COMMUNITY-BASED NURSING AND COMMUNITY HEALTH–PUBLIC HEALTH NURSING

Community-based care and community health–public health (CH-PH) nursing are not new concepts for nursing. Nursing has played a vital role in the community since the middle to late 1800s, as visiting nurses provided care to the sick and poor in their homes and communities and educated patients and family members. Although community health (CH) nursing, public health (PH) nursing, community-based nursing, and home health nursing may be discussed together and aspects of care in each type do overlap, there are distinctions among these terms. Confusion exists regarding the differences, and the similar settings may blur these distinctions (Hunt, 2000; Kovner, 2001). The central idea
of CH-PH nursing is that nursing intervention can promote wellness, reduce the spread of illness, and improve the health status of groups of citizens. CH-PH nursing practice is concerned with the general and comprehensive care of the community at large, with emphasis on primary, secondary, and tertiary prevention. Nurses in these settings have traditionally focused on health promotion, maternal and child health, and chronic care.
Community-based nursing occurs in a variety of settings within the community and is directed toward individuals and families (Hunt, 2000). It includes home health care nursing. Most community-based and home health care is directed toward specific patient groups with identified needs; these needs usually relate to illness, injury, or disability resulting most often from advanced age or chronic illness. However, both community-based and CH-PH nurses are now expanding to meet the needs of many groups of patients with a variety of problems and needs. Home health care will be a major aspect of community-based care discussed throughout this text. Home health care services are provided by communitybased programs and agencies for specific populations (eg, the elderly, ventilator-dependent patients), as well as by hospital-based home health care agencies, hospices, independent professional nursing practices, and freestanding health care agencies. As trends continue toward shortened hospital stays and increased use of outpatient health care services, the need for nursing care in the home and community setting has increased dramatically. Because nursing services are being provided outside as well as within the hospital, nurses have a choice of practicing in a variety of health care delivery settings. These settings include acute care medical centers, ambulatory care settings, clinics, urgent care centers, outpatient departments, neighborhood health centers, home health care agencies, independent or group nursing centers, and managed care agencies. Community nursing centers, which have emerged over the past two decades with the advent of NPs, are nurse managed and provide primary care services that include ambulatory and outpatient care, immunizations, health assessment and screening services,
and patient and family education and counseling. The populations that these centers serve are varied, but most typically they include a high proportion of patients who are rural, very young, very old, poor, or members of racial minorities—groups that are generally underserved. The numbers and kinds of agencies that provide care in the home and community have expanded because of the expanding needs of patients requiring care. Home health care nurses are challenged because patients are discharged from acute care institutions to their homes and communities early in the recovery process and with more complex needs. Many are elderly, and many have multiple medical and nursing diagnoses and multisystem health problems that require acute and intensive nursing care. Medical technologies such as ventilatory support and intravenous or parenteral nutrition therapy, once limited to acute care settings, have been adapted to the home care setting. As a result, the community-based care setting is becoming one of the largest practice areas for nursing. Home care nursing is now a specialty area that requires advanced knowledge and skills in general nursing practice, with emphasis on community health and acute medical-surgical nursing. Also required are high-level assessment skills, critical thinking, and decision-making skills in a setting where other health care professionals are not available to validate observations, conclusions, and decisions. Home care nurses often function as acute care nurses in the home, providing “high-tech, high-touch” services to patients
with acute health care needs. In addition, they are responsible for patient and family teaching and for contacting community resources and coordinating the continuing care of the patient. For these reasons, the scope of medical-surgical nursing encompasses not only the acute care setting within the hospital but also the acute care setting as it expands into the community and the home. Throughout this textbook, emphasis is placed on the home health care needs of patients, with particular attention given to the teaching, self-care management, and health maintenance needs of patients and their families.