Lect. 9 Roles and Functions of the Community Health Nurse

TERNOPIL STATE MEDICALUNIVERSITY

INSTITUTEOF NURSING

DEPARTMENT nOF CLINICAL nIMMUNOLOGY, ALLERGOLOGY

AND nGENERAL PATIENT CARE

 

Lecture 9

 

Roles and nFunctions of the Community Health Nurse

 

 

 

After studying this chapter, you should be able to:

 

·        nDescribe the role of the CHN as nClinician, Collaborator, Manager , and Leader as he/she works in communities with nother health care providers

·        nDescribe the role of the CHN as nEducator, Advocate, and Researcher in his/her Community

 

 

Introduction

 

 

Role and nFunctions of the Community Health Nurse

 

  nCommunity health nurses have nalways practiced in a wide variety of settings and assumed various roles. Ithis topic, the seven major roles and six of the most common settings for CHN npractice are examined.

 

The seven major roles are:

• clinician

• educator

• advocate

• manager

• collaborator

• leader

• researcher

n

 

Clinician

The role of the clinician or care provider is a familiar one for most npeople. In community health the clinician views clients in the context of nlarger systems. The family or group must be considered in totality. The ncommunity health nurse provides care along the entire range of the nwellness-illness continuum; however, promotion of health and prevention of nillness are emphasized. Skills in observation, listening, communication, counselling, nand physical care are important for the community health nurse. Recent concerns nfor environment, sociocultural, psychological, and neconomic factors in community health have created a need for stronger skills iassessing the needs of populations at the community level.

 

Educator

One of the nmajor functions of the community health nurse is that of health educator. As neducators, nurses seek to facilitate client learning on a broad range of ntopics. They may act as consultants to individuals or groups, hold formal nclasses, or share information informally with clients. Self-care concepts, ntechniques for preventing illness, and health promotion strategies are nemphasized throughout the health teaching process.

A nurse educator is a nurse who teaches nand prepares licensed practical nurses (LPN) and registered nnurses (RN) for entry into practice positions. Nurse Educators also nteach in graduate programs at Master’s and doctoral level which prepare advanced practice nurses, nurse educators, nnurse administrators, nurse nresearchers, and leaders in complex healthcare and educational norganizations.

Nurse educators ncombine clinical expertise and a passion for teaching into rich and rewarding ncareers. These professionals, who work in the classroom and the practice nsetting (hospital setting or community setting), are responsible for preparing and nmentoring current and future generations of nurses. Nurse educators play a npivotal role in strengthening the nursing workforce, serving as role models and nproviding the leadership needed to implement evidence-based practice. Nurse neducators are responsible for designing, implementing, evaluating and revising nacademic and continuing education programs for nurses. These include formal nacademic programs that lead to a degree or certificate, or more informal ncontinuing education programs designed to meet individual learning needs.

Nurse educators nare critical players in assuring quality educational experiences that prepare nthe nursing workforce for a diverse, ever-changing health care environment. nThey are the leaders who document the outcomes of educational programs and nguide students through the learning process. Nurse educators are prepared at nthe master’s or doctoral level and practice as faculty in colleges, nuniversities, hospital-based schools of nursing or technical schools, or as nstaff development educators in health care facilities. They work with recent nhigh school graduates studying nursing for the first time, nurses pursuing nadvanced degrees and practicing nurses interested in expanding their knowledge nand skills related to care of individuals, families and communities. Nurse neducators often express a high degree of satisfaction with their work. They ntypically cite interaction with students and watching future nurses grow iconfidence and skill as the most rewarding aspects of their jobs. Other benefits nof careers iursing education include access to cutting-edge knowledge and nresearch, opportunities to collaborate with health professionals, aintellectually stimulating workplace and flexible work scheduling. Given the ngrowing shortage of nurse educators, the career outlook is strong for nurses ninterested in teaching careers. Nursing schools nationwide are struggling to nfind new faculty to accommodate the rising interest iursing among new nstudents. The shortage of nurse educators may actually enhance career prospects nsince it affords a high level of job security and provides opportunities for nnurses to maintain dual roles as educators and direct patient care providers

A nurse educator nis a registered nurse who has advanced education, including advanced clinical ntraining in a health care specialty. Nurse educators serve in a variety of nroles that range from adjunct (part-time) clinical faculty to dean of a college nof nursing. Professional titles include Instructional or Administrative Nurse nFaculty, Clinical Nurse Educator, Staff Development Officer and Continuing nEducation Specialist among others. Nurse educators combine their clinical nabilities with responsibilities related to: Designing curricula developing ncourses/programs of study Teaching and guiding learners evaluating learning ndocumenting the outcomes of the educational process.

Nurse educators nhave the unique opportunity to share their clinical expertise in educational nsettings to shape the next generation of nurses. Current faculty indicates that nthe most positive aspect of their role is the interaction with students. nNursing faculty may also engage in scholarly inquiry that will further nilluminate the nature of teaching and learning and will ultimately shape future neducational processes and outcomes

 

Advocate

 In health care the concept of nadvocacy has become increasingly important over recent years as consumers ndemand better quality, more responsiveness and easier access to such services. The nrise of consumerism through every walk of life has had its influence oexpectations of health care, and there is an increasing demand for nuser-empowerment and public accountability for services.

Two underlying goals in client advocacy are described. One goal of the ncommunity health nurse as advocate is to help clients find out what services nare available, which ones they are entitled to, and how to obtain these services. nA second goal is to influence change and make the system more relevant and nresponsible to clients’ needs.

 

“Nurses must transmit the values of the nursing profession to society, nin order that society may change in accord with these values”

(Fowler, 1989, p n98)

 

Four characteristics required nfor successful advocacy are:

• assertiveness

• willingness to take risks

• good communication and negotiation skills

• ability to identify resources and obtai results

n

 

Advocacy has been defined nand implemented in many different ways, the major concepts include citizeadvocacy; self-advocacy; collective or class advocacy; legal advocacy; and the nfocus of this paper, the nurse at patient-advocate. The advocate may be the nperson themselves (self-advocacy); an appointed official employed by a service norganisation; an independent person or “befriender“; nan “expert” (e.g., legal advocate), or a professional who works nclosely with the person (such as the nurse as advocate). In any of these ndifferent forms and interpretations of advocacy, the nature of the act, the nrelationship involved, and the goals and outcomes are likely to differ nsignificantly. This proposed is concerned with the nurse acting as the npatient’s advocate within his or her professional role, and other formulations nare therefore excluded.

Superficially, aadvocate may be considered to be one who will always be acting in the person’s n”best interest” whatever that might be, and concerned with doing n”good”, however closer examination of the ethical basis of advocacy nsuggests that this is a simplistic and perhaps inaccurate portrayal of the nrole.

Iursing, the concept of the nnurse as the patient’s advocate has been a familiar one for a considerable time; nit is implied in various nursing codes (e.g., ANA, 1985; UKCC, 1984 & 1992).

There has been a commoassumption that advocacy is a major role for the nurse (Marks-Maran, 1993) and for some, advocacy is definitive of nnursing (e.g., Gadow, 1980, 1990) or as Murphy (1983) nstates “the highest order nursing act…” Others, (e.g., nMiller etal, 1983; Trandel-Korenchuk, n1983) however argue that nurses cannot act effectively as advocates because of ntheir duties and loyalties to their employers, and the medical profession.

Some nurses who have ntaken their advocacy role to its full extent have often found themselves iconflict with their employers, other professionals or even their peers whethey pursue issues on the behalf of their patients. In some instances (for nexample Graham Pink, cited by Snell, 1991) this has ultimately lead to ndisciplinary action and dismissal, even though the nurses professional body had njudged that they had not acted outside of their professional code of conduct. nSupport for advocacy and patient advocates may therefore be more theoretical nthan actual, and an appreciation of this situation may well inhibit other nurses nfrom full realisation of the patient advocacy role. The dilemmas posed for nnurses considering this role are therefore significant. It is arguable that for nmany nurses advocacy is acknowledged and implemented only within certain limits nand boundaries, and it is suggested that nurses often curtail or modify their nadvocacy activities when conflict with powerful authority figures, within or nwithout nursing, appears to be likely.

 

Models of advocacy:

 

 

The advocate as guardiaof patient’s rights

 

This model of advocacy nhas some parallel with the legalistic definition given above. It is based othe premise that the nurse is able to inform the patient of their rights, and ncan then enable them to exercise those rights, or intervene to ensure that ntheir rights are respected (Gillette, 1988). Gates (1994) definition of nadvocacy could be seen as fitting within this model.

Criticisms of this model nare that the nurse-patient relationship is not conceived in these terms by neither party, and the nurse is not the best skilled or equipped to fulfil this nrole (Fowler, 1989; Melia, 1987). The legalistic or npatient’s rights model may be too narrow a conception to deal with everyday nproblems experienced by patients and their nurses, for example, treatment and ncare decisions are rarely as clear-cut as being supported by claiming a right.

Also this perspective tends to npre-suppose a confrontational stance that may prevent nurses from taking aadvocacy role.

 

The advocate as nconservator of the patient’s best interests

 

The idea that the nadvocate should be involved in helping the patient receive care or make decisions nthat are in his or her best interests would at first consideration seem nunarguable. The great difficulty with this approach is deciding what the npatient’s best interests are, and by whose definition?

Paternalism, described by Gadow (1983) may often be the rationale or motive behind n”best interest” decisions. Paternalism is defined by Gadow as:

 

“The use of coercion to provide a good that nis not desired by the one whom it is intended to benefit”

                                                                          n(Gadow, n1983, p 43)

 

The advocate as nconservator of the patient’s best interests

 

An example of this might nbe the patient who is persuaded to continue with aggressive treatment of nterminal illness because they have a theoretical chance of survival. In such aexample “good” provided (i.e. potential cure) is defined according to nthe nurse’s or physician’s values based on cure (Gadow, n1989), however “good” for the patient may relate much more to the ncare experience in such a situation. In this instance, advocacy as paternalism ncannot be defended as offering benefit in relation to the patient’s values, and nit also negates the principle of self-determination. The nurse’s actions may be nguided by “beneficence” (to do well) or “utilitarianism” n(actions that are judged by their social utility, or that offer the greatest ngood to the greatest number of people (Harman, 1977). The outcomes derived may nnot coincide with the patient’s self-determined best interests.

 

The advocate as nprotector of patient’s autonomy

 

Kohnke (1982) is a proponent of this model of advocacy, and nidentifies two principle tasks for the nurse, informing and supporting. nInforming involves providing sufficient information for making informed ndecisions about health care, and the supporting task which is concerned with nreinforcing and upholding the patient’s decision.

This model, however noffers little assistance for the nurse caring for patients who are unable to ncommunicate or make informed decisions, and the justification of action (or nnon-action) based on the client’s right to self-determination may often bring nthe nurse into conflict with other ethical and legal considerations. Also, nQuinn & Smith (1987) argue that respect for autonomy does not presume that nthe individual will make the best or even safe decisions for themselves, and nthere is much evidence in daily life that individuals do not do so, although it npossible to make arguments such as that a decision to commit a n”dangerous” act, say for example misuse of drugs, may be in the npersons “best interests” given their own value system. Gadow (1979, 1983, and 1989) is a significant contributor nto the advocacy literature with her concept of “Existential Advocacy“. nShe proposes this concept as the philosophical

 

The advocate as nprotector of patient’s autonomy

 

Kohnke (1982) is a proponent of this model of advocacy, and nidentifies two principle tasks for the nurse, informing and supporting. nInforming involves providing sufficient information for making informed ndecisions about health care, and the supporting task which is concerned with nreinforcing and upholding the patient’s decision.

This model, however noffers little assistance for the nurse caring for patients who are unable to ncommunicate or make informed decisions, and the justification of action (or nnon-action) based on the client’s right to self-determination may often bring nthe nurse into conflict with other ethical and legal considerations. Also, nQuinn & Smith (1987) argue that respect for autonomy does not presume that nthe individual will make the best or even safe decisions for themselves, and nthere is much evidence in daily life that individuals do not do so, although it npossible to make arguments such as that a decision to commit a n”dangerous” act, say for example misuse of drugs, may be in the npersons “best interests” given their own value system. Gadow (1979, 1983, and 1989) is a significant contributor to nthe advocacy literature with her concept of “Existential Advocacy“

 

The advocate as a nchampion of social justice

 

 This view of advocacy as Fowler suggests, takes the nurse’s role as aadvocate from the patient’s bedside to beyond the institutional walls (1989, p n98). There may be an element of advocacy for individual patients, but the focus nis on social and political change to deal with inequities and inequalities iprovision of care at both macro’ and micro-allocation levels.

 

Manager

 

 The manager’s role is common to all nurses. Nurses serve as managers whethey oversee client care, supervise ancillary staff, do case management, ruclinics and conduct community health needs assessment projects. The nurse nengages in four steps of the management process of planning, organizing, nleading and controlling evaluation. Each of these functions is described in the ntext. Specific decision-making behaviours are part of the manager’s role as nwell as human, conceptual and technical skills.

The nNurse Manager plays an essential role in healthcare. She sets the tone of any nHealthcare System. The Manager is the backbone of the organization. The quality nof patient care, as well as staff recruitment and retention success, rests with nthis key role. Over time it will be the strength of the nurse manager group nthat determines the success or failure of nursing leadership, the COO, and evethe CEO.

And nyet it is rare that nurse managers are given the opportunity to acquire the noperational, financial, and management skills essential to their success – and nthe success of their organization.

As ncritical as it is to develop those concrete and pragmatic skills noted above, nthere is also a delicate subtle art to being a Nurse Manager… to balancing nthe tensions between quality and cost … to dealing with multiple nstakeholders, presenting conflicting agendas … to dealing with stress and npressure every day …to implementing processes needed to ensure that nindividualized compassionate care is provided consistently in the most nefficient and effective manner possible…and we show you a system to succeed.

There are three keys to succeeding as a nNurse Manager

 

·        nA Complete and nComprehensive Understanding of the Nurse Manager Role and Access to Best nPractices

·        nA Comprehensive System for nSuccess;

·        nA Toolkit to Succeed

 

 

 

n

Description:	The goal of a nurse manager is to facilitate and deliver quality nursing care as well as to coordinate and manage the environment in which the care is delivered. The first-line manager/head nurse assumes responsibility for the personnel, resources, and patient care on a nursing unit. A nurse supervisor is often responsible for several nursing units or all units for a particular function such as staffing or a shift, such as night supervisor. A manager directs and promotes the development of nursing staff assigned to the unit. Nurse administrators establish and control the budget and support the implementation of standards of nursing practice and guidelines of care
Settings:	Hospitals, long-term care, ambulatory care, or community/public/home health agencies
Characteristics:	Personal satisfaction, power, recognition, prestige, and economic gain; opportunities for promotion
Drawbacks:	Scope of responsibility, pressures of competition, hard work, and high degree of flexibility; consumer issues, economy, politics, manpower, and technology
Desirable skills:	Fact finding, analyzing, advice seeking, listening, negotiating, and collaborating; risk-taking, tolerance for ambiguity, assertiveness, self-reliance, and achievement orientation; human relations, coaching, and compassionate approach
Education:	RN with BSN, MSN, or doctorate

 

Collaborator

 

 Collaboration with clients, other nurses, physicians, social workers, nphysical therapists, nutritionists, attorneys, secretaries, and other ncolleagues is part of the role of the community health nurse. Collaboration is ndefined as working jointly with to hers in a common endeavour to cooperate as npartners.

 

Skills required for successful collaboration are

 

·        nCommunicatioskills,

·        nAssertiveness, n

·        nConsultant nskills.

 

 

Leader

 

 

The role of leader is distinguished from the role of manager. As a leader, nthe community health nurse directs, influences, or persuades others to effect nchange that will positively affect people’s health. Acting as a change agent nand influencing health planning at the local, state and national levels are elements nof the role of the leader.

 

Characteristics nof an Effective Leader

A good leader nmust be:

• A lifelong nlearner

• A good ncommunicator with effective interpersonal skills

• Able to look nat the whole picture

• A good nteacher

• Able to nfoster growth in others by mentoring and providing opportunities

• A model for neffective change

• Accountable

• A nproblem-solver

• A promoter nof collaboration

• nKnowledgeable in area of expertise

• nGoal-oriented

• A person who nseeks opportunities for growth

• Open-minded

• A good time nmanager

• Able to nremain calm when everyone else is not

 

 

Researcher

 

In the role of researcher, community health nurses nengage in systematic investigation, collection, and analysis of date to enhance ncommunity health practice Research in community health may range from simple ninquiries to complex agency or organizational studies. Attributes of a nurse nresearcher include a questioning attitude, careful observation, nopen-mindedness, analytical skills, and tenacity.

 

n

Description:	Involves all aspects of working with pharmaceutical/medical/nursing research
Practice roles:	Clinical data coordinator, clinical research assistant, clinical research monitor, research assistant
Characteristics:	Opportunity to be part of groundbreaking studies, projects
Drawbacks:	Some work is temporary or part time, travel may be required, work can be tedious. Position may rely on availability of grant money
Desirable skills:	Strong observation and analytical skills, detail-oriented. Grant writing experience helpful in some situations
Education:	Varies. BS may be required. Some positions may require MS or higher. Advanced nursing research usually requires PhD
Employers:	Pharmaceutical companies, contract research organizations, teaching and university hospitals, educational institutions, temporary technical placement agencies

 

 

Typical functions:

 

 

The functions performed by nemployees in this job family will vary by level, but may include the following:

·     · nAssesses health status of individuals, families, and communities; develops nplans and implements appropriate nursing interventions.

·     · nEvaluates and determines health resources necessary to meet individual, family nand community health needs.

·     · nDelivers professional nursing care in an assigned unit, clinic, home, or other nsetting.

·     · nEducates individuals, families, communities, and members of the health care nteam about the principles of disease prevention and health promotion.

·     ·Provides nsupervision to other professional or paraprofessional personnel; collaborates nwith other professionals in the management of health care.

·     · nDelegates tasks as may safely be performed by others, consistent with neducational preparation and that do not conflict with the provisions of the nOklahoma Nursing Practice Act.

·     · nAssures quality health care through use of various measures such as record nreview, peer review, direct observation, and assessment of individual, family, nand community for the desired outcome.

·     · nPerforms specialized nursing functions as educationally prepared.

 

 

The role of the nurse needs to be expanded to include nprotection of women’s reproductive potential. Nursing has adjusted to the nchange in medical care through assistance in regaining of health in acute and nextended care facilities, in health maintenance, and in acting as primary care nproviders in providing information on prevention. Infertility increases with nage. The impact of contraceptive choices on fertility is reviewed for barrier ncontraception, oral contraception, IUDs, sterilization, and new contraceptive nmethods. At different stages in the life cycle there are methods of ncontraception that are more appropriate than others. The environmental effects non fertility are noted for diethylstilbestrol (DES), which may result in cell ncarcinoma and changes in the cervical ectropion, nuterine, and tubal anomalies; these effects in turmay lead to decreased fertility or fetal loss. DES nmay also affect male fertility. Chemicals in the workplace such as lead, nionizing radiation, ethylene oxide, and dibromochloropropane nare federally regulated because of deleterious effects on reproduction. Other nmetals and chemicals that may affect fertility are indicated. The prevention of nsexually transmitted diseases has a significant impact on preservation of nfertility. Life style choices and counseling at early nstages of disease are important considerations. Women who smoke have an earlier nmenopause, have reduced estrogen levels, and increased nvaginal bleeding. Infant mortality is higher among women who smoke. Fetal alcohol syndrome is known, but alcohol’s effect ofertility is not well documented. Adolescent drug use may lead to later ndysfunction. Marijuana use in adults has been related to decreased levels of nfollicle stimulating hormone, luteinizing hormone, nand prolactin, which appears to be reversible iadults. Exposure to high levels of heat is related to male infertility (sperm nquality and number); increased scrotal temperature may be caused by febrile nillness, varicocele, hot tub usage, and tight jockey nshorts. Fertility impairment may be related to a previous medical or surgical nintervention. Options are available for organ preservation rather than outright nremoval. General health conditions related to infertility are identified. The nnurse practitioner as a preconception counselor may nscreen for potential infertility and collect a routine history and physical nexamination including testing.

 

 

References

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·        nKerfoot, K. (2001). The Leader as Synergist. MEDSURG nNursing, 10(2), 101-103.

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·        nPorter-O’Grady, nT. (1997). Quantum Mechanics and the Future of Healthcare Leadership. Journal nof Nursing Administration, 27(1), 15-20.

·        nPorter-O’Grady, nT. (1999). Quantum Leadership: New Roles for a New Age. Journal of Nursing nAdministration, 29(10), 37-42.

·        nSinghapattanapong, S. (2002, March 11). Nurse shortage hurts UCLA MedicalCenter. nUCLA Daily Bruin, p.1.

·        nSofarelli M.. & Brown, R. (1998). nThe need for nursing leadership in uncertain times. Journal of Nursing Management, 6(4), n201-207.

·        nSullivan, E.J. & Decker, P.J. (2001). Effective nLeadership and Management in Nursing (5^th ed.). nUpper Saddle River, NJ: Prentice Hall.