COMMUNITY BASED NURSING PRACTICE
HEALTH AND WELLNESS
Theories applied in Community Health Nursing
The concept of community is defined as “a group of people who share some important feature of their lives and use some common agencies and institutions.” The concept of health is defined as “a balanced state of well-being resulting from harmonious interactions of body, mind, and spirit.” The term community health is defined by meeting the needs of a community by identifying problems and managing interactions within the community
Basic Elements
The six basic elements of nursing practice incorporated in community health programs and services are:
(1) promotion of healthful living
(2) prevention of health problems
(3) treatment of disorders
(4) rehabilitation
(5) evaluation and
(6) research.
Major Roles
The focus of nursing includes not only the individual, but also the family and the community, meeting these multiple needs requires multiple roles. The seven major roles of a community health nurse are:
(1) care provider
(2) educator
(3) advocate
(4) manager
(5) collaborator
(6) leader, and
(7) researcher.
Major Settings
Settings for community health nursing can be grouped into six categories:
(1) homes
(2) ambulatory care settings
(3) schools
(4) occupational health settings
(5) residential institutions, and
(6) the community at large.
Community health nursing practice is not limited to a specific area, but can be practiced anywhere.
Theories and Models for community health nursing
The commonly used theories are:
(1) Nightingale’s theory of environment
(2) Orem’s Self care model
(3) Neuman’s health care system model
(4) Roger’s model of the science and unitary man
(5) Pender’s health promotion model
(6) Roy’s adaptation model
(7) Milio’s Framework of prevention
(8) Salmon White’s Construct for Public health nursing
(9) Block and Josten’s Ethical Theory of population focused nursing
(10) Canadian Model
(11) Milio’s Framework of prevention
Nancy Milio a nurse and leader in public health policy and public health education developed a framework for prevention that includes concepts of community-oriented, population focused care.(1976,1981).
The basic treatise is that behavioral patterns of populations and individuals who make up populations are a result of habitual selection from limited choices. She challenged the commootion that a main determinant for unhealthful behavioral choice is lack of knowledge. Governmental and institutional policies, she said set the range of options for personal choice making. It neglected the role of community health nursing, examining the determinants of community health and attempting to influence those determinants through public policy.
Salmon White’s construct for public health nursing
Mark Salmon White (1982) describes a public health as an organized societal effort to protect, promote and restore the health of people and public health nursing as focused on achieving and maintaining public health.
He gave 3 practice priorities i.e.; prevention of disease and poor health, protection against disease and external agents and promotion of health. For these 3 general categories of nursing intervention have also been put forward, they are:
(1) education directed toward voluntary change in the attitude and behaviour of the subjects
(2) engineering directed at managing risk-related variables
(3) enforcement directed at mandatory regulation to achieve better health.
Scope of prevention spans individual, family, community and global care. Intervention target is in 4 categories:
1.Human/Biological
2. Environmental
3. Medical/technological/organizational
4. Social
Block and Josten’s Ethical Theory of population focused nursing
Derryl Block and Lavohn Josten, public health educators proposed this based on intersecting fields of public health and nursing. They have given 3 essential elements of population focused nursing that stem from these 2 fields:
(1) an obligation to population
(2) the primacy of prevention
(3) centrality of relationship- based care
the first two are from public health and the third element from nursing. Hence it implies to nursing that relation-based care is very important in population focused care.
Canadian Model for community
The community health nurse works with individuals, families, groups, communities, populations, systems and/or society, but at all times the health of the person or community is the focus and motivation from which nursing actions flow. The standards of practice are applied to practice in all settings where people live, work, learn, worship and play.
The philosophical base and foundational values and beliefs that characterize community health nursing – caring, the principles of primary health care, multiple ways of knowing, individual/community partnerships and empowerment – are embedded in the standards and are reflected in the development and application of the community health nursing process.
The community health nursing process involves the traditional nursing process components of assessment, planning, intervention and evaluation but is enhanced by community health nurses in three dimensions:
individual/community participation in each component,
multiple ways of knowing, each of which is necessary to understand the complexity and diversity of nursing in the community; knowledge and utilization of all these ways of knowing forms evidence-based practice consistent with these standards, and the inherent influence of the broader environment on the individual/community that is the focus of care (e.g. the community will be affected by provincial/territorial policies, its own economic status and by the actions of its individual citizens). The standards of practice are founded on the values and beliefs of community health nurses, and utilization of the community health nursing process.
The model illustrates the dynamic nature of community health nursing practice, embracing the present and projecting into the future. The values and beliefs (green or shaded) ground practice in the present yet guide the evolution of community health nursing practice over time. The community health nursing process provides the vehicle through which community health nurses work with people, and supports practice that exemplifies the standards of community health nursing. The standards of practice revolve around both the values and beliefs and the nursing process with the energies of community health nursing always being focused on improving the health of people in the community and facilitating change in systems or society in support of health. Community health nursing practice does not occur in isolation but rather within an environmental context, such as policies within their workplace and the legislative framework applicable to their work.
Every nurse is accountable for the fundamental knowledge and expectations of basic nursing practice regardless of their practice focus or setting. These standards expand upon generic nursing practice expectations and identify the practice principles and variations specific to community health nursing practice. While nurses with varied levels of preparation may practice in the community setting, these standards apply specifically to the practice of registered nurses.
Standards of Practice:
define the scope and depth of community nursing practice
• establish criteria or expectations for acceptable nursing practice and safe, ethical care
• support ongoing development of community health nursing
• promote community health nursing as a specialty
• provide the foundation for certification of community health nursing as a specialty by the Canadian Nurses Association
• inspire excellence in and commitment to community nursing
All community health nurses are expected to know and use these standards when working in any of the areas of practice, education, administration or research. Nurses in clinical practice will use the standards to guide and evaluate their own practice. Nursing educators will include the standards in course curricula to prepare new graduates for practice in community settings. Nurse administrators will use them to direct policy and guide performance expectations. Nurse researchers will use these standards to guide the development of knowledge specific to community health nursing. Nurses may enter community health nursing as new practitioners and require experience and opportunities for additional learning and skill development to help them develop their practice. The Community Health Nursing Standards of Practice become basic practice expectations after two years of experience. The practice of expert community health nurses will extend beyond these standards.
Community health nurses are registered nurses whose practice specialty promotes the health of individuals, families, communities and populations, and an environment that supports health. They practice in diverse settings such as homes, schools, shelters, churches, community health centres and on the street. Their position titles may vary as much as their practice settings.
The practice of community health nursing combines nursing theory and knowledge, social sciences and public health science with primary health care. Community health nurses view disease prevention, health protection and health promotion as goals of professional nursing practice (Smith, 1990). They collaborate with individuals, families, groups, communities and populations to design and carry out community development, health promotion and disease prevention strategies. They identify and promote care decisions that build on the capacity of the individual or community.
A critical part of their practice is to mobilize resources to support health by coordinating care and planning services, programs and policies with individuals, caregivers, families, other disciplines, organizations, communities and government(s).
Mission
Community health nurses view health as a resource for everyday living. Their practice promotes, protects and preserves the health of individuals, families, groups, communities and populations wherever they live, work, learn, worship and play, in an ongoing rather than an episodic process (Cradduck, 2000). Their practice is based on a unique understanding of how the environmental context influences health. Community health nurses work at a high level of autonomy and build partnerships based on the principles of primary health care, caring and empowerment.
Values and beliefs
The following values and beliefs are based on Canadian Nurses Association’s Code of Ethics for Registered Nurses (2002a) and interpreted from the community health nursing perspective. The community health nurse values and believes in
Caring
Community health nurses recognize that caring is an essential and universal humaeed and that its expression in practice varies across cultures and practice domains. In community health nursing practice in Canada, caring is based on the principle of social justice. Community health nurses support equity and the fundamental right of all humans to accessible, competent health care and essential determinants of health. Caring community health nursing practice acknowledges the physical, spiritual, emotional and cognitive nature of individuals, families, groups and communities. Caring is expressed through competent practice and development of relationships that value the individual and community as unique and worthy of a nurse’s “presence” and attention. Community health nurses preserve, protect and enhance human dignity in all of their interactions.
The principles of primary health care.
Primary health care represents a fundamentally different way of thinking about health and health care for community health nurses and their practice. Primary health care differs significantly from primary care (first point of access to care) and is an integral part of the Canadian health care system. Community health nurses value the following key principles of primary health care as described by the World Health Organization (1978):
• universal access to health care services
• focus on the determinants of health
• active participation by individuals and communities in desions that affect their health and life
• partnership with other disciplines, communities and sectors for health
• appropriate use of knowledge, skills, strategies, technology and resources
• focus on health promotion and illness prevention throughout the life experience
Community health nurses recognize the impact of the social, political and economic environment on the health of individuals and the community, and on their own practice.
Multiple ways of knowing
Community health nurses integrate multiple types of knowledge into their practice. Five fundamental ways of knowing iursing have been identified: aesthetics, empirics, personal knowledge, ethics and socio-political knowledge (Carper, 1978; White, 1995). Each type is an essential part of the integrated knowledge base of community health nursing practice:
• Aesthetics, the art of nursing, means adapting knowledge and practice to particular rather than universal circumstances. It encourages nurses to explore possibilities, promotes individual creativity and style, and contributes to the transformative power of community health nursing.
• Empirics, the science of community health nursing, includes research, epidemiology and theories and models (incorporating publicly verifiable, factual descriptions, explanations and predictions based on subjective and objective data). Empirical knowledge is generated and tested by scientific research (Fawcett, Watson, Neuman & Hinton, 2001).
• Personal knowledge, the most fundamental way of knowing, comes from discovery of self, values and morals and lived experience. It involves continuous learning through reflective practice. Reflective practice in community health nursing ombines critical examination of practice, interpersonal relationships and intuition to evaluate, adapt and enhance practice
• Ethics, or moral knowledge, describes the moral obligations, values and goals of community health nursing. It is guided by moral principles and ethical standards set by the Canadian Nurses Association (2002). Ethical inquiry clarifies values and beliefs and uses dialogue to examine the social and political impact of community health nursing on the health environment (Fawcett et al., 2001).
• Socio-political knowledge, or emancipatory knowing, goes beyond personal knowing and nurse-client introspection. It places nursing within the broader social, political and economic context where nursing and health care happen. It equips the nurse to question the status quo and structures of domination in society that affect the health of individuals ancommunities.
Each way of knowing is necessary to understand the complexity and diversity of nursing in the community. By integrating multiple ways of knowing into the practice of community health nursing, the individual nurse becomes a co-creator of nursing knowledge. Critical examination of this nursing knowledge contributes to evidence-based community health nursing practice.
By recognizing diverse evidence for practice, community health nursing is able to question and move beyond the status quo, evolve and create relevant and effective action for community health.
Individual and community partnership
Community health nurses believe that the individual or community must be an active partner in decisions that affect their health and well-being. Their participation is essential throughout the nursing process: to define their own health needs during assessment, set their own priorities among health goals, control the choice and use of various actions to improve their health and lives, and evaluate the efforts made. Community health nurses identify the health values of the individual or community throughout the nursing process, including what health means to that particular individual or community.
Community health nurses work with individuals and communities to build capacity so they can participate in and make decisions about their health. For community health nurses this participation is the basis of therapeutic, professional, caring relationships that promote empowerment. Community health nurses also make their expertise available as a resource to people they work with.
Along with capacity building work, community health nurses have an advocacy role and responsibility. Their knowledge and experience equip them to advocate in partnership with clients who are vulnerable or intimidated in a particular situation and help them to access services (case advocacy). Community health nurses also advocate for changes in policies, systems and resource allocation (class advocacy) to increase opportunities for health within society (Pope, Snyder & Mood, 1995).
Empowerment
Community health nurses recognize that empowerment is an active, involved process where people, groups and communities move towards increased individual and community control, political efficacy, improved quality of community life and social justice.
Empowerment is a community concept because individual empowerment builds from working with others to produce change and wanting increased freedom of choice for others and society. Empowerment is not something that can be done to or for people—it involves people discovering and using their own strengths. Empowering strategies or environments (e.g., healthy workplaces that support flex time or exercise) build capacity by helping individuals, groups and communities discover their strengths and ability to take action to improve their quality of life.
Community health nursing
While community health nursing concepts and competencies are part of the practices of nurses with varied functions and position titles across Canada, these practice standards apply directly to home health and public health nursing. Home health and public health nursing are linked historically through common beliefs, values, traditions, skills and above all their unique focus on promoting and protecting community health. Home health and public health nursing differ in their client and program emphasis.
A home health nurse is a community health nurse who
• combines knowledge from primary health care (including the determinants of health), nursing science and social sciences
• focuses on prevention, health restoration, maintenance or palliation
• focuses on clients, their designated caregivers and their families
• integrates health promotion, teaching and counseling in clinical care and treatment
• initiates, manages and evaluates the resources needed for the client to reach optimal well-being and function
• provides care in the client’s home, school or workplace
• has a nursing diploma or a degree (a baccalaureate degree iursing is preferred)
A public health nurse is a community health nurse who
• combines knowledge from public health science, primary health care (including the determinants of health), nursing science and social sciences
• focuses on promoting, protecting and preserving the health of populations
• focuses on populations and links health and illness experiences of individuals, families and communities to population health promotion practice
• recognizes that a community’s health is closely linked with the health of its members and is often reflected first in individual and family health experiences
• recognizes that healthy communities and systems that support health contribute to opportunities for health for individuals, families, groups and populations
• practices in increasingly diverse settings, such as community health centres, schools, street clinics, youth centres and nursing outposts—and with diverse partners—to meet the health needs of specific populations
• has a baccalaureate degree iursing
The relationship between home health nursing and public health nursing practice is like the shifting lens of a camera. Home health nurses begin with a close-up lens, zooming in and focusing
The five interrelated standards for community health nursing are
1. Promoting health
2. Building individual and community capacity
3. Building relationships
4. Facilitating access and equity
5. Demonstrating professional responsibility and accountability
These standards are based on the values and beliefs of community health nursing, nursing knowledge and partnerships with people in the community. They apply to practice in all settings where people live, work, learn, worship and play.
The values and beliefs ground community health nursing practice in the present and guide its development over time.
The practice standards and community health nursing process reflect community health nursing’s philosophical base and foundational values and beliefs: caring, the principles of primary health care, multiple ways of knowing, individual and community partnerships and empowerment.
The community health nursing process (CHN process)
represents how community health nurses work with people and put the standards into practice. The community health nursing process includes the traditional nursing process components of assessment, planning, intervention and evaluation. Community health nurses enhance this process through
individual or community participation in each component
multiple ways of knowing
awareness of the influence of the broader environment on the individual or community that is the focus of their care (e.g., the community will be affected by provincial or territorial policies, its own economic status and the actions of its individual citizens)
Community health nursing practice does not happen in isolation but within an environmental context (socio-political environment).
It is influenced by social, economic and political forces that shape legislation and public policies. Community health nursing practice is delivered through several agencies such as provincial or municipal departments of health, regional health authorities and non-governmental organizations. Community health nurses are accountable to a variety of authorities and stakeholders (e.g., regulatory bodies, employers and the public). Their practice is influenced by multiple legislative and policy mandates (mostly provincial or territorial iature and both internal and external to their work situation). The organizations community health nurses work for also influence their practice through their organizational structures, processes, values and principles, policies, goals, objectives, standards and outcomes. These diverse influences can be enabling factors, or they may constrain how community health nursing is practiced.
All community health nurses are expected to know and use the following standards of practice:
1. Promoting health
a) Health promotion
b) Prevention and health protection
c) Health maintenance, restoration and palliation
2. Building individual and community capacity
3. Building relationships
4. Facilitating access and equity
5. Demonstrating professional responsibility and accountability
These standards apply to community health nurses working in practice, education, administration or research. The standards set a benchmark for new community health nurses and become basic practice expectations after two years of experience. The practice of expert community health nurses will extend beyond these standards. Each standard applies to the practice of home health nurses and public health nurses—nurses may emphasize different elements of specific standards according to their ractice focus.
Each practice standard contains
• the standard statement
• a description of the standard in the context of community health nursing
• indicators (activities) that show how community health nurses apply and meet this standard
The list of indicators or activities for each standard begins with the heading “The community health nurse.” They are based on the four components of the nursing process—assessment, planning, intervention and evaluation—and provide criteria for measuring the actual performance of an individual nurse. The standards and indicators combine to describe and distinguish the specific practice of community health nursing.
Standard 1: Promoting health
Community health nurses view health as a dynamic process of physical, mental, spiritual and social well-being. Health includes self-determination and a sense of connection to the community.
Community health nurses believe that individuals and communities realize hopes and satisfy needs within their cultural, social, economic and physical environments. They consider health as a resource for everyday life that is influenced by circumstances, beliefs and the determinants of health.
Social, economic and environmental health determinants include:
• income and social status
• social support networks
• education
• employment and working conditions
• social environments
• physical environments
• biology and genetic endowment
• personal health practices and coping skills
• healthy child development
• health services
• gender
• culture
Community health nurses promote health using the following strategies:
(a) health promotion,
(b) prevention and health protection
(c) health maintenance, restoration and palliation
They recognize they may need to use these strategies together when providing care and services. This standard incorporates these strategies from the frameworks of primary health care (World Health Organization, 1978), the Ottawa Charter for Health Promotion (World Health Organization, 1986) and the Population Health Promotion Model (Health Canada, 2000).
Health promotion
Community health nurses focus on health promotion and the health of populations. Health promotion is a mediating strategy between people and their environments. It is a positive, dynamic, empowering and unifying concept based in the socio-environmental approach to health. It recognizes that basic resources and conditions for health are critical for achieving health. The population’s health is closely linked with the health of its members and is often reflected first in individual and family experiences from birth to death. Community health nurses also consider socio-political issues that may be underlying individual and community problems. Healthy communities and systems support increased options for well-being in society.
The community health nurse
1. Collaborates with individual, community and other stakeholders to do a holistic assessment of assets and needs of the individual or community.
2. Uses a variety of information sources to access data and research findings related to health at the national, provincial, territorial, regional and local levels.
3. Identifies and seeks to address root causes of illness and disease.
4. Facillate planned change with the individual, community or population by applying the Population Health Promotion Model.
•Identifies the level of intervention necessary to promote health.
•Identifies which determinants of health require action or change to promote health.
• Uses a comprehensive range of strategies to address health-related issues.
5. Demonstrates knowledge of and effectively implements health promotion strategies based on the Ottawa Charter for Health Promotion.
• Incorporates multiple strategies: promoting healthy public policy, strengthening community action, creating supportive environments, developing personal skills and reorienting the health system.
• Identifies strategies for change that will make it easier for people to make healthier choices.
6. Collaborates with the individual and community to help them take responsibility for maintaining or improving their health by increasing their knowledge, influence and control over the determinants of health.
7. Understands and uses social marketing, media and advocacy strategies to raise awareness of health issues, place issues on the public agenda, shift social norms and change behaviours if other enabling factors are present. 8. Helps the individual and community to identify their strengths and available resources and take action to addresstheir needs.
9. Recognizes the broad impact of specific issues on health promotion such as political climate and will, values and culture, individual and community readiness, and social and systemic structures.
10. Evaluates and modifies population health promotion programs in partnership with the individual, community and other stakeholders.
Prevention and health protection
The community health nurse applies a range of activities to minimize the occurrence of diseases or injuries and their consequences for individuals and communities. Governments often make health protection strategies mandated programs and laws for their overall jurisdictions.
The community health nurse
1. Recognizes the differences between the levels of prevention (primary, secondary, tertiary).
2. Selects the appropriate level of preventive intervention.
3. Helps individuals and communities make informed choices about protective and preventive health measures such as immunization, birth control, breastfeeding and palliative care.
4. Helps individuals, groups, families and communities to identify potential risks to health.
5. Uses harm reduction principles to identify, reduce or remove risk factors in a variety of contexts including the home, neighbourhood, workplace, school and street.
6. Applies epidemiological principles when using strategies such as screening, surveillance, immunization, communicable disease response and outbreak management, and education.
7. Engages collaborative, interdisciplinary and intersectoral partnerships to address risks to individual, family, community or population health and to address prevention and protection issues such as communicable disease, injury and chronic disease.
8. Collaborates on developing and using follow-up systems in the practice setting to ensure that the individual or community receives appropriate and effective service.
9. Practices in accordance with legislation relevant to community health practice (e.g., public health legislation and child protection legislation).
10. Evaluates collaborative practice (personal, team and intersectoral) for achieving individual and community outcomes such as reduced communicable disease, injury, chronic disease or impacts of a disease process.
Health maintenance, restoration and palliation
Community health nurses provide clinical nursing care, health education and counselling to individuals, families, groups and populations whether they are seeking to maintain their health or dealing with acute, chronic or terminal illness. Community health nurses practice in health centres, homes, schools and other community-based settings. They link people to community resources and coordinate or facilitate other care needs and supports. The activities of the community health nurse may range from health screening and care planning at an individual level to intersectoral collaboration and resource development at the community and population level.
The community health nurse
1. Assesses the health status and functional competence of the individual, family or population within the context of their environmental and social supports.
2. Develops a mutually agreed upon plan and priorities for care with the individual and family.
3. Identifies a range of interventions including health promotion, disease prevention and direct clinical care strategies (including palliation), along with short- and long-term goals and outcomes.
4. Maximizes the ability of an individual, family or community to take responsibility for and manage their health needs according to resources and personal skills available.
5. Supports informed choice and respects the individual, family or community’s specific requests while acknowledging diversity, unique characteristics and abilities.
6. Adapts community health nursing techniques, approaches and procedures as appropriate to the challenges in a particular community situation or setting.
7. Uses knowledge of the community to link with, refer to or develop appropriate community resources.
8. Recognizes patterns and trends in epidemiological data and service delivery and initiates strategies for improvement.
9. Facilitates maintenance of health and the healing process for individuals, families and communities in response to significant health emergencies or other community situations that negatively impact health.
10. Evaluates individual, family and community outcomes systematically and continuously in collaboration with individuals, families, significant others, community partners and other health practitioners.
Standard 2: Building individual and community capacity
Building capacity is the process of actively involving individuals, groups, organizations and communities in all phases of planned change to increase their skills, knowledge and willingness to take action on their own in the future. The community health nurse works collaboratively with the individual or community affected by health-compromising situations and with the people and organizations that control resources. Starting where the individual or community is, community health nurses identify relevant issues, assess resources and strengths, and determine readiness for change and priorities for action. They take collaborative action by building on identified strengths and involving key stakeholders such as individuals, organizations, community leaders. They work with people to improve the determinants of health and “make it easier to make the healthier choice.” Community health nurses use supportive and empowering strategies to move individuals and communities toward maximum autonomy.
The community health nurse
1. Works collaboratively with the individual, community, other professionals, agencies and sectors to identify needs, strengths and available resources.
2. Facilitates action in support of the five priorities of the Jakarta
Declaration to:
• promote social responsibility for health
• increase investments for health development
• expand partnerships for health promotion
• increase individual and community capacity
• secure an infrastructure for health promotion
3. Uses community development principles.
• Engages the individual and community in a consultative process.
• Recognizes and builds on the readiness of the group or community to participate.
• Uses empowering strategies such as mutual goal setting, visioning and facilitation.
• Understands group dynamics and effectively uses facilitation skills to support group development.
• Helps the individual and community to participate in the resolution of their issues.
• Helps the group and community to gather available resources to support taking action on their health issues.
4. Uses a comprehensive mix of community and populationbased strategies such as coalition building, intersectoral partnerships and networking to address concerns of groups or populations.
5. Supports the individual, family, community or population to develop skills for self-advocacy.
6. Applies principles of social justice and engages in advocacy to support those who are not yet able to take action for themselves.
7. Uses a comprehensive mix of interventions and strategies to customize actions to address unique needs and build individual and community capacity.
8. Supports community action to influence policy change in support of health.
9. Actively works with health professionals and community partners to build capacity for health promotion.
10. Evaluates the impact of change on individual or community control and health outcomes.
Standard 3: Building relationships
Community health nurses build relationships based on the principles of connecting and caring. Connecting involves establishing and nurturing relationships and a supportive environment that promotes the maximum participation and self-determination of the individual, family and community. Caring involves developing empowering relationships that preserve, protect and enhance human dignity.
Community health nurses build caring relationships based on mutual respect and understanding of the power inherent in their position and its potential impact on relationships and practice.
One of the unique challenges of community health nursing is building a network of relationships and partnerships with a wide variety of relevant groups, communities and organizations. These relationships happen within a complex, changing and often ambiguous environment with sometimes conflicting and unpredictable circumstances.
The community health nurse
1. Recognizes her or his personal beliefs, attitudes, assumptions, feelings and values about health and their potential effect on interventions with individuals and communities.
2. Identifies the individual and community beliefs, attitudes, feelings and values about health and their potential effect on the relationship and intervention.
3. Is aware of and uses culturally relevant communication when building relationships. Communication may be verbal or non-verbal, written or graphic. It may involve face-to-face, telephone, group facilitation, print or electronic methods.
4. Respects and trusts the ability of the individual or community to know the issue they are addressing and solve their own problems.
5. Involves the individual, family and community as an active partner to identify relevant needs, perspectives and expectations.
6. Establishes connections and collaborative relationships with health professionals, community organizations, businesses, faith communities, volunteer service organizations and other sectors to address health-related issues.
7. Maintains awareness of community resources, values and characteristics.
8. Promotes and supports linkages with appropriate community resources when the individual or community is ready to receive them (e.g., hospice or palliative care, parenting groups).
9. Maintains professional boundaries in often long-term relationships in the home or other community settings where professional and social relationships may become blurred.
10. Negotiates an end to the relationship when appropriate (e.g., when the client assumes self-care or when the goals for the relationship have been achieved).
Standard 4: Facilitating access and equity
Community health nurses embrace the philosophy of primary health care. They collaboratively identify and facilitate universal and equitable access to available services. They collaborate with colleagues and with other members of the health care team to promote effective working relationships that contribute to comprehensive client care and optimal client care outcomes.
They are keenly aware of the impact of the determinants of health on individuals, families, groups, communities and populations. The practice of community health nursing considers the financial resources, geography and culture of the individual and community.
Community healths nurses engage in advocacy by analyzing the nants of health and influencing other sectors to ensure their policies and programs have a positive impact on health. Community health nurses use advocacy as a key strategy to meet identified needs and enhance individual and community capacity for self-advocacy.
The community health nurse
1. Assesses and understands individual and community capacities including norms, values, beliefs, knowledge, resources and power structures.
2. Provides culturally sensitive care in diverse communities and settings.
3. Supports individuals and communities in their choice to access alternate health care options.
4. Advocates for appropriate resource allocation for individuals, groups and populations to support access to conditions for health and health services.
5. Refers, coordinates or facilitates access to services in the health sector and other sectors.
6. Adapts practice in response to the changing health needs of the individual and community.
7. Collaborates with individuals and communities to identify and provide programs and delivery methods that are acceptable to them and responsive to their needs across the life span and in different circumstances.
8. Uses strategies such as home visits, outreach and case finding to ensure access to services and health-supportingconditions for potentially vulnerable populations (e.g., persons who are ill, elderly, young, poor, immigrants, isolated or have communication barriers).
9. Assesses the impact of the determinants of health on the opportunity for health for individuals, families, communities and populations.
10.Advocates for healthy public policy by participating in leg islative and policy-making activities that influence health determinants and access to services.
11. Takes action with and for individuals and communities at the organizational, municipal, provincial, territorial and federal levels to address service gaps and accessibility issues.
12.Monitors and evaluates changes and progress in access to the determinants of health and appropriate community services.
Standard 5: Demonstrating professional responsibility and accountability
Community health nurses work with a high degree of autonomy when providing programs and services. Their professional accountability includes striving for excellence, ensuring that their knowledge is evidencebased and current, and maintaining competence and the overall quality of their practice. Community health nurses are responsible for initiating strategies that will help address the determinants of health and generate a positive impact on people and systems.
Community health nurses are accountable to a variety of authorities and stakeholders as well as to the individual and community they serve.
This range of accountabilities places them in a variety of situations with unique ethical dilemmas. One dilemma might be whether responsibility for an issue lies with the individual, family, community or population, or with the nurse or the nurse’s employer. Other dilemmas include the priority of one individual’s rights over the rights of another, individual or societal good, allocation of scarce resources and quality versus quantity of life.
The community health nurse
Takes preventive or corrective action individually or in partnership to protect individuals and communities from unsafe or unethical circumstances.
Advocates for societal change in support of health for all.
Uses nursing informatics (including information and communication technology) to generate, manage and process relevant data to support nursing practice.
Identifies and takes action on factors which affect autonomy of practice and quality of care.
Participates in the advancement of community health nursing by mentoring students and new practitioners.
Participates in research and professional activities.
Makes decisions using ethical standards and principles, taking into consideration the tension between individual versus societal good and the responsibility to uphold the greater good of all people or the population as a whole.
Seeks help with problem solving as needed to determine the best course of action in response to ethical dilemmas, risks to human rights and freedoms, new situations and new knowledge.
Identifies and works proactively—through personal advocacy and participation in relevant professional associations—to address nursing issues that will affect the population.
Contributes proactively to the quality of the work environment by identifying needs, issues and solutions, mobilizing colleagues and actively participating in team and organizational structures and mechanisms.
Provides constructive feedback to peers as appropriate to enhance community health nursing practice.
Documents community health nursing activities in a timely and thorough manner, including telephone advice and work with communities and groups.
Advocates for effective and efficient use of community health nursing resources.
Uses reflective practice to continually assess and improve personal community health nursing practice.
Seeks professional development experiences that are consistent with current community health nursing practice, new and emerging issues, the changing needs of the population, the evolving impact of the determinants of health and emerging research.
Acts upon legal obligations to report to appropriate authorities any situations of unsafe or unethical care provided by family, friends or other individuals to children or vulnerable adults.
Uses available resources to systematically evaluate the availability, acceptability, quality, efficiency and effectiveness of community health nursing practice.
Faith Community Nursing practice is also known as parish or congregational nursing. Regardless of the name used by a faith community to identify the nurse who serves on its ministry staff, the nurse and the practice are guided by the Faith Community Nursing Scope & Standards of Practice published by the American Nurses Association (ANA) . The American Nurses Association is the recognized professional organization for nurses in the United States. ANA sets universal standard for nursing care and professional performance common to all nurses engaged in clinical practice – Standards of Clinical Nursing Practice. Based on the generic standards, the American Nurses Association recognizes specialty nursing practice by identifying the specialty and delineating its unique scope and standards of practice. The Faith Community Nursing Scope & Standards of Practice were developed from the generic standards in cooperation with the Health Ministries Association, Inc., adopted and officially recognized by the ANA in 1998.
Faith Community Nursing practice is an independent practice of professional nursing. It is defined by the jurisdiction’s (Florida) nursing practice act, and focuses on health promotion within the context of the client’s (faith community, family or individual) values, beliefs and faith practices. Based on the Scope and Standards of Parish Nursing Practice, the faith-based nurse maintains standards of care as demonstrated by the nursing process – assessment, diagnosis, planning (outcomes), implementation, and evaluation – to all members of the faith and extended community. And, s/he practices according to the standards of professional performance that describe competencies in a variety of behaviors within the parish nurse role: quality of care, performance appraisal, education, collegiality, ethics, collaboration, research, and resource utilization. Together the standard of care and professional practice define faith-based nursing practice.
Health Ministry
Faith Community Nursing is a part of a broader outreach – health ministry. A health ministry focuses on the health and healing needs of the members of a particular faith community and its extended community. In faith communities people find continuing connectedness, encouragement, hope and love. Health ministries continue this tradition by centering on personal presence, listening and teaching. Examples of health ministries include: visiting the homebound or sick; encouraging healthy lifestyles; providing support – individually or in groups; presenting information on health promotion and disease prevention; monitoring individual concerns/needs; connecting through written or telephone communications; etc. Health ministry is any extension of the faith community that is perceived as caring. It does not require a medical background. Any person can be involved in health ministry. It merely requires a heart for caring, time and training directed toward improved listening skills, therapeutic communications and spiritual presence. Health ministry and parish nursing frequently coexist and sometimes the parish nurse is the staff person responsible for the health ministry outreach.
Faith Community Nursing
Qualifications: Since Faith Community Nursing is an independent practice, the International Parish Nurse Resource Center specifies that the requirements for parish nursing include:
- a minimum of a baccalaureate degree iursing
- five (5) plus years experience in medical surgical nursing
- community assessment skills
- health counseling skills
- Community health experience (preferred)
- Completion of the “standard curriculum for parish nursing” developed by the International Parish Nurse Resource Center. (Programs)
Roles: Parish nurses function within the parameters of seven (7) major roles. These are:
1. Health Educator – focusing on a variety of educational activities for all ages that explore the relationship between values, attitudes, lifestyle, faith and health.
2. Personal Health Counselor – assisting individuals to deal with health issues and problems and may include hospital, home, nursing home, etc. visits.
3. Referral Agent – providing congregational and community resources for healing and wellness.
4. Health Advocate – encouraging all systems (congregant, faith community, primary health resources) to find the best solution for healing and wholeness – body, mind and spirit.
5. Facilitator of Volunteers – recruiting and coordinating resources within the faith community to serve in its various health ministries.
6. Developer of Support Groups – facilitating the development of support groups to meet member needs and those of the external community.
7. Integrator of Faith and Health – seeking, in all activities and contacts, to promote the understanding of the relationship between faith and health.
Job Description: The job description for the faith-based nurse, although common in functions, is fashioned within the parameters of the denomination or faith community it serves. This position is designed to provide whole person health promotion and disease prevention services and spiritual care. The major accountabilities and position activities are listed below. For a more complete description of the accountabilities access the International Parish Nurse Resource Center Information for Parish Nurses.
I. Accountabilities
A. Health Educator
B. Personal Health Counselor
C. Referral Agent
D. Health Advocate
E. Trainer of Volunteers
F. Developer of Support Groups
G. Integrator of Faith and Health
II. Position Activities
A. Management
B. Professional Development
C. Professional Education
D. Research
III. Employment Conditions
A. Hours/week (minimum is 10)
B. Salary (not less than $25/hour)
C. Benefits (may include: holidays, vacation, health insurances, retirement plan, continuing education funds, travel re-imbursement, etc.)
D. Liability Insurance
E. Office environment
F. Budget for program
G. Confidentiality statement
Critical thinking is the disciplined, intellectual process of applying skilful reasoning as a guide to belief or action (Paul, Ennis & Norris). In nursing, critical thinking for clinical decision-making is the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care (Heaslip). Critical thinking when developed in the practitioner includes adherence to intellectual standards, proficiency in using reasoning, a commitment to develop and maintain intellectual traits of the mind and habits of thought and the competent use of thinking skills and abilities for sound clinical judgments and safe decision-making.
Intellectual Standards for Reasoning
Practitioners iursing who are critical thinkers value and adhere to intellectual standards. Critical thinkers strive to be clear, accurate, precise, logical complete, significant and fair when they listen, speak, read and write. Critical thinkers think deeply and broadly. Their thinking is adequate for their intended purpose (Paul, Scriven, Norris & Ennis). All thinking can be examined in light of these standards and as we reflect on the quality of our thinking we begin to recognize when we are being unclear, imprecise, vague or inaccurate. As nurses, we want to eliminate irrelevant, inconsistent and illogical thoughts as we reason about client care. Nurses use language to clearly communicate in-depth information that is significant to nursing care. Nurses are not focused on the trivial or irrelevant.
Nurses who are critical thinkers hold all their views and reasoning to these standards as well as, the claims of others such that the quality of nurse’s thinking improves over time thus eliminating confusion and ambiguity in the presentation and understanding of thoughts and ideas.
Elements of Reasoned Thinking
Reasoning iursing involves eight elements of thought. Critical thinking involves trying to figure out something; a problem, an issue, the views of another person, a theory or an idea. To figure things out we need to enter into the thinking of the other person and then to comprehend as best we can the structure of their thinking. This also applies to our own thinking as well. When I read an author I’m trying to figure out what the author is saying; what problem or issue the author is addressing, what point of view or frame of reference he is coming from, what the goal or purpose is of this piece of writing, what evidence, data or facts are being used and what theories, concepts, principles or ideas are involved. I want to understand the interpretations and claims the author is making and the assumptions that underlie his thinking. I need to be able to follow the author’s lines of formulated thought and the inferences which lead to a particular conclusion. I need to understand the implications and consequences of the author’s thinking. As I come to understand the author in-depth I will also begin to recognize the strength and weakness of his reasoning. I will be able to offer my perspective on the subject at hand with a clear understanding of how the author would respond to my ideas on the subject.
The Elements of Thought
All thinking, if it is purposeful, includes the following elements of thought (Paul, 1990).
1. The problem, question, concern or issue being discussed or thought about by the thinker. What the thinker is attempting to figure out.
2. The purpose or goal of the thinking. Why we are attempting to figure something out and to what end. What do we hope to accomplish.
3. The frame of reference, points of view or even world view that we hold about the issue or problem.
4. The assumptions that we hold to be true about the issue upon which we base our claims or beliefs.
5. The central concepts, ideas, principles and theories that we use in reasoning about the problem.
6. The evidence, data or information provided to support the claims we make about the issue or problem.
7. The interpretations, inferences, reasoning, and lines of formulated thought that lead to our conclusions.
8. The implications and consequences that follow from the positions we hold on the issue or problem.
Wheurses reason they use these elements of thought to figure out difficult questions and recognize that their thinking could be flawed or limited by lack of in-depth understanding of the problem at issue therefore, they critically monitor their thinking to ensure that their thinking meets the standards for intellectual thought.
In summary, as a critical thinker, I am able to figure out by reading or listening critically what nurse scholars believe about nursing and on what basis nurses act as they practice nursing. To do this I must clearly comprehend the thinking of another person by figuring out the logic of their thinking. I must comprehend clearly the thinking of myself by figuring out my own thoughts on the subject at hand. Finally, I must use intellectual standards to evaluate my thinking and the thinking of others on a given problem such that I can come to a defensible, well reasoned view of the problem and therefore, know what to believe or do in a given circumstance. To do this I must be committed to developing my mind as a self-directed, independent critical thinker. I must value above all else the intellectual traits and habits of thought that critical thinkers possess.
Intellectual Traits and Habits of Thought
To develop as a critical thinker one must be motivated to develop the attitudes and dispositions of a fair-minded thinker. That is, one must be willing to suspend judgments until one truly understands another point of view and can articulate the position that another person holds on an issue. Nurses come to reasoned judgments so that they can act competently in practice. They continually monitor their thinking; questioning and reflecting on the quality of thinking occurring in how they reason about nursing practice. Sloppy, superficial thinking leads to poor practice.
Critical inquiry is an important quality for safe practice. Nurses must pose questions about practice and be willing to attempt to seek answers about practice. Nurses must be willing to attempt to seek answers to the difficult questions inherent in practice, as well as the obvious. Question posing presupposes intellectual humility and a willingness to admit to one’s areas of ignorance as well as, intellectual curiosity and perseverance and willingness to seek answers. Critical thinkers iursing are truth seekers and demonstrate open-mindedness and tolerance for others’ views with constant sensitivity to the possibility of their own bias.
Nurse’s who are critical thinkers value intellectually challenging situations and are self-confident in their well reasoned thoughts. To reason effectively, nurses have developed skills and abilities essential for sound reasoning.
Critical Thinking Skills and Abilities
Critical thinkers iursing are skilful in applying intellectual skills for sound reasoning. These skills have been defined as information gathering, focusing, remembering, organizing, analyzing, generating, integrating and evaluating (Registered Nurse’s Association of British Columbia, 1990). The focus of classroom and clinical activities is to develop the nurse’s understanding of scholarly, academic work through the effective use of intellectual abilities and skills. As you encounter increasingly more complex practice situations you will be required to think through and reason about nursing in greater depth and draw on deeper, more sophisticated comprehension of what it means to be a nurse in clinical practice. Nursing is never a superficial, meaningless activity. All acts in nursing are deeply significant and require of the nurse a mind fully engaged in the practice of nursing. This is the challenge of nursing; critical, reflective practice based on the sound reasoning of intelligent minds committed to safe, effective client care.
To accomplish this goal, students will be required to reason about nursing by reading, writing, listening and speaking critically. By doing so you will be thinking critically about nursing and ensuring that you gain in-depth knowledge about nursing as a practice profession.
Critical Thinking…a Holistic Approach
Critical Listening: A mode of monitoring how we are listening so as to maximize our accurate understanding of what another person is saying. By understanding the logic of human communication – that everything spoken expresses point of view, uses some ideas and not others, has implications, etc., critical thinkers can listen so as to enter empathetically and analytically into the perspective of others.
Critical Thinking: 1) Disciplined, self-directed thinking which implies the perfection of thinking appropriate to a particular mode or domain of thinking. 2) Thinking that displays master of intellectual skills and abilities. 3) The art of thinking about your thinking while you are thinking in order to make your thinking better: more clear, more accurate, or more defensible.
Critical Writing: To express oneself in languages required that one arrange ideas in some relationships to each other. When accuracy and truth are at issue, then we must understand what our thesis is, how we can support it, how we can elaborate it to make it intelligible to others, what objections can be raised to it from other points of view, what the limitations are to our point of view, and so forth. Disciplined writing requires disciplined thinking; disciplined thinking is achieved through disciplined writing.
Critical Reading: Critical reading is an active, intellectually engaged process in which the reader participates in an inner dialogue with the writer. Most people read uncritically and so miss some part of what is expressed while distorting other parts. A critical reader realizes the way in which reading, by its very nature, means entering into a point of view other than our own, the point of view of the writer. A critical reader actively looks for assumptions, key concepts and ideas, reasons and justifications, supporting examples, parallel experiences, implications and consequences, and any other structural features of the written text to interpret and assess it accurately and fairly. ( Paul, 1990, pp 554 & 545 )
Critical Speaking: Critical speaking is an active process of expressing verbally a point of view, ideas and thoughts such that others attain an in-depth understanding of the speaker’s personal perspective on an issue. Monitoring how we express ourselves verbally will ensure that we maximize accurate understanding of what we mean through active dialogue and openness to feedback on our views. (Heaslip, 1993).
Wellness is generally used to mean a healthy balance of the mind, body and spirit that results in an overall feeling of well-being.
The term has been defined by the Wisconsin-based National Wellness Institute as an active process of becoming aware of and making choices toward a more successful existence. This is consistent with a shift in focus away from illness in viewing human health, typical of contexts where the term wellness is used. In other words, wellness is a view of health that emphasizes the state of the entire being and its ongoing development.
Achieving or maintaining wellness could be determined by individual awareness and ability to measure states of health including mental health, physical activity, nutritional intake, fiscal responsibility, productivity, as well as emergency preparedness and avoiding common pitfalls. Wellness can also be described as a state that combines health and happiness. Thus, those factors that contribute to being healthy and happy will also likely contribute to being well. Factors that contribute to health and happiness have long been recognized, at least since the time of Ancient Greeks. To achieve a state of wellness, one has to work on its determinants. The determinants of wellness are often considered to be: awareness and the initiative to improve one’s state of physical, mental, emotional, spiritual, environmental, social and/or occupational health.
Wellness programs vary depending on the target market and who is promoting them. Wellness programs are most commonly promoted in progressive companies and schools along with personal wellness programs marketed directly to health seeking individuals. Wellness programs attempt to facilitate life improvements though recommending positive lifestyle changes. Wellness programs are often pursued by people seeking recovery from an illness or specific health condition or by those interested in improving their overall health.
Supporters of wellness programs may claim there are many factors that contribute to wellness: living in a clean environment, eating healthy food, regular physical exercise, balance in career; family; and relationships, spiritual awareness and some programs include faith-based worship. Faith-based wellness programs may suggest a spiritual component in their models, however, it would be opposition to most secular wellness programs which tend to be inclusive any individual’s spiritual beliefs or practices.
The aging population participates in wellness programs in order to feel better and have more energy. Wellness programs allow individuals to take increased responsibility for their health behaviors. People often enroll in a private wellness program to improve fitness, stop smoking, or to learn how to manage their weight.
Workplace wellness programs are recognized by more and more companies for their value in improving health and well-being of their employees. They are part of a company’s health and safety program. These wellness programs are designed to improve employee morale, loyalty, and productivity. They could consist of as little as a gym full of exercise equipment that is available to their employees on company property during the workday. But they may also cover smoking cessation programs, nutrition; weight; or stress management training, nature and outdoors activities, health risk assessments, and health screenings.
How do you develop a workplace health and wellness program for the workplace?
Workplace health and wellness programs should be a part of the overall company strategy for a healthy workplace. Health and safety legislation and other workplace policies or programs can provide a basis for a workplace health (or health promotion) program. When setting up any program, remember to include training and other support (e.g., time to attend sessions) and choices where possible.
Remember that for health and safety programs, there are specific laws and regulations that must be complied with. Workplace health programs are a different from traditional health and safety programs because there is no legislative mandate. However, the purpose of a workplace health and wellness program is to offer a comprehensive health service for all employees. Therefore it is important to remember that employees are potentially exposed to a wide variety of health hazards or situations at work on a regular basis. As such, it is impossible to deal with workplace health / wellness issues in isolation from health and safety, and vice versa.
What are some key elements of a workplace health program?
When planning the workplace health program, remember to be clear about your:
· Objectives: know what you want to see happen as a result of your efforts.
· Target audience: who is the program for? All staff? Only certain groups?
· Type of program or campaign: what tone will your program have? Informative? Fun? Fearful?
Should a workplace health committee be established?
Generally, a joint labour/management committee is recommended. A committee has the advantage of being able to work with key groups at your organization, including the health and safety committee.
How do you implement your program?
There are a few steps that an organization should follow when developing a workplace health and wellness program for the workplace. When planning to implement your program, one should recognize that every organization is different and therefore everyone’s needs may vary too.
What are the steps?
Step 1: Take ownership and leadership and get support from the “top”.
Have someone who is interested in taking on the role and being the contact point of the program. It may be a joint committee from labour and management or someone who wants to take interest in leading the project.
Like any policy, it will not be successful without support from senior management. After recognizing that this program presents an investment, it will make a difference when getting support from senior management.
Step 2: Get support from everyone.
Talk to as many people or groups as you can. Other people who can help, if they are not involved already, include:
· Union / worker representatives,
· Management,
· Health and safety professional(s),
· Human resources professional(s),
· Your employee assistance program (EAP) provider,
· Medical or occupational health staff, and
· Local groups from your community who may be able to help include:
o Public Health,
o Canadian Cancer Society, and
o Heart and Stroke Foundation of Canada.
Step 3: Acknowledge current or informal activities and collect baseline data.
There may be groups already established in many companies and may help you form a basis for your workplace active living program. Acknowledging these existing activities (for example, a group of people going for walks together at lunch) may encourage new ideas for your program, like a ‘walkers mileage club’. Where everyone is encouraged to walk a little, but awarded with a points system that over a certain period those are awarded or acknowledged when attaining the most points.
Step 4: Identify the key needs and expectations of the workplace.
You want to find out the employees:
· needs,
· attitudes, and
· preferences.
regarding specific aspects of implementing a workplace health program. You can survey employees with:
· a full-length survey (can be confidential),
· an open one-to-one interview,
· a mini-survey, or
· suggestion boxes placed around the organization.
You can also conduct surveys by:
· hosting a luncheon round table meeting,
· sending out an informal email questionnaire,
· sending a survey with pay cheque stubs, or
· conducting a survey available on your organizations intranet site.
It is crucial in finding out the needs of your audience before designing your program or policy.
Step 5: Develop a detailed plan.
Based on steps one to four:
· Identify what needs to be done.
· Prioritize these needs.
· Set realistic targets and timelines. Have both short-term and long-term goals.
· Plan how and when the program will be initiated.
· Plan how to maintain interest.
· Know what resources you need for each step (time, money, people, etc.).
When delivering your program, make sure you organize your activities into such as:
· Education / Awareness – providing knowledge.
· Skill building – getting individuals actively involved in changing their behaviour.
· Work Environment – changes in the workplace to support the initiative.
Step 6: Put your plan into action.
Now it is time to communicate your program to everyone. Promoting your program can be done in many ways such as:
· posters around the workplace,
· postings on your organizations intranet or internet,
· bulletin boards,
· management telling employees about the program (i.e. manager and HR department),
· host demo days,
· flyers / pamphlets / brochures,
· kiosk where all material is promoted or found,
· exhibition fairs, and
· e-mail or mail
Formally introducing corporate policies that state the importance of the workplace health program are an additional essential step.
Step 7: Monitor, evaluate and maintain the program.
Now it is time to monitor, progress and track results of your program. Always know that there is room for change and improvement for both short-term and long-term goals. Make sure you:
Review and Evaluate your program:
· A review of the program can help you know what is working and what is not. Gathering the right information is essential but it does not have to be complicated. Be sure to take baseline data so you can compare results of later programs.
· When reviewing the outcomes, remember to evaluate the program based on the aims and objectives you set in the beginning.
Maintain the Program:
· Use the results of your review and evaluation to help gauge what is working and what could be enhanced.
