DEPARTMENT
OF CLINICAL IMMUNOLOGY, ALLERGOLOGY
AND
GENERAL PATIENT CARE
Roles and Functions of the Community Health Nurse
After studying this
chapter, you should be able to:
·
Describe the role
of the CHN as Clinician, Collaborator, Manager , and Leader as he/she works in
communities with other health care providers
·
Describe the
role of the CHN as Educator, Advocate, and Researcher in his/her Community
Introduction
Role and Functions of the Community Health
Nurse
Community
health nurses have always practiced in a wide variety of settings and assumed
various roles. In this topic, the seven major roles and six of the most common
settings for CHN practice are examined.
The seven major roles are:
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clinician
·
educator
·
advocate
·
manager
·
collaborator
·
leader
·
researcher
Clinician
The role of the clinician or care provider is a
familiar one for most people. In community health the clinician views clients
in the context of larger systems. The family or group must be considered in
totality. The community health nurse provides care along the entire range of
the wellness-illness continuum; however, promotion of health and prevention of
illness are emphasized. Skills in observation, listening, communication,
counselling, and physical care are important for the community health nurse.
Recent concerns for environment, sociocultural, psychological, and economic
factors in community health have created a need for stronger skills in assessing
the needs of populations at the community level.
Educator
One of the major functions of
the community health nurse is that of health educator. As educators, nurses
seek to facilitate client learning on a broad range of topics. They may act as
consultants to individuals or groups, hold formal classes, or share information
informally with clients. Self-care concepts, techniques for preventing illness,
and health promotion strategies are emphasized throughout the health teaching
process.
A nurse educator
is a nurse who teaches and prepares licensed practical nurses (LPN) and registered
nurses (RN) for entry into practice positions. Nurse Educators also
teach in graduate programs at Master’s and doctoral level which prepare advanced practice nurses, nurse educators,
nurse administrators, nurse
researchers, and leaders in complex healthcare and educational
organizations.
Nurse educators combine clinical expertise and a passion for teaching into
rich and rewarding careers. These professionals, who work in the classroom and
the practice setting (hospital setting or community setting), are responsible
for preparing and mentoring current and future generations of nurses. Nurse
educators play a pivotal role in strengthening the nursing workforce, serving
as role models and providing the leadership needed to implement evidence-based
practice. Nurse educators are responsible for designing, implementing,
evaluating and revising academic and continuing education programs for nurses.
These include formal academic programs that lead to a degree or certificate, or
more informal continuing education programs designed to meet individual
learning needs.
Nurse educators are critical players in assuring quality
educational experiences that prepare the nursing workforce for a diverse,
ever-changing health care environment. They are the leaders who document the
outcomes of educational programs and guide students through the learning
process. Nurse educators are prepared at the master's or doctoral level and
practice as faculty in colleges, universities, hospital-based schools of
nursing or technical schools, or as staff development educators in health care
facilities. They work with recent high school graduates studying nursing for
the first time, nurses pursuing advanced degrees and practicing nurses
interested in expanding their knowledge and skills related to care of
individuals, families and communities. Nurse educators often express a high
degree of satisfaction with their work. They typically cite interaction with
students and watching future nurses grow in confidence and skill as the most
rewarding aspects of their jobs. Other benefits of careers in nursing education
include access to cutting-edge knowledge and research, opportunities to collaborate
with health professionals, an intellectually stimulating workplace and flexible
work scheduling. Given the growing shortage of nurse educators, the career
outlook is strong for nurses interested in teaching careers. Nursing schools
nationwide are struggling to find new faculty to accommodate the rising
interest in nursing among new students. The shortage of nurse educators may
actually enhance career prospects since it affords a high level of job security
and provides opportunities for nurses to maintain dual roles as educators and
direct patient care providers
A nurse educator is a registered nurse who has advanced
education, including advanced clinical training in a health care specialty.
Nurse educators serve in a variety of roles that range from adjunct (part-time)
clinical faculty to dean of a college of nursing. Professional titles include
Instructional or Administrative Nurse Faculty, Clinical Nurse Educator, Staff
Development Officer and Continuing Education Specialist among others. Nurse
educators combine their clinical abilities with responsibilities related to:
Designing curricula developing courses/programs of study Teaching and guiding
learners evaluating learning documenting the outcomes of the educational
process.
Nurse educators have the unique opportunity to share their clinical
expertise in educational settings to shape the next generation of nurses. Current
faculty indicates that the most positive aspect of their role is the
interaction with students. Nursing faculty may also engage in scholarly inquiry
that will further illuminate the nature of teaching and learning and will
ultimately shape future educational processes and outcomes
Advocate
In health care the concept of advocacy has
become increasingly important over recent years as consumers demand better
quality, more responsiveness and easier access to such services. The rise of
consumerism through every walk of life has had its influence on expectations of
health care, and there is an increasing demand for user-empowerment and public
accountability for services.
Two underlying goals in client
advocacy are described. One goal of the community health nurse as advocate is
to help clients find out what services are available, which ones they are entitled
to, and how to obtain these services. A second goal is to influence change and
make the system more relevant and responsible to clients' needs.
"Nurses must transmit the
values of the nursing profession to society, in order that society may change in
accord with these values"
(Fowler, 1989, p 98)
Four characteristics required
for successful advocacy are:
·
assertiveness
·
willingness
to take risks
·
good
communication and negotiation skills
·
ability to identify resources and obtain results
Advocacy has been defined and
implemented in many different ways, the major concepts include citizen
advocacy; self-advocacy; collective or class advocacy; legal advocacy; and the
focus of this paper, the nurse at patient-advocate. The advocate may be the person
themselves (self-advocacy); an appointed official employed by a service
organisation; an independent person or "befriender"; an
"expert" (e.g., legal advocate), or a professional who works closely
with the person (such as the nurse as advocate). In any of these different
forms and interpretations of advocacy, the nature of the act, the relationship
involved, and the goals and outcomes are likely to differ significantly. This
proposed is concerned with the nurse acting as the patient’s advocate within
his or her professional role, and other formulations are therefore excluded.
Superficially, an advocate may
be considered to be one who will always be acting in the person’s "best
interest" whatever that might be, and concerned with doing
"good", however closer examination of the ethical basis of advocacy
suggests that this is a simplistic and perhaps inaccurate portrayal of the
role.
In nursing, the concept of the
nurse as the patient’s advocate has been a familiar one for a considerable
time; it is implied in various nursing codes (e.g., ANA, 1985; UKCC, 1984 &
1992).
There has been a common
assumption that advocacy is a major role for the nurse (Marks-Maran, 1993) and
for some, advocacy is definitive of nursing (e.g., Gadow, 1980, 1990) or as
Murphy (1983) states "the highest order nursing act..."
Others, (e.g., Miller etal, 1983; Trandel-Korenchuk, 1983) however argue
that nurses cannot act effectively as advocates because of their duties and
loyalties to their employers, and the medical profession.
Some nurses who have taken
their advocacy role to its full extent have often found themselves in conflict
with their employers, other professionals or even their peers when they pursue
issues on the behalf of their patients. In some instances (for example Graham
Pink, cited by Snell, 1991) this has ultimately lead to disciplinary action and
dismissal, even though the nurses professional body had judged that they had
not acted outside of their professional code of conduct. Support for advocacy
and patient advocates may therefore be more theoretical than actual, and an
appreciation of this situation may well inhibit other nurses from full
realisation of the patient advocacy role. The dilemmas posed for nurses
considering this role are therefore significant. It is arguable that for many
nurses advocacy is acknowledged and implemented only within certain limits and
boundaries, and it is suggested that nurses often curtail or modify their
advocacy activities when conflict with powerful authority figures, within or
without nursing, appears to be likely.
Models
of advocacy:
The advocate as guardian of
patient’s rights
This model of advocacy has some parallel with
the legalistic definition given above. It is based on the premise that the
nurse is able to inform the patient of their rights, and can then enable them
to exercise those rights, or intervene to ensure that their rights are
respected (Gillette, 1988). Gates (1994) definition of advocacy could be seen
as fitting within this model.
Criticisms of this model are that the
nurse-patient relationship is not conceived in these terms by either party, and
the nurse is not the best skilled or equipped to fulfil this role (Fowler,
1989; Melia, 1987). The legalistic or patient’s rights model may be too narrow
a conception to deal with everyday problems experienced by patients and their
nurses, for example, treatment and care decisions are rarely as clear-cut as
being supported by claiming a right.
Also this perspective tends to pre-suppose a
confrontational stance that may prevent nurses from taking an advocacy role.
The advocate as conservator of
the patient’s best interests
The idea that the advocate should be involved in
helping the patient receive care or make decisions that are in his or her best
interests would at first consideration seem unarguable. The great difficulty
with this approach is deciding what the patient’s best interests are,
and by whose definition?
Paternalism, described by Gadow (1983) may often
be the rationale or motive behind "best interest" decisions.
Paternalism is defined by Gadow as:
"The use of
coercion to provide a good that is not desired by the one whom it is intended
to benefit"
(Gadow, 1983, p 43)
The advocate as conservator of
the patient’s best interests
An example of this might be the patient who is
persuaded to continue with aggressive treatment of terminal illness because
they have a theoretical chance of survival. In such an example "good"
provided (i.e. potential cure) is defined according to the nurse’s or
physician’s values based on cure (Gadow, 1989), however "good" for
the patient may relate much more to the care experience in such a situation. In
this instance, advocacy as paternalism cannot be defended as offering benefit
in relation to the patient’s values, and it also negates the principle of
self-determination. The nurse’s actions may be guided by
"beneficence" (to do well) or "utilitarianism" (actions
that are judged by their social utility, or that offer the greatest good to the
greatest number of people (Harman, 1977). The outcomes derived may not coincide
with the patient’s self-determined best interests.
The advocate as protector of
patient’s autonomy
Kohnke (1982) is a proponent of this model of
advocacy, and identifies two principle tasks for the nurse, informing and
supporting. Informing involves providing sufficient information for making
informed decisions about health care, and the supporting task which is
concerned with reinforcing and upholding the patient’s decision.
This model, however offers little assistance for
the nurse caring for patients who are unable to communicate or make informed
decisions, and the justification of action (or non-action) based on the
client’s right to self-determination may often bring the nurse into conflict
with other ethical and legal considerations. Also, Quinn & Smith (1987)
argue that respect for autonomy does not presume that the individual will make
the best or even safe decisions for themselves, and there is much evidence in
daily life that individuals do not do so, although it possible to make
arguments such as that a decision to commit a "dangerous" act, say
for example misuse of drugs, may be in the persons "best interests"
given their own value system. Gadow (1979, 1983, and 1989) is a significant
contributor to the advocacy literature with her concept of "Existential
Advocacy". She proposes this concept as the philosophical
The advocate as protector of
patient’s autonomy
Kohnke (1982) is a proponent of this model of
advocacy, and identifies two principle tasks for the nurse, informing and
supporting. Informing involves providing sufficient information for making
informed decisions about health care, and the supporting task which is
concerned with reinforcing and upholding the patient’s decision.
This model, however offers little assistance for
the nurse caring for patients who are unable to communicate or make informed
decisions, and the justification of action (or non-action) based on the
client’s right to self-determination may often bring the nurse into conflict
with other ethical and legal considerations. Also, Quinn & Smith (1987)
argue that respect for autonomy does not presume that the individual will make
the best or even safe decisions for themselves, and there is much evidence in
daily life that individuals do not do so, although it possible to make
arguments such as that a decision to commit a "dangerous" act, say
for example misuse of drugs, may be in the persons "best interests"
given their own value system. Gadow (1979, 1983, and 1989) is a significant
contributor to the advocacy literature with her concept of "Existential
Advocacy"
The advocate as a champion of
social justice
This view
of advocacy as Fowler suggests, takes the nurse’s role as an advocate from the
patient’s bedside to beyond the institutional walls (1989, p 98). There may be
an element of advocacy for individual patients, but the focus is on social and
political change to deal with inequities and inequalities in provision of care
at both macro’ and micro-allocation levels.
Manager
The
manager's role is common to all nurses. Nurses serve as managers when they
oversee client care, supervise ancillary staff, do case management, run clinics
and conduct community health needs assessment projects. The nurse engages in
four steps of the management process of planning, organizing, leading and
controlling evaluation. Each of these functions is described in the text.
Specific decision-making behaviours are part of the manager's role as well as
human, conceptual and technical skills.
The Nurse Manager plays an
essential role in healthcare. She sets the tone of any Healthcare System. The
Manager is the backbone of the organization. The quality of patient care, as
well as staff recruitment and retention success, rests with this key role. Over
time it will be the strength of the nurse manager group that determines the
success or failure of nursing leadership, the COO, and even the CEO.
And yet it is rare that nurse
managers are given the opportunity to acquire the operational, financial, and
management skills essential to their success – and the success of their
organization.
As critical as it is to develop
those concrete and pragmatic skills noted above, there is also a delicate
subtle art to being a Nurse Manager... to balancing the tensions between
quality and cost ... to dealing with multiple stakeholders, presenting
conflicting agendas ... to dealing with stress and pressure every day ...to
implementing processes needed to ensure that individualized compassionate care
is provided consistently in the most efficient and effective manner
possible...and we show you a system to succeed.
There
are three keys to succeeding as a Nurse Manager
·
A
Complete and Comprehensive Understanding of the Nurse Manager Role and Access
to Best Practices
·
A Comprehensive
System for Success;
·
A Toolkit to Succeed
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Nurse Managers keys : |
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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 |
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Settings: |
Hospitals, long-term care, ambulatory care, or community/public/home
health agencies |
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Characteristics: |
Personal satisfaction, power, recognition, prestige, and economic gain;
opportunities for promotion |
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Drawbacks: |
Scope of responsibility, pressures of competition, hard work, and high
degree of flexibility; consumer issues, economy, politics, manpower, and
technology |
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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 |
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Education: |
RN with BSN, MSN, or doctorate |
Collaborator
Collaboration with clients, other nurses,
physicians, social workers, physical therapists, nutritionists, attorneys,
secretaries, and other colleagues is part of the role of the community health
nurse. Collaboration is defined as working jointly with to hers in a common
endeavour to cooperate as partners.
Skills
required for successful collaboration are
·
Communication skills,
·
Assertiveness,
·
Consultant skills.
Leader
The role of leader is
distinguished from the role of manager. As a leader, the community health nurse
directs, influences, or persuades others to effect change that will positively
affect people's health. Acting as a change agent and influencing health
planning at the local, state and national levels are elements of the role of
the leader.
Characteristics of an
Effective Leader
A good leader must be:
• A lifelong learner
• A good communicator with effective
interpersonal skills
• Able to look at the whole picture
• A good teacher
• Able to foster growth in others by
mentoring and providing opportunities
• A model for effective change
• Accountable
• A problem-solver
• A promoter of collaboration
• Knowledgeable in area of expertise
• Goal-oriented
• A person who seeks opportunities for
growth
• Open-minded
• A good time manager
• Able to remain calm when everyone else
is not
Researcher
In
the role of researcher, community health nurses engage in systematic
investigation, collection, and analysis of date to enhance community health
practice Research in community health may range from simple inquiries to
complex agency or organizational studies. Attributes of a nurse researcher
include a questioning attitude, careful observation, open-mindedness,
analytical skills, and tenacity.
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Description: |
Involves
all aspects of working with pharmaceutical/medical/nursing research |
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Practice roles: |
Clinical
data coordinator, clinical research assistant, clinical research monitor,
research assistant |
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Characteristics: |
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Drawbacks: |
Some
work is temporary or part time, travel may be required, work can be tedious. Position may rely on availability of grant money |
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Desirable skills: |
Strong
observation and analytical skills, detail-oriented. Grant writing experience helpful
in some situations |
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Education: |
Varies.
BS may be required. Some positions may require MS or higher. Advanced nursing research usually requires PhD |
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Employers: |
Pharmaceutical
companies, contract research organizations, teaching and university
hospitals, educational institutions, temporary technical placement agencies |
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