MacDonald/Jakubec: Stanhope and Lancaster’s Community Health Nursing

in Canada, 4th Edition

Chapter 01: Community Health Nursing

Answers to Case Studies from Textbook

CHN IN PRACTICE: A CASE STUDY

Identifying the Inequities
You are joining CHN Kristin as an additional CHN at the community health centre in Houston, a
small town in northern British Columbia with a population of approximately 3200 people. Key
activities in the surrounding area are fishing and other outdoor recreation, and the main
industries are tourism, mining, and forestry. Keep in mind that all communities have some health
inequities.

Think About It
1. What information would you need to explore in your new community in order to identify the
possibility of health inequities? Provide rationales for your choices.

ANSWERS
1. Health inequities can be understood by exploring the relationship of employment, housing,
income, food security, education and other determinants and social determinants to health status
and outcomes. Key social determinants can create inequities that can and should be addressed
through social and environmental considerations (addressing the concerns as individual health
problems is, at best, a band aid to a much larger wound).

CHN IN PRACTICE: A CASE STUDY

Ethical Principles
Kristin works with Geoff, a 51-year-old single man who works seasonally picking mushrooms
and resides in a pickers’ campsite during the summer season. Geoff’s summer work is complete,
and he has found temporary shelter “squatting” in an unoccupied cabin in Houston, British
Columbia where he has resided for the past five years on and off, preferring to live “off the grid.”
Geoff’s temporary employers has alerted the Huston community health centre that Geoff was
diagnosed with tuberculosis but has not received treatment. His employer reported that during
the last few weeks of the picking season, Geoff had a persistent, productive, blood-streaked
cough, excessive sweating, and considerable weight loss.
Kristin visited Geoff’s cabin and invited him to the health centre with a plan to convince him
to get treatment in the hospital one hour away and arrange transportation for him to get there.
Geoff is a self-professed loner who tends to be suspicious of others and does not want to be part
of the “system” or be confined to a hospital. Kristin is attentive to his perspective, bus she is also
aware of her role in protecting the health of the public, and Geoff’s active illness is contagious.
The ethical principle most relevant to this situation is the harm principle, which is described by
John Stuart Mill as follows: “The only purpose for which power can be rightfully exercised over
any member of a civilized community, against his will, is to prevent harm to others. His own
good, either physical or moral, is not a sufficient warrant.”

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Answers to Case Studies from Textbook 1-2

While Geoff refuses to be hospitalized, the concern is not for his welfare (he is not refusing
treatment) but for the welfare of the public’s health. Temporarily restricting Geoff’s freedom by
arranging for his treatment in hospital would be for the prevention of harm to others. If the
restriction were only for the perceived welfare of Geoff as an individual, it would be considered
paternalistic and a violation of the harm principle.

Think About It
1. Is there a way to find a compromise?
2. How can Kristin explain the ethical rationale for hospital treatment to Geoff in a way that
preserves his dignity?
3. How can Kristin maintain Geoff’s dignity even if she has to exercise power over him to get
treatment in hospital for the public good?

ANSWERS
1. In this case Geoff may be willing to receive treatment, but will still need to be monitored. If
there is capacity within the health centre for Geoff to be treated with home care follow-up, there
may be a feasible compromise. He must, however, be treated with minimal exposure of
vulnerable others in the community.

2. Kristin can explain that because of the public health consequences of this illness, hospital
treatment—even if not Geoff’s preference—may be the best public health treatment, a short-term
solution with longer-term benefits for managing this infectious disease.

3. If Geoff is not willing to work with a compromise, and is posing a risk to public health, Kristin
could initiate treatment in hospital by promoting the idea of a self-initiated admission versus an
imposed admission. If there is a forced public health concerned admission, Kristin, could support
Geoff through the admission, and liaise with the hospital staff so they can better understand
Geoff’s reluctance and suspiciousness. In this way, the CHN can act in a mediator role.

CHN IN PRACTICE: A CASE STUDY

Upstream, Midstream, and Downstream Approaches
In January, Kristin notices a spike in the numbers of clients attending the community health
centre with complaints of colds and respiratory irritation or seeking allergy and asthma
treatment. Assessing these individuals, she notices a commonality. Many workers in the
community, attempting to save money, reside in overcrowded rented cabins during the winter
while off work and away from seasonal work camps that provide housing at mining, forestry, or
fishing work sites during spring, summer and fall.

Think About It
1. Reflecting on possible levels of intervention—upstream, midstream, and downstream—how
could Kristin address this issue?

ANSWERS

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Answers to Case Studies from Textbook 1-3

1. Upstream, Kristin could consider collaborating with the regional housing societies and
agencies to communicate the costs to these individuals and the community due to a lack of
affordable housing.
Midstream, Kristin could consider education and support for cold and respiratory prevention
(such as handwashing and other strategies) for the seasonal workers in the community.
Downstream Kristin could address this issue with treatments for cold and respiratory
irritation.

CHN IN PRACTICE: A CASE STUDY

Identifying Levels of Prevention
Mr. Yablonzski, a 75-year old retired miner, was discharged from the hospital in Smithers,
British Columbia, with a referral from the Houston community health centre for home health
care services at his home in Houston. This referral was made to assess his respiratory status
following a diagnosis of chronic obstructive pulmonary disease (COPD).
Episodic care from CHN Kristin involves teaching Mr. and Mrs. Yablonzski about Mr.
Yablonzski’s medications and how to implement healthy lifestyle patterns. Because Mr.
Yablonzski lives with his wife and daughter, Kristin conducts a family nursing assessment (see
Chapter 12) to determine the family’s current health status, its health concerns, and its strengths
and capacities. The family’s psychosocial adaptation and the client’s level of self-care and
adjustment are also assessed. Based on her assessment, Kristin identifies health-enhancing
behaviours such as smoking cessation, nutrition, moderate exercise, stress management, and
immunization, especially flu vaccines. She also assesses Mr. Yablonzski’s rehabilitation to help
him reach his optimal level of functioning.
Distributive care from Kristin involves teaching Mr. Yablonzski ways to prevent
exacerbating his condition (e.g., medical follow-up and lifestyle adaptations to increase his
adherence to the programs set out for him) so that he can achieve his optimal level of
functioning.

Think About It
1. What levels of prevention do medical follow-up, smoking cessation and moderate exercise
reflect?

ANSWERS
1. Medical follow-up reflects a tertiary level of prevention for COPD; smoking cessation reflects
a secondary level of prevention—or preventing worsening of a disease or condition such as
COPD; and moderate exercise reflects a primary level of prevention.

CHN IN PRACTICE: A CASE STUDY

Collaborative Community Health Practice
In the town of Houston, British Columbia, Kristin has established collaborations with several
CHNs and other practitioners, including home health services, a contracted substance use and
addictions service social worker, the region’s Northern Society for Domestic Peace, as well as
the environmental health officer and community mental health nurse in the bigger town
approximately one hour away. A recent resurgence of the mining and natural resource industries

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Answers to Case Studies from Textbook 1-4

has added to community prosperity. It has also led to an increase in transient workers and greater
disposable income for people in the town—with added concerns of substance use and violence in
the community.

Think About It
1. To what extent do you think that practices of collaboration can be used in Kristin’s CHN
practice in Houston to address her current concerns?

ANSWERS
1. Answers will vary—with different rationales.

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