NUR 100 Sherpath Week #

Ch 3 Community Based Nursing / Public Health Nursing Lec DATE

Community-based nursing is a branch of community health nursing that focuses on providing direct nursing care for
individuals in a community. In community-based nursing, care takes place not in an inpatient hospital or traditional
outpatient clinic, but in a location in the community or in an individual's home. Occupational, school, corrections,
private-duty, parish, camp, forensic, home, hospice, and palliative care nurses are some of the many nursing specialists
who practice in community settings.

Community-based nursing focuses on interventions necessary to help individuals prevent illness, maintain or regain their
health, or die with dignity in a community. The term client, rather than patient, is commonly used in this area of nursing
practice to identify the person receiving care. As is true in all areas of nursing practice, the relationship between the
nurse and the patient is participatory and collaborative.

Community-Based Nursing Locations

Community-based nursing may take place at any number of locations within a community. Community-based nurses are
employed in a wide variety of organizations, including:

 Home health agencies (public  Teen outreach centers  Senior centers

and private)  Churches  Camps
 Schools  Homeless shelters  Workplaces
 Corrections facilities  Public nursing clinics

The Role of the Community-Based Nurse

Essential functions of community-based nurses include advocating for patients, conducting routine checkups, caring for
the sick or dying, managing chronic conditions, providing patient education, and connecting patients with necessary
health-related resources.

One of the most important responsibilities of community-based nurses is to be familiar with local health care service
agencies. Community-based nurses maintain current information about health and social services available within the
community and match each patient with services in line with the patient's unique needs and preferences.

Overview of Home Care Nursing

An integral part of community-based nursing is home care nursing, a dynamic field of care that provides services for
health-related issues in the patient's home. The purpose of home care nursing is to promote, maintain, or restore health
at an optimal level of functioning and to reduce the effects of disability and illness for individual patients and their
families in the home setting.

Home care nurses care for patients with conditions across the clinical spectrum, from acute illnesses to long-term health
conditions, permanent disabilities, and terminal illnesses. Patients who receive home health care represent all age
groups, from newborns to older adults. Home health care services are typically reimbursed by Medicare, Medicaid, and
private health insurance companies.

Types of Home Care Nursing

Home care nurses can be generalists or specialists in certain fields. Examples of home care nursing specialty areas
include mental health care, wound/ostomy care, infusion/IV line care, prenatal care, newborn care, lactation support,
chronic disease management, palliative care, and hospice care.

Page 1 of 12
 NUR 100 Sherpath Week #
Ch 3 Community Based Nursing / Public Health Nursing Lec DATE

Palliative Care Hospice Care

Palliative care is comfort care offered to End-of-life care for the terminally ill is called hospice care.
patients at any stage of a serious illness.

The goal of palliative care nursing is to relieve The goals of hospice nursing are to relieve suffering throughout the
or reduce intensity of uncomfortable illness, to be of support to the patient and family, and to work with the
symptoms, but not to produce a cure. family, providing grief support after the death of the patient.

Responsibilities of the Home Care Nurse

Common responsibilities of home care nurses are to visit patients in the home and provide hands-on nursing care,
education, and case management.

The coordination of home health care services most often is provided by a registered nurse, but a multidisciplinary team
may be involved depending on the needs of the patient. The team members may include specialty nurses, physical
therapists, occupational therapists, social workers, pharmacists, registered dieticians, advanced practice nurses, and
health care practitioners, as well as unlicensed assistive personnel such as home care aides and personal care assistants.

The role of the registered nurse in home health care is essentially autonomous in that the nurse must be highly
proficient in physical and mental health assessment, be well versed in technical and clinical skills, possess strong critical-
thinking and clinical reasoning abilities, and demonstrate excellent organizational skills.

Respectful Relationships

Home care nurses are guests in the patient's place of residence. Respect for the patient's personal environment,
resources, and caregivers must be demonstrated throughout the visit.

It is vitally important for home care nurses to establish trusting relationships and to interact effectively with patients,
their families, and other caregivers. These efforts are key to promoting open communication and compliance with
procedures that need to be performed routinely when the nurse is not present.

Professional Performance Standards in Home Care

The American Nurses Association (ANA) has developed specific standards and defined the unique scope of practice for
home care nursing. The Standards of Professional Performance for Home Care Nursing describes the competent level of
behavior for the professional role of a home health nurse (ANA, 2014b).

STANDARDS OF PROFESSIONAL PERFORMANCE FOR HOME CARE NURSING

1. Quality of Care The home health care nurse systematically evaluates the quality and effectiveness of his or her
nursing practice.

2. Performance The home health care nurse evaluates his or her own nursing practice in relation to professional
Appraisal practice standards, scientific evidence, and relevant statutes and regulations.

3. Education The home health care nurse acquires and maintains current knowledge of and competency in
nursing practice.

4. Collegiality The home health care nurse interacts with and contributes to the professional development of
Page 2 of 12
 NUR 100 Sherpath Week #
Ch 3 Community Based Nursing / Public Health Nursing Lec DATE

peers and other health care practitioners.

5. Ethics The home health care nurse's decisions and actions on behalf of patients are determined in an
ethical manner.

6. Collaboration The home health care nurse collaborates with the patient, family, and other health care
practitioners in providing patient care.

7. Research The home health care nurse uses research.

8. Resource The home health care nurse assists the patient and family in becoming informed consumers
Utilization about the risks, benefits, and costs of planning and delivering patient care.

Overview of Home Care Assessments

Like acute care nursing, home care nursing follows the nursing process.

Nursing Process Key Responsibilities in Home Care Nursing

Step

Assessment Assess the patient and the patient's environment according to agency standards and best practice.

Diagnosis Analyze assessment data to determine nursing diagnoses.

Goal Identification Identify measurable patient-centered goals.

Planning Develop a plan of care, including collaborative care with other professionals or agencies.

Implementation Independently or collaboratively implement interventions to meet established goals.

Evaluation Evaluate progress toward attainment of goals.

Basic Home Care Assessment

During a home care assessment, the nurse focuses on the patient's direct health care needs as well as a vast number of
environmental factors with potential impact on patient safety. These factors include conditions affecting mobility, such
as the presence of steps, carpeting or throw rugs, safety railings, and grab bars in the tub or shower.

Examples of factors considered in a basic home care assessment are:

 The patient's ability to obtain access to and prepare food or light meals.

 The patient's level of hygiene and ability to groom, dress independently, and bathe.

 The height of the toilet and the patient's ability to ambulate and transfer to the toilet.

Living conditions are evaluated for safety and infection control purposes: Is the home relatively clean, with functioning
smoke alarms? Is the patient able to use the telephone in case of an emergency? As is evident, the role of the home care
nurse in assessment is even broader than that of the acute care nurse.

Page 3 of 12
 NUR 100 Sherpath Week #
Ch 3 Community Based Nursing / Public Health Nursing Lec DATE

Outcome and Assessment Information Set (OASIS) 

must be completed by nurses working for Medicare-certified home health agencies (Centers for Medicare and Medicaid
Services, 2010b).

OASIS is a data set of outcome measures for adult home health care patients that is used to track outcome-based quality
improvement. For adult patients who receive skilled care, OASIS is used to document the plan of care, note patient
characteristics, and evaluate and improve the clinical performance of each home health care agency. The OASIS
document, which is approximately 24 pages long, is completed by the home health care nurse:

 at the start of care  every 2 months until care is completed  at discharge

Nurses use the OASIS data set to assess home care patients in each of the following areas:

 Current and past medical and surgical history

 Influenza and pneumococcal vaccination status

 Living arrangements and activities-of-daily-living capability

 Sensory status and neurologic, emotional, and behavioral status

 Integumentary status

 Respiratory and cardiac status

 Elimination status

 Medication regimen and patient and caregiver understanding of required medications and schedule

 Therapy needs and schedule

 Hospitalizations, including admission and discharge plans from inpatient facilities or agencies

 Plan of care management

Nursing Diagnoses in Home Care Nursing

Identifying nursing diagnoses for a home health patient uses the same process that is used for an individual in an acute
care setting. Nursing diagnoses are patient-centered.

Examples of nursing diagnoses related to home care issues are:

 Caregiver Role Strain related to 24-hour care giving responsibilities as evidenced by disturbed sleep and
inadequate time to meet personal needs

 Social Isolation related to unacceptable social behavior as evidenced by verbalization of hostility when

interacting with others and stated preference to be alone

 Nutrition Imbalance: Less Than Body Requirements related to inability to obtain access to and prepare food as
evidenced by 20-lb weight loss in 1 month

Page 4 of 12
 NUR 100 Sherpath Week #
Ch 3 Community Based Nursing / Public Health Nursing Lec DATE

Establishing Goals in Home Care Nursing

Once nursing diagnoses are identified and prioritized, the home care nurse can establish goals. Goals in home care
nursing are patient-centered. Examples of measurable patient-centered goals that align with home care nursing
diagnoses are:

Nursing Diagnosis Measurable Patient-Centered Goal(s)

Caregiver Role Strain related to 24-hour care giving   Patient and caregiver will verbalize options for
responsibilities as evidenced by disturbed sleep and caregiver respite at conclusion of meeting with
inadequate time to meet personal needs. home care nurse.

Social Isolation related to unacceptable social behavior as
evidenced by verbalization of hostility when interacting with
others and stated preference to be alone.
 Patient will verbalize two causes of hostile
emotion within one week.
 Patient will make time once a day to visit with
family members for 15 minutes within 3 days.

Nutrition Imbalance: Less Than Body Requirements related to  Patient will verbalize understanding of contact
inability to obtain access to and prepare food as evidenced by information for Meals on Wheels at conclusion
20-lb weight loss in 1 month. of meeting with home care nurse.

 Patient's weight will increase by 2 pounds within

2 weeks.

Implementation and Evaluation

Interventions commonly implemented in home care nursing include patient assessment, education, risk management,
disease management, referrals, and coordination of services between agencies.

Because the home care nurse often functions both as a direct care provider and a care manager, evaluating effectiveness
of care for home care patients involves independent evaluation of patient progress as well as communication with
multiple professionals to determine if goals were met.

Public Health Nursing 

Community health nursing:

 broad category of nursing and related services designed to

serve a community and its members.
 Branches of include:
1. Public health nursing focuses on the health of a
population
2. community-based nursing focuses on providing care
to individuals within that community.

The terms community health nursing, public health nursing,

and community-based nursing describe specialty practices
related to care of communities and community members.
Page 5 of 12
 NUR 100 Sherpath Week #
Ch 3 Community Based Nursing / Public Health Nursing Lec DATE

1. Community health nursing is a broad term that

encompasses work done in communities to
addresses issues of health and disease either
within a population or for a specific individual of a
community.

2. Public health nursing is a branch of community

health nursing that focuses on health promotion
and disease prevention in a population.

3. Community-based nursing is a branch of

community health nursing that focuses on
providing direct nursing care for individuals in a
community setting, such as in a home, school, or
workplace.

Public health nursing examines the greater

community as a whole—the city, county, state,
nation, continent, world—and designs collaborative
and interdisciplinary strategies to keep the population
healthy by preventing or controlling disease and
threats to human health. Essential services include:

1. Assessment services:

a. Monitoring health status to identify community health problems

b. Diagnosing and investigating health problems and hazards

2. Policy Development services:

a. Informing, educating, and empowering individuals and populations about health issues

b. Mobilizing community partnerships to identify and solve health problems

c. Developing policies that support individual and community health efforts

3. Assurance services:

a. Enforcing laws and regulations that protect health and ensure safety

b. Linking populations to necessary heath care services

c. Assuring a competent health care workforce

d. Evaluating effectiveness of health services

e. Conducting research for new insights and innovative solutions to health problems

Page 6 of 12
 NUR 100 Sherpath Week #
Ch 3 Community Based Nursing / Public Health Nursing Lec DATE

Target Populations in Public Health

In public health nursing, assessments, planning, and interventions focus on a defined population.

target population   a defined group of people within a community.

 Identified in order to study the population and customize services to best meet that
population's needs

Target populations may be broad or focused. Examples include:

 Women over 40 years of age in the United States  Expectant parents in a suburb of Chicago
 All people living in a large metropolitan area  Older adults living in a particular senior high-rise
 Children in preschools in a tri-state area center

Vulnerable  are target populations at high risk for health problems

populations   of particular concern to public health nurses

Populations at high risk for compromised health as a result of life experiences and circumstances, beliefs, dependency,
or lack of resources include:

 People who have experienced a natural disaster, such as an earthquake, or a human-caused disaster, such as
a terrorist attack
 Minority groups within a larger population, including members of various cultural, racial, religious, age, and
gender groups
 Refugees and immigrants  Mentally ill and disabled people
 Military personnel and veterans  Substance abusers or people with severe chronic illnesses
 Workers exposed to chemicals or  People who have been emotionally, physically, or sexually
radiation abused or neglected
 Homeless people or families

Health and Disease Factors: Epidemiology

Many factors affect the health of members of a community:

 Host factors or intrinsic factors include genetics, age, gender, ethnic group, immunization status, and human
behavior.

 Environmental factors or extrinsic factors relate to:

o the immediate physical environment

o the biologic environment (including food sources and vectors of disease, such as animals and insects),
o socioeconomic influences, such as:
 workplace conditions
 residence in an urban versus a rural setting
 potential impact of social unrest or disaster on a community.

Page 7 of 12
 NUR 100 Sherpath Week #
Ch 3 Community Based Nursing / Public Health Nursing Lec DATE

Public health nurses, in collaboration with other public health specialists from various disciplines, study factors that
influence health and disease within a population. Public health professionals who specialize in epidemiology study
factors that influence the frequency and distribution of disease, injury, and other health-related events and their causes
within a population. The purpose of their work is to establish programs to measure and prevent disease and control its
spread.

Epidemiology study of incidence and prevalence (pervasiveness or extent) of disease within a population

Descriptive  the first stage of epidemiologic investigation. It focuses on describing disease distribution by
epidemiology  characteristics relating to time, place, and person.
 consists of studies that are conducted once a disease is evident. Data collected in descriptive
epidemiology studies describe the time and place of occurrence of the disease and the
characteristics of people affected by the disease.
Analytic  descriptive data, generates a hypothesis of why the disease might be occurring in the
epidemiology community, and then tests the hypothesis.

 Essential Functions of the Public Health Nurse

work to promote health and prevent or manage disease within a population. Common employment include public
health agencies and county or state departments of health.

What makes nurses ideal community health practitioners is: the foundation and preparation for nursing practice, which
is grounded in the sciences, liberal arts, and social sciences; the nursing process itself, including evidence-based
interventions; and the critical component of evaluating outcomes. It is not uncommon to see nurses leading community
planning meetings with other collaborative disciplines as initiatives are developed to improve the health outcomes of a
target group, community, or nation.

Levels of Community Health Care Services

Public health organizations implement a variety of community health interventions and services, which can be
categorized into three levels of prevention:

Primary interventions designed to prevent disease or disability i.e.

prevention   food banks offering healthy food options for low-income populations
 employee wellness programs
 fitness classes
 smoking cessation programs
Secondary focuses on identifying an illness or phenomenon and limiting its impact or recurrence through
prevention  specific interventions. i.e.
 blood pressure screening for older adults
 toxin screening for migrant workers who may be exposed to pesticides
 screening for exposure to domestic violence
 training nurses in recognition of signs of child abuse
Tertiary involves interventions for those populations already experiencing symptoms of disease or disability.
prevention  focuses on maintenance or restoration of health, and rehabilitation. i.e.
 cancer patient support groups
 pain management counseling
 cardiac rehabilitation programs
 workplace modifications for disabled workers

Page 8 of 12
 NUR 100 Sherpath Week #
Ch 3 Community Based Nursing / Public Health Nursing Lec DATE

The Role of the Public Health Nurse

Essential functions of public health nurses include provision of education, promotion of healthy lifestyles, coordination
of services, consultation with public entities, and participation in regulatory activities (ANA, 2013).

Essential function Example of intervention

1. Provide health education Design breast feeding promotion posters and written materials for distribution in free
clinics

2. Promote healthy Promote healthy food choices through outreach programs in middle schools
lifestyles

3. Coordinate services Connect low-income populations with quality affordable health care services

4. Consult with government Advocate with housing authorities to ensure accessible and safe housing for
officials vulnerable populations

5. Participate in regulatory Establish isolation or quarantine for a patient or population with a known high risk
activities communicable disease

Professional Standards in Public Health Nursing

Public health nurses practice in accordance with professional standards, scope of practice, and health care policy laws.

The American Nurses Association's (ANA's) Public Health Nursing: Scope and Standards of Practice (2013) publication
mandates that public health nurses, like all nurses, engage in the following professional practices:

1. Participation in research 4. Leadership

2. Responsible resource utilization 5. Advocacy
3. Ethical behavior

The Quad Council of Public Health Organizations establishes standards to guide the evolution and development of
nursing practice aimed at population-based care. The skills reflected in these standards are similar to those used in acute
and ambulatory care settings. The focus of interventions, however, is working with populations rather than just one
person or family.

The Nursing Process in Public Health: Overview

Public health nursing, like direct care nursing, is grounded in the nursing process. In public health nursing, however, each
step of the nursing process focuses on a defined population rather than on an individual.

Nursing Process Step

Unique features in public health nursing
1. Assessment Assessments of a community or target population are done using community health assessment
instruments, community health assessment questions, and/or vital statistics records.

Page 9 of 12
 NUR 100 Sherpath Week #
Ch 3 Community Based Nursing / Public Health Nursing Lec DATE

Nursing Process Step

Unique features in public health nursing
2. Diagnosis Nursing diagnoses are population-centered and identify greatest problems or needs within the
population.

3. Planning Goals are population-centered. Interventions are planned on the primary, secondary, and
tertiary levels of prevention.

4. Intervention Interventions are implemented in the target population.

5. Evaluation Effectiveness of an intervention is evaluated for the target population using the population-
centered goal as the evaluation criteria.

Community Assessment Tools

One commonly used community health assessment instrument is the windshield survey.

 a visual assessment of a community done by walking or driving through a community.

 begins the initial needs assessment by collecting data through observation of the community's:

 geography  Industry  Communication

 population  Education  Transportation
 environment  recreation  public services

Factors documented in a windshield survey include:

1. Whether people are walking or are engaged in physical activity

2. Availability of single- or multiple-family private and public housing units
3. Availability of health, safety, and social services agencies, located along a bus route or other public
transportation line
4. Presence of spiritual or religious places of worship, educational institutions, and news and media services, as
well as types of open and closed businesses and industries
5. Availability of grocery stores
6. General appearance and condition of neighborhoods

Community-Focused Health Assessment Questions

Asking key informants community-focused health assessment questions can provide the public health nurse with insight
into the health issues and needs of a community. Some community assessment questions are broad and open-ended to
help discern general information, whereas others seek to assess specific factors within a community, such as nutritional
resources or the availability of walking and biking trails. Examples include:

1. What is the history of the community?

2. What sources of information are available to help with identifying key data?
3. What are the environmental and sanitation services that protect the water supply, inspect restaurants, and
license day care facilities?
Page 10 of 12
 NUR 100 Sherpath Week #
Ch 3 Community Based Nursing / Public Health Nursing Lec DATE

4. What health promotion and educational services exist, and where are they located?
5. Are there school nurses in each building?
6. Are there public health clinics and health fairs?
7. What preventive services are available, where, and to what populations?
8. Are target populations able to gain access to health care services where they are located?
9. Who are the stakeholders in the community, and what are their main concerns?

Demographic Assessment Tools

Some assessments of populations are conducted most efficiently through demographic research using online public
resources.

By examining vital statistics records available on the Internet for global, national, state, county, or community regions,
nurses can identify the leading causes of disease and death in those areas in regard to non-communicable diseases, such
as heart disease, cancer, hypertension, and diabetes. Reference websites also help community nurses identify the
incidence and prevalence of communicable diseases, such as tuberculosis (TB), sexually transmitted infections (STIs), and
HIV/AIDS, and the life expectancy of target populations.

Useful demographic assessment tools and community health planning resources include the following:

 WHO data and statistics  Centers for Disease Control and Prevention

 United States Census data  Healthy People 2020
 State department of health data websites  Occupational Safety and Health Administration

Nursing Diagnoses in Public Health Nursing

Identifying nursing diagnoses based on community assessment data is similar to the process used for an individual.
However, nursing diagnoses in public health are population-centered. A variety of needs may emerge as a result of a
thorough community assessment, making it necessary for the nurse to carefully prioritize diagnoses before initiating
goals and interventions in collaboration with community partners.

Examples of nursing diagnoses related to public health are:

 Deficient Community Health related to increased risk of pertussis as evidenced by inadequate immunization of

children and adults in the community

 Risk for Injury with the risk factor of potential chemical exposure to individuals living within 500 feet of chemical
spill site

 Ineffective Community Coping related to extensive hurricane damage as evidenced by residents expressing

powerlessness and lack of financial resources to restore services

Establishing Goals in Public Health Nursing

Once the greatest concerns of a community or defined population are determined through nursing diagnosis, the public
health nurse can establish goals. Note that goals in public health nursing are population-centered.

Examples of measurable population-centered goals that align with public health nursing diagnoses are:

Page 11 of 12
 NUR 100 Sherpath Week #
Ch 3 Community Based Nursing / Public Health Nursing Lec DATE

Nursing Diagnosis Measurable Population-Centered Goal

Deficient Community Health related to increased risk of pertussis  Immunization rates of children and adults in
as evidenced by inadequate immunization of children and adults the community will increase by 10% within the
in the community. next year.

Risk for Injury with the risk factor of potential chemical exposure  Individuals living within 500 feet of the
to individuals living within 500 feet of chemical spill site. chemical spill site will show no signs of chemical
injury one week after the spill.

Ineffective Community Coping related to extensive hurricane  Residents will verbalize understanding of

damage as evidenced by residents expressing powerlessness and how to contact two sources of help to restore
lack of financial resources to restore services. services within three days.

Determining goals for community health must include key stakeholders (individuals or groups with an investment or
significant interest in a topic).

For instance, if the public health nurse consultant in a large manufacturing plant identifies a risk for injury from
inconsistent use of safety goggles by drill press operators, the owners of the company and the workers themselves
would be stakeholders. In this case, the nurse would want to collaborate with representatives from both groups to
establish a safety-related goal acceptable to all parties. This approach would help ensure compliance with agreed-on
procedures, thus increasing the likelihood that the best possible outcome, i.e., consistent use of safety goggles would be
achieved.

Planning and Implementing Interventions: Collaboration

Planning and implementing public health interventions often require collaborative efforts to help a target population
reach an established goal. It is vital that nurses establish and maintain strong relationships with key collaborative
partners to enhance cooperation.

Public health nurses collaborate with a wide variety of professionals and agencies, including:

 Community leaders  Physical and occupational therapists

 Primary health care providers  Administrators of child and adult day care centers
 Dentists  Community hospital administrators and staff
 Dieticians  Visiting nurse association representatives and leaders
 Biostatisticians  Public officials, including governors, mayors, and council members
 Epidemiologists  City parks and recreation department officials
 Accountants  Public health department officials
 Health policy makers  Media outlets (television, radio, newspaper, and online resources,
 Nurse educators including social media sites)

Evaluation of Public Health Nursing Interventions

Just as interventions must be collaborative within the community setting, so must evaluation of programs and services.
A nurse can lead the evaluation process by designing strategies and tools that will determine whether outcome criteria
are met. Data and statistical analysis to support outcome findings is especially significant in working with business
owners and government agencies that invest financially in public health services.
Page 12 of 12