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Community/Public Health Nursing Introduction Public health nursing dates back to 1861, when Florence Nightingale initially spoke out on the issue, advocating change in the care of the ill. Nightingale thought that the home was the most appropriate and cost-effective place to care for someone. Through her efforts, many programs were designed to help train nurses to care for people in their own homes in addition to an institutional setting. Nightingale strongly believed that all people were better served when cared for in their own homes (Monteiro, 1985). In America, Lillian Wald started the public health tradition in the late 1800s in New York City. She had the idea that the current system of bedside clinical nursing or teaching families to provide care in homes was insufficient. She developed interventions addressing health policy, school health, and testified to Congress in order to address community issues such as poverty, child labor, and pollution (Nies & McEwen, 2006). From this foundation, community health/public health (CH/PH) nursing has evolved to include many differing perspectives, concepts, and theories. Community health and public health are unique in that

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the main focus is on prevention of illness and disease as opposed to the medical model in which treatment or action is not taken until a condition presents itself. Community and public health are based on the premise of the three Ps: prevention, promotion and protection. Within these three levels are subsections: primary, secondary, and tertiary. These same three levels of prevention are utilized in the acute care setting. For example, when considering a staph infection, primary prevention would involve education about staph and how it is transmitted. Secondary prevention addresses screening or detecting the presence of the disease and keeping it from spreading or getting worse (i.e., returning to the highest level of normalcy). Tertiary prevention involves ensuring this will not occur again, perhaps through proper precautions such as hand washing. Community Health/Public Health Nursing Today, CH/PH nursing focuses on the health and well-being of communities and populations. The CH/PH nurse may care for the individual, family, and groups or aggregates with the overall focus of preserving the health of communities or populations. This population is determined by the nurse’s place of employment, government health agencies, or community sites. The overall objective is not to care for individuals in their homes but to find methods to encourage health for the greatest number within a given community. Therefore, these nurses are vital intermediaries in creating healthy communities through collaborative partnerships with health providers, health entities, and the public, and are also actively involved in health policy development. Refer to chapter 1 in the textbook (Maurer & Smith, 2009), which explains the difference between community health nursing and community-based nursing. Community health (CH) nursing is unique compared with other areas of nursing practice. This specialty is a combination of public health nursing art and science and nursing art and science. The table below compares community health nursing with other clinical practice areas in nursing. Community Health Nursing Other Clinical Practice Client Total community, aggregates, groups, families, individuals Individual patient and family Major Goal of Practice Maintains, promotes, or improves health of entire community Personal health services Client Entry Into HCDS Outreach to groups Client comes into system Breadth and Scope of Practice Comprehensive care for all aspects of community health over a long time Episodic service Provider-Client Relationship Mutual participation Client dependent, cooperative, or mutual participation The Center for Public Health Nursing (Keller, Strohschein, Shaeffer, 2004) defines the following as the cornerstones of public health nursing: • Focuses on the health of entire populations, with emphasis on the determinants of health. • Reflects the priorities and needs of communities served. • Establishes caring relationships with communities, families, individuals, and systems served. • Grounded in social justice, compassion, sensitivity to diversity, and respect for the worth of all people, with special emphasis on the vulnerable. • Applies a holistic approach to health, encompassing the mental, physical, emotional, spiritual, social, and environmental aspects of health. • Health is promoted through strategies driven by epidemiological evidence. • Practices effective collaboration with community resources, but can and will work alone, if necessary. • Authority for independent action is derived from the Nurse Practice Act. CH Nurse Practice and Subspecialties The CH nurse addresses the individual, family, and groups or aggregates and their impact on the broader community. Aggregate means a group with one or more common characteristics, and may be defined by health status (e.g., people with hypertension), demographic variable (e.g., single mothers), or the setting (e.g., those in a senior center). The focus of the community health nurse practice is prevention, health promotion, and risk reduction. This is accomplished through a collaborative approach with other health professionals, health and community entities, and most importantly, the target population (Williams, 2004). Community health nurse generalists and specialists provide care in differing roles (Maurer & Smith, 2009). The specific subspecialties in which these roles can be practiced are school nursing, parish nursing, correctional health nursing, occupational health nursing, hospice nursing, home health nursing, public health department nursing, forensic nursing, camp nursing, rural health nursing, and more. Working in any of these subspecialties allows for the care of communities through individuals, families, and aggregates utilizing a variety of concepts and theories. Additional Core Concepts in CH Nursing There are many concepts and theories utilized in the practice of CH nursing. The Maurer and Smith (2009) text explains concepts such as ethics, systems theory, nursing theory, public health theory, levels of prevention, justice, direct/indirect care, and epidemiology (refer to chapters 1 and 7). Additional concepts such as public health core functions are critical in CH nursing. Public Health Core Functions In 1998, the Institute of Medicine’s publication The Future of Public Health identified three primary functions, called core functions, of public health. It is imperative that CH nurses become familiar with, and skillful at, these functions. The core public health functions are assessment, policy development, and assurance. • Assessment: Regular collection, analysis, and information sharing about health conditions, risks, and resource in a community, including diagnosis of health problems and hazards (Institutes of Medicine, 2003) • Policy development: Use of information gathered during assessment to include the community members and mobilize coalitions to develop local and state health policies and to direct resources toward those policies (Institutes of Medicine, 2003) • Assurance: According to the Institutes of Medicine (2003), assurance is the function that will enforce laws and regulations that protect health and ensure safety, link people to needed personal health services and assure the provision of health care when otherwise unavailable, assure a competent public health and personal health care workforce, and evaluate effectiveness, accessibility, and quality of personal and population-based health services (p. 99). • These core functions provide a basis to ensure that society can be healthy. The public core functions are represented at all levels of government and many public and private groups. Individuals can also work with these functions toward a healthy public (Stanhope & Lancaster, 2004). Political and Legislative Processes “Professional advocacy, untempered by a wider vision of health care and patient concerns, will lose nursing the purity of its voice. For it is the quality of this dedication to patients which gives nursing its power.” This quote by Rory Hays, a lobbyist for the Arizona Nurses Association, sums up the importance of nurses maintaining a voice in health care and patient issues (Arizona Nurses Association, n.d.a). In order to care appropriately for a patient or client in community health nursing, a nurse must be educated in legislative issues, lobbying, health policy, and political activism. Basic information, such as how a bill becomes a law, critical lobbying techniques, and how to see political development or activism in the form of a framework, will assist a nurse with the critical political influence that will provide a voice for nursing and the broader community. Influence in Politics There are many other ways in which nurses can influence the political arena. The Arizona Nurses Association (n.d.b) provides the following 10-step plan. 1. Vote. 2. Contribute to a nursing association’s political action committee. 3. Write to a legislator from the community. 4. Attend a Nurses’ Legislative Day. 5. Become active in local politics. 6. Volunteer for nursing-endorsed candidates. 7. Call local representatives and find out what their stand is on important health care issues. 8. Write a letter to the editor of a newspaper regarding health policy issues. 9. Contribute to nursing-endorsed candidates. 10. Be a contact person for legislators (i.e., legislative liaison). Nurses who are aware of the steps and/or practice any or all of the steps can assess their political development. This is important for growth and development within the political arena. Framework for a Nurse’s Political Development Nurses develop politically at different paces, if at all. A framework modified by Kelly (2007) addresses the five steps by which a nurse can be categorized in relation to political development. This framework can assist nurses in assessing their current stage of development and ideas, or direct them on how to proceed to the next stage. 1. Apathy: “The apathetic nurse doesn’t belong to professional organizations, takes little or no interest in legislative politics as they relate to nursing and health care, and may not be a registered voter” (Kelly, 2007, p. 55). 2. Buy-In: “The nurse starts to recognize the importance of activism within professional nursing organizations but hasn’t taken an active role in these organizations. He or she starts to become interested in legislative politics related to critical nursing issues, but takes little or no political action. Nurses at this stage are likely to be registered voters” (Kelly, 2007, p. 55). 3. Self-Interest: “The nurse seeks involvement in professional organizations to further his or her career and seeks to develop and use political expertise to promote professional selfinterest” (Kelly, 2007, p. 55). 4. Political Interest: “The nurse is active at the professional organizational level and may hold an organizational office at the local or state level. He or she has moved beyond self-interest and recognizes the need for activism on behalf of the public” (Kelly, 2007, p. 55). 5. Leading the Way: “The nurse serves in an elected or appointed position at the state or national level of a professional organization. To provide true leadership on broad health care interests within legislative politics, he or she may seek appointment to policy-making bodies. Some nurse-leaders seek election to political office” (Kelly, 2007, p. 55). Conclusion Power is “the ability to influence others, the ability to do or act, and achievement of the desired result” (Hitchcock, Schubert, & Thomas, 2002, p. 428). This statement defines what nurses need in order to lead the way in health care issue and policy. Nurses influence others with their voices, as well as advocate for their patients and communities. Nurses who have a grasp on basic legislative knowledge, appropriate lobbying techniques, and their political development are better prepared to use their voices and have the power to make a difference. References Arizona Nurses Association. (n.d.a). A legislative hotline. Retrieved March 26, 2009, from
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