play an important role in professionalizing health and social care practitioners. 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 is the patient's or client's space that you are invading - it is unknown what is or has recently happened in that person's home. It may not be convenient for the patient or client to allow you into a particular room.
CAR SAFETY
ORGANISATIONAL SUPPORT
PRINCIPLES OF RISK MANAGEMENT
IDENTIFY THE HAZARDS
Senior nurses will carry out the assessment of the risk with contributing evidence from the team. Documentation should be comprehensive and accurate, with a full account of intervention and assessment of the situation (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 clear that organizations must clearly enable nurses to raise concerns, which must then be investigated promptly 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 clinicians to engage with high-risk patients to initiate behavioral or treatment changes and institute preventive measures to reduce risk (Billings et al., 2012). However, few prediction models have been validated and evidence of 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 attributed, among other things, to the ignorance of the problem by health professionals (Lazarou et al., 2011). In order to improve the recognition of mental health problems, it is imperative that nurses and especially those working in community settings appreciate the importance of rapid diagnosis, which assumes an understanding and knowledge of the underlying aspects of the problem and an understanding of their role in dealing with depression (Lazarou et al., 2011).
FALLS
Community nurses may come into contact with people who have sustained injuries or who have lost mobility or have 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 individual, multifactorial risk assessment.
SAFEGUARDING ADULTS, CHILDREN AND YOUNG PEOPLE
In the long run, compared to their peers, "provided children" generally perform worse in terms of education and mental health. Joint Commissioning Committee for Mental Health (2013) Guidelines for Commissioners of Older People's Mental Health Services.
THE FEATURES OF A THERAPEUTIC RELATIONSHIP
It is recognized as central to achieving the best interests and outcomes for individuals and families (Porr et al., 2012; Canning et al., 2007). The characteristics of the therapeutic relationship in relation to the person's health condition and the promotion of 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, goes against current perspectives on best practice (Wilson et al., 2007).
WHEN THE BALANCE IS NOT MAINTAINED: FAILURES IN THERAPEUTIC RELATIONSHIPS
The results of underinvolvement are a lack of nurse understanding of the person's perspective, conflict, and standardized rather than contextually dependent care (Milton, 2008). When balance is not maintained: Failures in therapeutic relationships are often seen as one of the most desirable qualities for a nurse.
INFLUENCE OF THE CURRENT AND FUTURE CONTEXT ON THERAPEUTIC RELATIONSHIPS
Trades Union Congress (TUC) (2015) Good practice in workplace mental health; Report of the TUC Seminar February 2015. Accessed 1 September 2015) https://www.tuc.org.uk/sites/default/files/GoodPracticeMentalHealth_0.pdf. Wilson PM (2001) A political analysis of the expert patient in Britain: Self-care as an expression of pastoral power.
THEORIES OF GROWTH AND DEVELOPMENT
The importance of developing a broad point of view and an awareness of all aspects of the lifespan continuum should support effective care provision. It is useful to consider some of the theories that support growth and development and a life span approach.
BIOMEDICAL INFLUENCES
Margaret Clay aged 78 Lives in a 3 bed semi-detached house on the outskirts of town in an urban area Type 2 diabetes diagnosed 10 years ago, on controlled diet Jack Clay (deceased) aged 79 Married for 58 years Died 6 months ago after myocardial infarction. Although essential to the delivery of care, it is important to recognize that biomedical factors will be overridden by psychosocial influences.
PSYCHOSOCIAL INFLUENCES
The effects of aging can be an emerging problem. 2004) emphasize the concept of 'the midlife crisis' as a period of uncertainty and change that can be seen as a last chance to achieve some life goals. It is important to recognize that expected norms throughout the lifespan can be challenged and changed by long-term illness.
EXPLORING THE MEANING OF ASSESSMENT
The purpose of this chapter is to examine 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. However, it is likely that finding a perfect assessment tool for ambulatory care 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 valid assessment tool will be included in the documentation and as a practitioner you should be able to identify this clearly. Unfortunately, unless the entire model is used, life activities become a checklist and as a result the information gathered can often become superficial and essential details are missing.
EXPLORING THE CONCEPT OF NEED
ANALYZING CONCEPTUAL ASPECTS OF ASSESSMENT
ADOPTING NEW ROLES
The holistic assessment tool created by Gough (2008), which can be seen in Box 7.3, was developed with a prescribing focus in mind. The tool provides community nurses with guidance to undertake a holistic assessment and although all aspects may not be assessed on the first visit, the assessment tool allows community nurses to respond to the needs determined by both patient and nurse, thus implementing a partnership approach .
CRITICAL REFLECTION ON DECISION MAKING
CONTEXT OF DECISION MAKING
An understanding of the link between physical and mental health is important for community nurses. Source: Naylor C, Parsonage M, McDaid D et al., (2012) Long-term conditions and mental health The cost of co-morbidities.
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 or her ability or willingness to cope, and the caregiver's quality of life.
THE IMPACT OF CARING
Community care assessments look at the role of the carer and the help the carer provides. Most caregivers who live with the person they care for find the constant need to be present and alert the most taxing feature of the role.
SUPPORTING CARERS
The review of the literature indicates that professionals, voluntary services and family carers must work together effectively, with a clear role for nurses in making 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 in providing appropriate support to carers and this clearly indicates that they have their own training needs (Jack and O'Brien, 2010; Whitehead et al., 2012).
LITERATURE REVIEW AND RESEARCH
This chapter deals with the concept of spirituality in the care provided by nurses. Finally, the competence of nurses to handle the spiritual aspects of care is seen along with the importance of observational skills and communication, essential tools in the repertoire of all nurses.
