Chapter 1
Nursing Today
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Historical Perspective Highlights

Nurses:





Respond to needs of patients
Actively participate in policy
Respond and adapt to challenges
Make clinical judgments and decisions about
patients’ health care needs based on knowledge,
experience, and standards of care
Nursing:

Care is provided according to standards of
practice and a code of ethics.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
2
Development of a Profession

Nursing has struggled with its definition, its
image, and its role in the healthcare delivery
system
–
–

Due in part to its history
Fact that it has both theoretical and practical aspects
Role of the nurse in the healthcare delivery
system has probably never been more important
than it is today.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
3
Historical Influences on the
Development of Nursing


Healthcare in ancient cultures
Historic perspectives and early images of nursing



Folk image
Religious image
Servant image
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4
The Beginning of Change

Early providers of nursing care
−
−
Sisters of charity in France and the United States
Sisters of the holy cross in France and the United States
− Catholic religious orders in Mexico and South America
− Ursuline sisters in Canada
− Deaconesses at Kaiserwerth, Germany and Pittsburgh,
Pennsylvania
− Nursing sisters in England and Ireland
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5
The Nightingale Influence



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Dramatically changed the form and direction of
nursing
Set standards for nursing education and made
significant recommendations for changes in how
hospitals operated and how nursing was practiced
Many of her recommendations are valid today
Wrote Notes on Nursing
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6
Florence Nightingale’s Basic
Principles of Nursing Education



Trained teaching hospitals are associated with
medical schools
Nurses reside in nurses’ houses
School matron is final authority in:
−
−
Curriculum
Living arrangements
− All aspects of the school



Education includes theoretical material and
practical experience
Teachers are paid for instruction
Records are kept on students
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7
Florence Nightingale




First practicing epidemiologist
Organized first school of nursing
Improved sanitation in battlefield hospitals
Her practices remain a basic part of nursing
today.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
8
Civil War to the Beginning of the
Twentieth Century

The growth of nursing in the United States:
 Clara
Barton founded the American Red
Cross.
 Dorothea Lynde Dix
 Mother Bickerdyke
 Harriet Tubman
 Mary Mahoney
 Isabel Hampton Robb
 Lillian Wald and Mary Brewster: Henry Street
Settlement
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9
The Establishment of Early Schools



Nursing services provided by most hospitals
during the 1860s were disorganized and
inadequate.
In 1869 the American Medical Association
established a committee to study the issue of
training for nurses.
The New England Hospital for Women and
Children is often credited with being the first
hospital to establish a formal 1 year program to
train nurses in 1872.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
10
Characteristics of the Early Schools



Primarily apprenticeships
Long hours during which students provided
much of the workforce of the hospital with little
time left for study
Job description 1887
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11
The Twentieth Century


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
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Movement toward scientific, research-based
practice and defined body of knowledge
1901: Army Nurse Corps established
1906: Mary Adelaide Nutting, first professor of
nursing at Columbia University
1908: Navy Nurse Corps established
1920-1923: Study of nursing education
1940s and 1950s: Associations emerged
1970: Emergency Room Nurses Organization
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12
Nursing Image


Struggle with image
Groups waging campaigns to:




Improve image
Attract individuals to profession
Critical issue because of nursing shortage
A positive image is needed to attract qualified
individuals into the profession
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13
The Twenty-First Century





Nursing code of
ethics
Changes in
curriculum
Nursing in multiple
care settings
Advances in
technology and
informatics
End-of-life care
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14
Influences on Nursing

Changes in society lead to changes in
nursing:






Health care reform
Demographic changes
Medically underserved
Threat of bioterrorism
Rising health care costs
Nursing shortage
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15
Nursing as a Profession

A profession has characteristics:
 Requires an extended education
 Requires a body of knowledge
 Provides a specific service
 Has autonomy
 Incorporates a code of ethics
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
16
Scope and Standards of Practice

Nursing: Scope and Standards of Practice




1960: Documentation began
Standards of Practice
Standards of Professional Performance
Goal

To improve the health and well-being of all
individuals, communities, and populations through
the significant and visible contributions of
registered nursing using standards-based practice
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17
Standards of Practice


Nursing standards provide the guidelines for
implementing and evaluating nursing care.
Six standards of practice:






Assessment
Diagnosis
Outcomes identification
Planning
Implementation
Evaluation
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18
Standards of Professional
Performance
Ethics
Quality of
Practice
Professional
Practice
Evaluation
Education
Communication
Resources
EvidenceBased Practice
and Research
Leadership
Environment
al Health
Collaboration
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
19
Code of Ethics



A code of ethics is the philosophical ideals of
right and wrong that define principles used to
provide care.
It is important for you to incorporate your own
values and ethics into your practice.
Ask yourself: How do your ethics, values, and
practice compare with established standards?
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
20
Quick Quiz!
1. Nursing is defined as a profession because
nurses
A. Perform specific skills.
B. Practice autonomy.
C. Utilize knowledge from the medical
discipline.
D. Charge a fee for services rendered.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
21
Programs that Prepare Graduates for RN
Licensure

Three major avenues to preparation for
licensure as a registered nurse exist in the
United States:





Diploma or hospital-based diploma
Associate degree
College-based baccalaureate degree
Master’s and doctoral prelicensure programs
Nontraditional prelicensure programs
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
22
Nursing Practice


Nurses practice in a variety of settings.
Nurses:
 Protect,
promote, and optimize our patients’
health
 Prevent illness and injury
 Alleviate suffering through the diagnosis and
treatment of human responses
 Advocate for the care of our patients
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
23
Nursing Practice




Nurse Practice Acts
Licensure and certification
Science and art of nursing practice
Benner’s stages of nursing proficiency:
 Novice
 Advanced
beginner
 Competent
 Proficient
 Expert
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
24
Professional Responsibilities


Nurses are responsible for obtaining and
maintaining specific knowledge and skills.
In the past:
 To

provide care and comfort
Now:
 To
provide care and comfort and to emphasize
health promotion and illness prevention
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
25
Professional Roles
Autonomy and Accountability
Caregiver
Advocate
Educator
Communicator
Manager
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26
Career Development

Nursing provides an
opportunity for you
to commit to lifelong
learning and career
development.
{Fig 1-2 here}
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
27
Professional Nursing Organizations





National League for Nursing (NLN)
American Nurses Association (ANA)
International Council of Nursing (ICN)
National Student Nurses Association (NSNA)
or Canadian Student Nurses Association
(CSNA)
Other professional organizations focus on
specific areas.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
28
Quick Quiz!
2. The NLN and the ANA are professional
organizations that deal with
A. Nursing issues of concern.
B. Political and professional issues affecting
health care.
C. Financial issues affecting health care.
D. All of the above issues.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
29
Forces for Change in Nursing Education

Incorporation of computer technology in nursing
education







Computer technology in the classroom
Computers in the hospital environment
Distance learning options
Establishment of programs that provide for
educational mobility
Increase in community-based practice experiences
Increase in emphasis on research
Education supporting evidence-based practice
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30
Additional Nursing Trends




Genomics
Public perception of nursing
Impact of nursing on politics and health policy
Future trends
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31
Chapter 2
The Health Care Delivery
System
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Challenges to Health Care




Reducing health care costs while maintaining
high-quality care for patients
Improving access and coverage for more
people
Encouraging healthy behaviors
Earlier hospital discharges result in more
patients needing nursing homes or home
care.
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33
Emphasis on Population Wellness

Health Services
Pyramid



{Fig 2-1 here}
Managing health
instead of illness
Emphasis on
wellness
Injury prevention
programs
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34
National Priorities Partnership

National Priorities:






Patient and family engagement
Population health
Safety/eliminating errors as possible
Care coordination
Palliative care for advanced illnesses
Overuse/reducing waste
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35
Institute of Medicine (IOM)

Nurses need to be transformed by:




Practicing to the full extent of their education and
training
Achieving higher levels of education and training
through an improved education system that
provides seamless progression
Becoming full partners, with physicians and other
providers, in redesigning the health care system
Improving data collection and the information
infrastructure for effective workforce planning and
policy making
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36
Case Study


Amy Sue Reilly is a 15-year-old white female of Irish
descent. She is a freshman at a Catholic high school.
Although her parents are divorced, Amy Sue reports
that her family (she has two brothers and lives with
her mother) is very close, and that her parents work
together to meet all their children’s needs.
Amy Sue has had asthma since she was 5 years old.
She has been able to control her asthma by taking
oral medications and by using inhalers when needed.
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37
Health Care Regulation and
Competition

Regulatory and competitive approaches

Professional standards review organizations
(PSROs)
• Created to review the quality, quantity, and cost of
hospital care provided through Medicare and Medicaid

Utilization review committees (URs)
• Review admissions, diagnostic testing, and treatments
provided by physicians who cared for patients receiving
Medicare
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38
Health Care Regulation and
Competition (cont’d)

Prospective payment system (PPS)





Diagnosis-related groups (DRGs)
Capitation
Resource utilization groups (RUGs)
Profitability
Managed care
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39
Health Care Regulation and
Competition (cont’d)

Patient Protection and Affordable Care Act




Access to health care for all
Reducing costs
Improving quality
Provisions include
• Insurance industry reforms
• Increased funding for community health centers
• Increased primary care services
• Improved coverage for children
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40
Health Care Settings and Services
1. Preventive
2. Primary
3. Secondary
4. Tertiary
5. Restorative
6. Continuing
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41
Health Care Accreditation/
Certification

Reasons:



Accreditation earned by the entire
organization


To demonstrate quality and safety
To evaluate performance, identify problems, and
develop solutions
Specific programs or services within an
organization earn certifications.
The Joint Commission and others
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42
Preventive and Primary Health Care
Preventive Care
Primary care
Focuses on improved health outcomes for an entire
population
Requires collaboration among health professionals,
health care leaders, and community members
Health promotion lowers overall costs:
Reduces incidence of disease
Minimizes complications
Reduces the need for more expensive resources
Occurs in home, work, and community settings
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43
Secondary and Tertiary Care






Also called acute care
Focus: Diagnosis and treatment of disease
Disease management is the most common
and expensive service of the health care
delivery system.
20% require 80% of health care spending.
Fastest growing age group of uninsured?
Postponement of care by uninsured
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44
Secondary and Tertiary Care
(cont’d)

Settings
Hospitals
Rural
Hospitals


Intensive Care
Units
Psychiatric
Care
Resource efficiency, word redesign
Discharge planning—nurses’ role
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45
Restorative Care





Serves patients recovering from an acute or
chronic illness/disability
Helps individuals regain maximal function and
enhance quality of life
Promotes patient independence and self-care
abilities
Requires multidisciplinary approach
Settings:
Home Care
Rehabilitation
Extended Care
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46
Restorative Care: Home Care




Provision of medically related professional and
paraprofessional services and equipment to patients
and families in their homes for health maintenance,
education, illness prevention, diagnosis and
treatment of disease, palliation, and rehabilitation
Involves coordination of services
Focuses on patient and family independence
Usually reimbursed by government (such as
Medicare and Medicaid in the United States), private
insurance, and private pay sources
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47
Restorative Care: Rehabilitation



Focus: To restore patients to their fullest
physical, mental, social, vocational, and
economic potential
Includes physical, occupational, and speech
therapy, as well as social services
Occurs in many health care settings, both
inpatient and outpatient
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48
Restorative Care: Extended Care

Extended care facility


Provides intermediate medical, nursing, or
custodial care for patients recovering from acute
illness or disabilities
Skilled nursing facility (intermediate care)

Provides care for patients until they can return to
their community or residential care location
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49
Continuing Care


For people who are disabled, functionally
dependent, or suffering a terminal disease
Available within institutional settings or in the
home:
Nursing Centers or Facilities
Assisted Living
Respite Care
Adult Day Care Centers
Hospice
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50
Continuing Care: Nursing Centers or
Facilities

Provide 24-hour intermediate and custodial
care




Nursing, rehabilitation, diet, social, recreational,
and religious services
Residents of any age with chronic or debilitating
illness
Regulated by standards: Omnibus Budget
Reconciliation Act of 1987
Interdisciplinary functional assessment is the
focus of clinical practice: MDS, RAIs
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51
Continuing Care: Assisted Living
—Offers a long-term care
setting with a home
environment and greater
resident autonomy
—Provides services such
as laundry, assistance
with meals, personal care,
housekeeping, and 24hour oversight
—Allows residents to live
in their own units
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52
Respite Care



The service provides short-term relief or “time
off” for persons providing home care to an ill,
disabled, or frail older adult.
Settings include home, day care, or health
care institution with overnight care.
Trained volunteers allow family caregivers to
leave the home for errands or social time.
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53
Quick Quiz!
1. A patient who needs nursing and
rehabilitation following a stroke would most
benefit from receiving care at a
A. Primary care center.
B. Restorative care setting.
C. Assisted-living center.
D. Respite center.
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54
Adult Day Care Centers



Provide a variety of health and social services
to specific patient populations who live alone
or with family in the community
May be associated with a hospital or nursing
home or may operate independently
Offer services to patients such as daily
physical rehabilitation and counseling
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55
Hospice




Family-centered care that allows patients to
live and remain at home
Focuses on palliative (not curative) care:
comfort, independence, and dignity
Provides patient and family support during
terminal illness and time of death
Many hospice programs provide respite care,
which is important in maintaining the health of
the primary caregiver and family.
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56
Case Study (cont’d)


Recently, Amy Sue has had some difficulty
breathing, especially during gym class.
Corrine is a 45-year-old African American
nurse, who recently accepted a job as a
school nurse for the four Catholic schools in
the area. Three of the schools are grade
schools, and one is Amy Sue’s high school.
Before she took this job, Corrine worked at a
pediatrician’s office.
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57
Issues in Health Care Delivery





Nursing shortage
Competency
Evidence-based practice
Quality and safety in health care/ Patientcentered care
Health care organizations are being
evaluated on the basis of outcomes such as
prevention of complications, patients’
functional outcomes, and patient satisfaction.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
58
Issues in Health Care Delivery
(cont’d)

Magnet Recognition Program



Nursing-sensitive outcomes
Nursing informatics and technological
advancements
Globalization of health care
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59
Case Study (cont’d)


Amy Sue’s difficulty managing her
asthma is significant for Corrine
because Corrine’s oldest daughter
has asthma.
In addition, because of her job in
the pediatrician’s office, Corrine
has had experience with caring for
children with asthma and with
helping patients access the health
care delivery system.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
60
Quick Quiz!
2. Technological advances in health care
A. Make the nurse’s job easier.
B. Depersonalize bedside patient care.
C. Threaten the integrity of the health care
industry.
D. Do not replace sound personal judgment.
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The Future of Health Care




Change opens up opportunities for
improvement.
Health care delivery systems need to address
the needs of the uninsured and the
underserved.
Health care organizations are striving to
become better prepared to deal with these
and other challenges in health care.
The solutions necessary to improve the
quality of health care depend largely on the
active participation of nurses.
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62
Chapter 3
Community-Based Nursing
Practice
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
New Stimulus for Community-Based
Nursing Practice


Because patients spend less time in acute
care settings, there is a growing need to have
organized health care services where the
population lives, works, and learns.
As community health care partnerships
develop, nursing is in a strategic position
to play an important role in health care
delivery and to improve the health of the
community.
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64
Focus of Community-Based Nursing
Health
Promotion
Disease
Prevention
Restorative
Care
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65
Community-Based Health Care

A model of care to reach all in a community



Focuses on assisting individuals and communities
with achieving a healthy living environment
Occurs outside of traditional health care
facilities
Provides services for acute and chronic
conditions
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66
Challenges

Public health
problems influenced
by:




Social lifestyles
Political policy
Economic initiatives
Current medical and
social problems
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67
Achieving Healthy Populations and
Communities

Healthy People Initiative (by USDHHS)


Establishes ongoing health care goals
Healthy People 2020

Goals are to increase life expectancy and quality
of life, and to eliminate health disparities through
improved delivery of health care services
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Improved Delivery of Health Care

Improved delivery of health care occurs
through
1. Assessment of health care needs of
individuals, families, and communities
2. Development and implementation of
public health policies
3. Improved access to care
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69
Assessment

Examples:




Systematic data collection (such as
incident rates) on the population
Monitoring the health status of the population
Accessing available information about the health
of the community
Examples of program results:



Adolescent smoking prevention
Sex education
Proper nutrition
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Public Health Policy Development +
Implementation

Health professionals provide leadership in


Developing public policies to support the health of
a population
Strong policies are driven by community
assessment:


Example: Assessment of level of lead poisoning in
young children
Example: Assessment of the number of people in
the community who need end-of-life care
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Improved Access to Care

Ensures that community-wide health services
are





Available to the total community
Accessible to the total community
Example: Five-level Health Services Pyramid
Role of community services near acute care
services
Healthy environments
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
72
Case Study


Kim Callahan is a student in a community
health nursing course. She is working in a
community nursing service within a large city.
Most of the patients in this agency are
Bosnian immigrants.
A major care initiative in this agency is to
provide well-child examinations and
immunizations to get children ready to enter
the public school system.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Community Health Nursing




Nursing practice in the community
Primary focus is on health care of individuals,
families, and groups.
Similar to public health nursing
Requires


Understanding the needs of a population
A set of skills and knowledge
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Community Health Nursing (cont’d)
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Essential public health functions:
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Community assessment
Policy development
Access to resources
Goal is to preserve, protect, promote, or
maintain health.
Provides direct care services to
subpopulations in a community
Competencies needed
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Nursing Practice in Community
Health
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Expert community health nurses:
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Understand the needs of a population or
community
Use critical thinking skills to apply knowledge
Understand resources
Needed skills:
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Patient advocacy
Communicating people’s concerns
Designing new systems that cooperate with
existing systems
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“Double Vision”
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Community health nurses:
Care for the
Assess the individual or
community as a family within the context of
whole
the community

Successful practice involves:
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Building relationships with the community
Being responsive to changes within the
community
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Community-Based Nursing
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Occurs in community settings
Involves acute and chronic care
Enhances individuals’ capacity for self-care
Promotes autonomy in decision making
Uses critical thinking skills
Reduces costs for the patient by providing
care near homes
Requires knowledge of family theory,
communication, group dynamics, and cultural
diversity
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Vulnerable Populations
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Examples:
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Immigrants
Poor and homeless
Abused
Substance abusers
Mentally ill
Older adults
Special needs of vulnerable populations are a
challenge.
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Multilevel Intervention
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Case Study (cont’d)
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Kim and her classmates conducted an
assessment of the community’s health care
needs and practices.
This is a close community that is facing many
challenges, although chronic disease is
absent in this population.
General preventive health care practices,
including well examinations and basic
screenings, are lacking.
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Competency in Community-Based
Nursing

Competency is
based on decision
making at the level
of the individual
patient.
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Competency in Community-Based
Nursing (cont’d)

Nurses utilize a variety of skills and talents:
Caregiver
Change Agent
Collaborator
Educator
Case Manager
Patient Advocate
Counselor
Epidemiologist
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Quick Quiz!
1. Vulnerable populations of patients are those
who are more likely to develop health
problems as a result of
A. Living at home.
B. Abusive habits.
C. Immigration.
D. Middle age.
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
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Case Study (cont’d)
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Many members of the Bosnian community
are suspicious of free/low-cost care.
Kim attends community meetings with her
community nurse preceptor to assess the
beliefs and concerns of the community.
Misunderstandings and fears about health
care services in this country are identified.
Kim uses beneficence—wanting to do the
most good for the most people.
Kim respects the community’s beliefs.
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Community Assessment


Assesses the community at large
Nurses care for patients from diverse
backgrounds and settings, but all
communities have three components:
Structure or Locale
People
Social Systems
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Case Study (cont’d)
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One single-parent family in the community is 30-yearold Katrina Dudek and her two children (aged 3 years
and 6 months).
Kim and the community health nurse work with Mrs.
Dudek to determine the health care needs of her
children and herself.
So far, Mrs. Dudek and her children have not
received any care.
Kim and Mrs. Dudek discuss the need for
immunizations of the children and set that as a goal.
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Quick Quiz!
2. In identifying needs for health policy and
health program development and services, a
community assessment focuses on which of
the following elements?
A. Structure
B. People
C. Social systems
D. Environments
E. All of the above
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Changing Patients’ Health


Nurses need an accurate assessment of
patients to design interventions that promote
health and prevent disease.
Patients are more likely to accept a change if
it is:
More Advantageous Compatible
Realistic
Easy to Adopt
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Case Study (cont’d)



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Kim identifies community leaders to serve as key
persons in educational programs.
Kim spends 12 weeks working with the community
agency and leaders to explain how the clinic provides
services and the confidentiality of these services.
Kim presented information in three homes as well.
A gradual increase was noted in the use of services,
including fewer “missed” appointments.
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