Community-Based Nursing

Community—Group of individuals who share some

characteristics, engage in multifaceted relationships,

and have the capacity to act collectively.

Community-based health care—Provision of health

care in settings near where individuals, families, or

groups live, work, or play.

Community health nursing—Provision of health-care

services to protect, promote, maintain, or improve

the health and quality of life of individuals, families,

and groups within the context of a population.

Hospice—Interdisciplinary services that focus on main-

taining comfort and quality of life of dying individu-

als and providing supportive care to grieving family

members.

Population (aggregate)—Group of people with at least

one shared specific feature.

Public health nursing—Nursing interventions that focus

on meeting the health needs of populations.

Respite care—Total care for an individual is delegated

to another for a specified time period to provide

relief from the duty of providing care and to limit

caregiver role strain.

Stigmatized population—Group of people who are

unaccepted and discriminated against and lack status

and power.

Telehealth care—Health care provided via use of the

internet, telephone, or fax machine.

Vulnerable population—A group of people who are

at increased risk for health problems because of

multiple stressors, unhealthy behaviors, and lack

of economic, social, and/or health-related

resources.

KEY TERMS

I. Definitions Related to Community-Based

Nursing

Community health-care terms are commonly confused

and used interchangeably because they share similarities.

However, these terms usually focus on different aspects of

health-care delivery in the community. This section pro-

vides definitions that attempt to clarify the differences

among common terms, such as community, population,

community health nursing, community-based nursing

care, and public health nursing.

A. Community

1. Group of individuals who share some characteris-

tics, engage in multifaceted relationships, and have

the capacity to act collectively.

2. Can include people living within a certain physical

boundary (e.g., people living in New York City) or

people who share a distinctive feature (e.g., Native

Americans).

B. Population (Aggregate)

1. Cluster or group of people with at least one shared

specific feature.

2. Examples include high-risk infants, adolescents,

older adults, or a cultural group, such as Latino

Americans.
C. Community Health Nursing

1. Concerned with protecting, promoting, main-

taining, and improving health and quality

of life.

2. Provides services to individuals, families, and

groups within the context of a population.

D. Community-Based Health Care

1. Focuses on caring for individuals, families, or

groups near where they live, work, and play.

2. Community settings include homes, health clinics,

schools, assisted-living facilities, rehabilitation

centers, nursing homes, and primary health-care

providers’ offices.

D. Telehealth Care

1. Provides services to people who live in geographic

areas where health care is not easily accessible.

2. Allows data to be transmitted via the internet, tele-

phone, or fax machine to primary health-care

providers and specialists for consultation.

3. Raises legal and ethical issues (e.g., who is

responsible for the patient, how is patient confi-

dentiality protected, and does the health-care

provider have to be licensed in the state in which

the patient lives?).

DID YOU KNOW?

The National Council of State Boards of Nursing’s

position on telehealth is that regulations associ-

ated with the state in which the patient lives are

applicable.
III. Foundations of Community-Based

Nursing

To work in the community, a nurse should understand the

need for health care to be delivered in community settings

and the ways in which health initiatives, such as Healthy

People 2020, help a community and its population to

achieve a healthier life. In addition, a nurse should under-

stand the characteristics of a healthy community in order

to be able to identify the characteristics of an unhealthy

community. The following content provides information

to help nurses better understand these issues.

A. Issues Promoting the Movement of Health Care

Into the Community

1. Federal legislation identified a prospective pay-

ment system for Medicare based on illnesses and

diseases. The introduction of diagnosis-related

groups (DRGs) into the U.S. health-care system, in

an effort to control costs, has resulted in patients

being discharged sooner and sicker from the hos-

pital to the community.

2. The aging of the U.S. population has resulted in a

larger percentage of individuals in the community

having chronic illnesses and disabilities, requiring

supportive care for the patient and respite care for

family members providing care.

3. The number of people who do not seek or can-

not afford health care is increasing. Examples

include vulnerable populations, such as people

who are immigrants, homeless, living below the

poverty level, uninsured, cognitively impaired,

or abused.

4. The focus of health care is changing from treat-

ment of diseases to health promotion and disease

prevention, which emphasizes a nurse’s teaching

role and requires educating children before

unhealthy habits become engrained.

82 Unit I Nursing Within the Context of Contemporary Health Care

E. Public Health Nursing

1. Focuses on meeting the health needs of populations.

2. Provides services, such as prenatal care, immu-

nizations for children, and screening for illnesses

(e.g., tuberculosis, scoliosis), and helps to prevent

individual disability and disease (e.g., correct use

of automobile restraining devices for children,

ways to reduce risk factors for cardiac disease).

II. Community-Based Settings

In addition to outpatient, occupational, extended care,

school, and hospice care settings (see Chapter 4), health-care

settings have evolved to meet the unique needs of certain

populations within the community (e.g., some individuals

reside in institutions, whereas others live in areas where

health care is inaccessible). Creative initiatives and

the use of technology (e.g., internet, fax machines) have

increased the number of people who now have access to

health care.

A. Mobile Health Clinics

1. Vans or buses with equipment and health-care

professionals who provide primary and secondary

health-care services at numerous places within a

geographic area.

2. Bring health care to the people.

3. Help to service migrant workers, who pose a

unique challenge to the provision of health-care

services because they move about the country

based on the timing of harvests.

B. Faith-Based Organizations

1. Religious organizations that provide health-care

services to individuals.

2. Address patients’ physical, emotional, and spiritual

needs.

3. Activities associated with faith-based organizations.

a. Coordination and training of volunteers who may

provide such services as companionship visits and

transportation to and from appointments.

b. Development and facilitation of support groups.

c. Referral services to community health-care

facilities and programs.

d. Presentation of programs involving health edu-

cation, illness prevention, and health promotion.

e. Discussion and education about health issues

on an individual basis.

f. Facilitation of assimilation of faith and health.

C. Correctional and Prison Environments

1. Provide routine examinations and screenings

on a scheduled basis as well as acute care when

needed.

2. Generally require nurses to meet certain physical

criteria and complete special training to provide

for their own safety, such as weapons training and

security procedures.

5. More people prefer to die at home rather than in a

health-care facility, necessitating the provision of

both physical and emotional care for patients and

family members.

B. Healthy People 2020 ([Link])

1. A national initiative instituted in 1979, and

updated every 10 years, that identifies health

improvement goals and priorities and also

includes new data on issues and progress

achieved toward previous goals.

2. Provides objectives in a format that enables

diverse groups to combine their efforts and

work as a team.

3. Has a major impact on all health-care programs,

but especially on activities and groups concerned

with community health needs.

4. Has four overreaching goals, according to the U.S.

Department of Health and Human Services (2012).

a. “Attain high-quality, longer lives free of prevent-

able disease, disability, injury, and premature

death.”

b. “Achieve health equity, eliminate disparities,

and improve the health of all groups.”

c. “Create social and physical environments that

promote good health for all.”

d. “Promote quality of life, healthy development,

and healthy behaviors across all life stages.”

C. Characteristics of a Healthy Community

1. Has an awareness of its members, populations,

and subgroups as being part of the community.

2. Provides opportunities for and encourages partici-

pation of individuals and groups in decision

making related to issues affecting the community.

3. Ensures that communication remains open and

information flows among all members and groups

in every direction within the community.

4. Detects, investigates, and dissects problems and col-

laborates and coordinates a response among mem-

bers and groups to meet their identified needs.

5. Ensures that community resources are available to

all members and groups within the community.

6. Focuses on promoting a high level of wellness and

health among all members and populations within

the community.

7. Has a well-organized base of community resources

available to meet needs and to intervene in a crisis

or natural disaster.

IV. Components of a Community Assessment

The provision of nursing care in the community is based

on the nursing process (assessment, analysis, planning,

implementation, and evaluation). Assessment is the most

significant step because it drives the rest of the nursing

process. It must be comprehensive and accurate. When

performing a community assessment, information must

be collected about the physical environment and infra-

structure of the community, characteristics of its popula-

tion, available resources and services, and the economic

and social systems within the community. This assessment

may be conducted by a community health nurse or in col-

laboration with others, such as various members of the

health-care team, members of community organizations,

and government officials.

A. Physical Environment of the Community

1. Natural boundaries and size of the community.

2. Types of housing.

3. Average household income.

4. Location of agencies and resources.

B. Population of the Community

1. Characteristics of community members, such as

age, gender, and educational level.

2. Growth trends.

3. Predominant ethnic and religious groups

represented.

4. Population density.

C. Safety and Transportation Systems Available to the

Population

1. Agencies and status of services provided regarding

water and sanitation.

2. Air quality.

3. Telephone service.

4. Numbers of police and emergency services

available.

5. Rail and bus systems.

D. Social Services Available to the Community

1. Schools, health-care agencies, and recreational

facilities and the programs they provide.

2. Number of health-care providers and services avail-

able, such as sources of health-care information,

extent of primary care, and home and long-term

care services.

3. Number and types of spiritual institutions.

4. Recreational organizations and clubs, such as

playgrounds, parks, beaches, and sports centers.

E. Status of the Members of the Community

1. Biological, emotional, and sociological nature of

the community.

2. Biological statistics, including data on illness

(morbidity) and death (mortality) rates and life

expectancy of members of the community.

3. Emotional and sociological statistics, including data

on indications of the general mental health of com-

munity members and satisfaction or dissatisfaction

with characteristics or features of the community.

F. Economic Status of the Community

1. Industries, employers, and occupations within the

community.

2. Economic level of the community, such as average

household income.

Chapter 5 Community-Based Nursing 83

E. Teacher

1. Focuses on health promotion and disease preven-

tion with individuals and groups through educa-

tional activities.
2. Presents programs on such topics as prenatal

classes, child safety, dental health, hypertension,

and nutrition.

3. Targets groups in schools, community organiza-

tions, and businesses.

VI. Specific Competencies of

Community-Based Nurses

All nurses should have a strong set of competencies to

provide patient-centered, comprehensive, safe, and

effective nursing care. However, community-based

nurses commonly work autonomously and require

in-depth expertise in specific areas of competency. They

must be proficient in skills related to communication,

collaboration, maintenance of continuity of care, and

provision of care to individuals of different ages. In

addition, community health nurses must be respectful of

the varied values, beliefs, and cultural heritage of the

populations within the community.

A. Collaborate With Others

1. Recognize that partnerships, networks, and coali-

tions are essential to effectively address the heath-

care needs of members and groups within a

community.

2. Maintain collegial working relationships with

other health team members to ensure consulta-

tion and cooperation in management of the

delivery of care.

3. Collaborate with other health-care providers in

identifying the need for change in social, political,

economic, or health-care systems within the

community.

4. Offer suggestions for changes compatible with the

norms and values of the community.

B. Communicate With Others

1. Have excellent communication skills when working in a

collaborative relationship with other health team

members and when communicating with members and

groups within a community.

2. Demonstrate respect verbally and nonverbally for

the expertise that each professional brings to the

team as well as for individual differences among

members and groups within the community.

C. Maintain Continuity of Care

1. Coordinate delivery of health-care services between

settings (e.g., hospital to home, rehabilitation center

to assisted-living facility, or nursing home to hospi-

tal) and between and among providers of health

care within the community.

84 Unit I Nursing Within the Context of Contemporary Health Care

3. Number of workplace health promotion and

illness prevention programs.

4. Number of population receiving public assistance.

G. Social System of the Community

1. Statistics related to crime and drug abuse within

the community.

2. Percentage of population attending school.

3. Ways communication flows.

4. Extent of interaction among members and groups

within the community.

5. Kind of government that runs the community.

6. Extent of participation of members in health-care

decision making within the community.

7. Availability of a welfare system to support the needy.

8. Types and extent of volunteer programs.

V. Specific Roles of Community-Based

Nurses

Chapter 4, “Health-Care Delivery,” explores traditional roles

of the nurse and provides examples of nursing activities

associated with each role. Here, some traditional roles of the

nurse are discussed from the prospective of working within

the community. In addition, a role specific to community

health nursing—nurse epidemiologist—is presented.

A. Nurse Epidemiologist

1. Provides surveillance and monitoring activities to

identify trends in health and risk factors that

threaten the health of specific populations or the

health of members of the general community.

2. Performs such activities as examining sources of

information, case findings, field studies, surveys,

and investigations; tracking illnesses, diseases, and

death rates; and providing information and reports

to appropriate local, state, or national officials.

B. Case Manager

1. Ensures that an appropriate plan of care is formu-

lated and implemented to meet the needs of

patients across a continuum of care within the

community setting.
2. Coordinates and promotes continuity of care

among health-care disciplines.

C. Advocate

1. Assists patients to work their way through the

health-care system and obtain appropriate services.

2. Engages in political action at the local, state,

or national level to advocate on behalf of the

community.

D. Change Agent

1. Mediates within a family system or within the

community, empowering people to effect change

to better meet health-care needs.

2. Utilizes information related to facilitating change

and managing resistance to change to be a more

effective change agent.

!!

2. Be involved in discharge planning as soon as a patient is

admitted to a hospital or extended-care facility when

the person is expected to return to the community.

3. Know the resources, agencies, and services that are

available in the community and make referrals on

behalf of the patient to support continuity of care.

4. Ensure that, with the patient’s consent, family

members and significant others are included in the

planning process because family members often

are the main caregivers.

D. Provide Care Across the Life Span

1. Provide services to patients of all ages from the

time they are born until they die.

2. Provide health-care services to special needs

populations within different age groups, such as

adolescents (e.g., pregnant teens who give birth

to low-birth-weight and premature infants), pre-

school and school-aged children (e.g., immuniza-

tion programs, health screening, and nutrition

services), and young adults (e.g., services for those

who have sexually transmitted diseases or sub-

stance abuse problems).

3. Coordinate hospice care to assist terminally ill

members of the community to die a peaceful,

dignified death.

DID YOU KNOW?

Hospice is a concept, not a place to go to die.

Hospice care provides interdisciplinary services that

focus on maintaining comfort and quality of life of

dying individuals and providing supportive care to

grieving family members. Hospice care can be pro-

vided in extended-care facilities, freestanding hos-

pices, or in the home. The location depends on the

patient’s physical and emotional needs and the abil-

ity of family members to provide care in the home.

Although patients of all ages receive hospice care, a

large percentage of these patients are older adults.

VII. Caring for Vulnerable Populations in the

Community

A vulnerable population is a group of people who are at an

increased risk for health problems because of multiple stres-

sors, unhealthy behaviors, or lack of economic, social, and/or

health-related resources. Examples of vulnerable populations

include those who are homeless or indigent; immigrants;

those who are severely mentally ill, abused, or neglected; older

adults; infants and children; substance abusers; and those

within a stigmatized population (see Box 5.1).

A. Commonalities of Nursing Care for Vulnerable

Populations

1. Provide emotional and culturally sensitive care.

2. Provide dignified, respectful, and nonjudgmental care.

3. Collaborate with other health-care professionals

to ensure that comprehensive care is planned and

implemented.

4. Engage patients in the planning process to ensure

that they have input and a vested interest in goal

achievement.

5. Involve family members in developing a plan of

care to address patient needs if the patient gives

consent or if the patient is a minor.

6. Establish priorities with the patient’s input because

what the nurse believes is most important might

not be what is most important to the patient.

7. Promote and acknowledge patient abilities to

foster independence and increase self-esteem.

8. Make referrals to appropriate community

resources and services.

9. Arrange for transportation and child care to

facilitate attendance at appointments.

10. Coordinate home-based care if the patient is

unable to leave the home or if a vulnerable patient

is at risk for not attending health-care services.

11. Arrange for participation in economic support

programs, such as food stamps, Medicaid, and the

Women, Infants, and Children (WIC) program.

12. Provide assistance for vocational counseling if the

patient is able to maintain employment.

B. Individuals Who Are Infants (Birth to 1 Year) or

Children

1. Infants and children are dependent on others to

meet their physiological and emotional needs.

2. They have immature immune systems to protect

themselves from infection.

3. They lack depth and breadth of physiological

responses to stress.

4. They lack judgment, which may result in injury.

5. They may be born into a hostile environment (e.g.,

inadequate nutrition, parents who abuse substances,

poverty).

Chapter 5 Community-Based Nursing 85

!!

!!

Box 5.1 Traits of Vulnerable Populations

• Have a higher probability of developing illness and less

favorable outcomes than other populations (because they

have a combination of risk factors)

• Have a higher incidence of morbidity and mortality and a

shorter life expectancy than the general population

• Have less access to health care

• Have greater difficulty managing reception of services

because of a lack of personal and economic resources and

dependency on others

• Experience a multiplicity of stressors that challenge delivery

of appropriate and adequate health care

• Experience more positive outcomes when their needs are

met early in a comprehensive manner before an issue

becomes a crisis

86 Unit I Nursing Within the Context of Contemporary Health Care

D. Individuals Who Are Homeless or Indigent

1. Generally live in substandard housing or in haz-

ardous conditions, such as insect-or vermin-infested

environments, or live outside in the elements.

2. Are less healthy because of such factors as inade-

quate nutrition, inaccessible facilities in which to

bathe and wash clothes, inadequate rest, and

absence of preventive health care, such as immu-

nizations and health screenings.

3. Are at increased risk for accidental injury, assault,

abuse, and infectious diseases, such as tuberculosis

and skin and respiratory infections.

4. Have a higher incidence of severe mental illness,

alcoholism, illegal drug use, and smoking than the

general population.

5. Specific nursing care for homeless and indigent

individuals and families.

a. Help patients find mobile health clinics, soup

kitchens, shelters, thrift shops, and housing.

b. Teach the importance of and ways to maintain

a clean, healthy environment.

c. Teach homeless people ways to avoid violence.

E. Individuals Who Are Immigrants

1. Generally do not speak English well enough to

communicate needs or find resources that support

health and wellness and treat illness.

2. If in the country illegally, often do not seek health care

until acutely ill because of a fear of being deported.

3. Often cannot afford health insurance or health-

care services because of low paying jobs or

dependence on day work.

4. Present with specific health problems, such as

tuberculosis, intestinal parasites, dental decay,

and hepatitis B.

5. May have experienced a traumatic event, such as

war, natural disaster, lack of economic opportunity,

or oppression, and are at risk for emotional distress.

6. Frequently engage in nontraditional healing prac-

tices that may or may not be helpful.

7. Specific nursing care for immigrant populations.

a. Learn as much as possible about the patient’s

culture and its impact on the patient’s health-

care needs.

b. Be sensitive to cultural values and beliefs and

demonstrate respect for nontraditional healing

practices unless they are harmful to the patient.

c. Assess the patient for signs and symptoms of

specific health problems unique to the patient’s

history, culture, and environment.

d. Use a professional interpreter so that information can

be correctly translated and confidentiality can be

maintained; ensure that all questions are answered

and understood to promote patient participation in

the planning process.

6. Specific nursing care for infants and children.

a. Ensure that infants and children receive

immunizations.

b. Ensure that they receive routine health care

(e.g., initially monthly and then yearly) and

dental care.

c. Educate parents about positive health-care

practices (e.g., nutrition, safety practices, and

developmental expectations).

C. Individuals Who Are Older Adults

1. Includes a rising percentage of adults over age 85

because of an increase in life span; these frail older

adults have multiple health problems, requiring

comprehensive health care.

2. Also includes a rising percentage of adults over

age 65 because of the aging of the large number of

people born between 1946 and 1960 (baby boomer

generation); these people have health promotion

and illness prevention needs to maintain health

and independence.

3. Demonstrate an increase in alcohol use in response

to depression, lack of social support, and lack of

companionship.

4. Experience socioeconomic stressors, such as

retirement, inadequate income, social isolation,

downsizing of home and lifestyle, and relocation,

which can also cause psychological and physiolog-

ical stress.

5. Generally live in their own homes, but may have

impaired mobility or lack of transportation,

which may require services to be provided in

the home.

DID YOU KNOW?

Home-care services support independence and help

avoid institutionalization of older adults.

6. Specific nursing care for older adults.

a. Provide opportunities that support the develop-

mental task associated with older adults

(integrity versus despair).

b. Assess patients for substance use (e.g.,

polypharmacy) and alcohol and prescription

drug abuse.

c. Encourage patients to engage in social activities

available in the community.

d. Arrange for home-care services so that older

adults are able to remain in their own homes

for as long as possible.

e. Arrange for respite care that relieves family mem-

bers from the caregiving role; varies in duration,

from as short as a few hours so a family member can

go to a movie or shop, to a week or more admission

to a nursing home while a family attends an event or

goes on vacation.