Unit 1: Community Health

Nursing
Current status, trend, socio-cultural issues and
challenges related to community health nursing

Presented by:
Nisha Dwa
Shushila Pokharel
Current Status:
• Community health nursing has evolved into a focus on care
of individual, families and communities.
• Community health nursing emphasizes on the personal and
environmental health of the total population and not just of
selected individuals.
• Community health nursing focuses on promoting health
related behaviors as well as providing personal health
services to members of populations or communities.
Contd…
• Community health nursing pays attention to the influence of
environment factors (physical, biological and sociocultural) on
the health of populations and priority is given to preventive and
health maintenance strategies rather than curative strategies.
• The nurse today performs demanding tasks to meet the needs of
the society.
• Her job is not only limited to the sick but also to prevent diseases
and to preserve and promote the health of the people.
Contd…
• As a home care nurse, they provide care to the patients at
their home itself.
• Nurses provide antenatal, postnatal and child care services in
the MCH and family planning services.
• The school health nurse renders services to promote and
protect the health of the school children.
Contd…
• They provide primary health care in the community, carry out
immunizations, conduct under five clinics, assess the social,
environmental and nutritional needs of the community.
• Nurses are employed in industries. They carry out the pre-
employment and periodic health checkup, care of sick, first
aid, industrial sanitation, safety and rehabilitation.
Current Trend:
According to Dr. E.G. Mcgaveran, these changes are divided into four
eras from middle of 19th century to middle of 20th century onwards.
• Empirical Era (Upto 1850)
• Basic Science Era (1850 to 1900)
• Clinical Science Era (1900 to 1950)
• Public Health/Community Science Era (1950 onwards)
One more era has been added by W.L. Barton from 1975-2000 AD
and is called as Political Science Era which is Health for All (HFA)
era.
Empirical Era (Upto 1850)

• The focus for this era was on relieving of symptoms.

• The objective was to make diagnosis and give treatment of
symptoms.
• Symptomatic treatment like use of poultices, ointments,
cupping, leaches, trepines, etc. to relieve variety of
symptoms.
Basic Science Era (1850 – 1900)

• The focus of this era was on curing of disease.

• The objective was to make diagnosis and give treatment of
disease and symptoms both.
• This change occurred due to invention of microscope and the
discovery of bacteria causing various diseases.
• This was the first scientific change from “Symptom Focus”
to “Disease Focus”.
Contd…
• The change was not liked by the health professionals of the
Empirical Era.
• Health practices were much more complicated, difficult and
expensive.
• Health professionals required necessary knowledge and skills.
• The education and training became very expensive.
• Research in laboratory investigations and disease became an
essential component of health practice.
• Traditional practices had to be discarded.
Clinical Science Era (1900 – 1950)
• The focus of this era was “Total Patient”.
• The objective was not only the scientific diagnosis and
treatment of his disease but assessment of an individual as a
whole which includes physical, emotional, mental, social and
spiritual self to identify his health status and health needs.
• The change from disease centered approach to patient
centered approach was due to new knowledge and skills in
the field of behavioural sciences and observation of the fact
that the correct treatment of disease did not necessarily cure
the patient.
Contd…
• Like the Basic Science Era, this era was also resisted and
resented by environment health professionals of that time.
• The health practices in this era were more complex, difficult
and expensive than those in the Basic Science Era.
Public Health or Community Health Science Era (1950 – 1975)

• This era is community centered era. This was yet another

tremendous change from patient centered focus to
community centered focus.
• The objective was scientific diagnosis and treatment of
families, groups and entire community.
• This era emerged due to new knowledge and advancement in
health science which has helped to recognize that each
community has a distinct entity comprising of its specific
geographic boundaries, physical setup, and people living and
interacting in this setup, having common life style, social
structure etc. and use of common resources.
Contd…
• During this era, man was considered in total context, in
relation to his environment.
• Community diagnosis and treatment gained greater
importance rather than individual patients.
• The interdisciplinary team approach was introduced in the
delivery of health care.
• Therefore, there was a realization that the health of a
community is established not merely by the absence of
disease but by considering the socio – economic and socio –
cultural factors which play a significant role in the
maintenance of health.
Political Science Era or Health for all Era (1975 onwards)

• This is people centered era.

• WHO conceived the goal of “Health for All (HFA)” in the 30 th
World Health Assembly in 1977.
• It was decided that main social goal of the Government and of the
WHO should be the attainment by all the people of the world by
the year 2000 AD, of a level of health that will permit them to
work productively and to participate actively in the social life of
their community.
• Primary health care was declared as the strategy to attain this goal
by WHO and UNICEF jointly during the International
Conference at Alma Ata in 1978.
Contd…
• Health for all is a social goal and is considered as integrated
part of socio-economic development of the community.
• Major emphasis is laid on preventive and promotive aspects
of health, well integrated with curative, rehabilitative and
environmental measures.
• Health now is the community’s concern and possession.
• The community is responsible for providing all facilities and
total care to all.
• Community health nursing practice primarily rests outside
the therapeutic institution.
• However, community health nursing links the hospital and
the community.
• Community health and community health nursing draws
knowledge from other sectors such as medicine, surgery,
pediatrics, obstetrics, gynaecology, dentistry, health
education and vital statistics.
The trends influencing community health and nursing can be
categorized as:

1) Demographic Trends:
• Increased life expectancy leading to greater percentage of
elderly individuals.
• Increased number of elderly individuals has resulted in a
need for greater emphasis on the prevention, diagnosis and
treatment of chronic disease.
2) Technological Trends:
• Technological trends that currently influence health and
health care delivery include such things as the knowledge
explosion, the increased ability to prolong life, environmental
pollution, increased pace of life.
3) Socio-cultural Trends:
• Health is taken as a right rather than a privilege.
• National health insurance policies have been introduced.
• Provisions for hospitalization, ambulatory care, and health
maintenance are provided.
• Health as a positive state rather than the absence of disease.
• Increasing use of mass communication techniques.
4) Economic Trends:
• The rising cost of health care causes the people to seek cost
effective facilities in the community hospitals rather than the
private hospitals.
• Self care by individuals is another consideration in the
provision of health care in today’s economy due to mal-
distribution of health care services.
CHANGING PRACTICES

• During the period from 18th century to early 19th century:

Care of the sick and control of communicable diseases
through some restrictive measures like isolation, quarantine
and by having control over selected component of
environmental sanitation through legislation.
Care of sick was done by family members and religious men
and women.
Contd…
• During the second half of 19th and the 20th century:
 The modern concept of public health laid its foundations.
It was felt that sufferings could not be relieved and diseases
could not be prevented through laws.
There are certain responsibilities which must be taken care of
by the individual, family and the community to control diseases
and to attain health.
 This idea initiated with the services to mothers and children to
reduce morbidity and mortality among them and health
education of people to practice hygienical measures.
• Public health nursing is the direct outgrowth of these public
health services when the need for trained personnel was felt
for providing service to mothers and children including
school children.
• These services were rendered to poor people and not to the
community at large.
• Gradually, the value of healthy individual in terms of health
as an asset for industrial production and for economic growth
was realized by the industrialists and the Government.
• Public health included in its preview industrial and
occupational health, accident prevention and control, mental
health services etc.
• There was also shift in focus from poor sick to all the people
in the community.
• For the last four to five decades, the area of public health
activities broadened and included in its horizon prevention
and control of chronic illnesses like heart diseases, metabolic
disorders, cancer, etc., social and behavioural problems like
alcoholism, drug dependence, etc., environmental pollution
and genetic problems, etc.
• Public health today encompasses all those activities which
contribute to health promotion, health protection, health
improvement and health maintenance of all the people.
• The services were initially rendered by lady health visitors
and later from 1930 onwards with the support of trained
public health nurses.
• From 1952 onwards Auxiliary nurse midwives have been
trained and included for providing primary health care
services in the villages under the supervision and guidance of
lady health visitors and public health nurses.
• Community health nursing practice is continuing,
comprehensive, directed towards all age groups, takes place
in wide variety of settings.
• The practice includes evaluation of health status, providing
direct care, health education, guidance and counselling to
individual, family and community according to their needs
and level of dependency.
• It lays major emphasis on preventive and promotive health
care service which are community focused rendered through
individual, family and groups.
• It is practiced within the domain of public health and
includes all public health activities in its preview.
WORLD PLANNING FOR THE 21 ST

CENTURY
• World health leaders recognized the need to plan for the
twenty-first century at the 30th world health assembly of the
World Health Organization (WHO), held in 1977.
• At that assembly, delegations from governments around the
world set as a target “that the level of health to be attained by
the turn of the century should be that which will permit all
people to lead a socially and economically productive life”.
• This target goal becomes known as “Health for all by the
year 2000”.
• The following year in Alma-Ata, the joint WHO/UNICEF
International Conference adopted a Declaration on Primary
health Care as the key to attaining the goal of “Health for all
by the Year 2000”.
• At the 34th World Health Assembly in 1981, delegates from
the member nations unanimously adopted a “Global
Strategy” and that same year, the United nations General
Assembly endorsed the “Global Strategy” and urged other
international organizations concerned with community health
to collaborate with World Health Organization.
• The underlying concept of “Health for All by the 2000” was the
health resources should be distributed in such a way that essential
health care services are accessible to everyone.
• As we now know, the lofty goal of health for all around the world
by the 2000 was not reached. That does not mean that the goal
was abandoned.
• With the passing into a new century, the program was renamed
Health for All (HFA). HFA continues to seek “to create the
conditions where people have, as a fundamental human right, the
opportunity to reach and maintain the highest level of health. The
vision of are newer HFA policy builds on the WHO Constitution, the
experience of the past and the needs for the future”.
• Even though the “Health for All by the year 2000” goal was
not reached, some progress was made, overall global health,
as measured by life expectancy at birth, did improve.
 Current Issues in
Community Health
Nursing
Ethical issues

• Nurses have always been concerned about

professional ethics and moral codes. Values may be
considered to be a set of beliefs and attitudes that
influence perceptions, guide our actions and have
desirable consequences in our interactions with
others. No one can consider ethics without
appreciating the nature of values.
• An ethical conflict will develop when there is a conflict
between moral values. The main responsibility of a
nurse is to reduce these types of ethical issues in the
basic moral principal that are to be followed in
professional life such as autonomy (self determination),
beneficence (doing good), non-maleficence(avoiding
harm), fidelity (keeping promises), truthfulness and
justice (treating people fairly).
To overcome these issues, the following steps should be
taken into consideration:

• Provide nursing care with respect for the human dignity of

all who require nursing care, regardless of socio-economic
status and other parameters.
• Safe guarding the client’s right to privacy and
confidentiality.
• Providing safety to the individual, group, and community.
• Assuming responsibility and accountability for nursing
judgements and actions.
• Protect the public from misinformation and
misrepresentation
• Accepting responsibilities, seeking consultation and
delegation nursing activities based on individual
competence and informed judgment, etc.
• To promote community and national effort to ensure the
availability and accessibility of high quality health
services.
Legal issues

• To avoid legal issues, a community health nurse must be

technically competent and well versed in nursing process.
Community health nurse must be aware of laws affecting
community health nursing practice. The common laws are
always influenced by justice and traditions of the community.
Community health nurses must be competent enough to
understand the public and their problems. They should be able
to manage the current issues effectively and try to prevent the
same through healthy interaction.
Professional issues
Environmental Health:
• Various types of pollution (water, air, noise pollution and
radiation)
• Hazardous materials at home, school and office e.g.
highly dangerous chemicals in household machines,
asbestos insulation and noise induced deafness, lack of
proper ventilation in laboratories, inefficient handling of
chemicals.
• Other occupational hazards that may induce
communicable diseases, cancer, TB, skin ailments, etc.

The community health nurse should be capable of

bringing in awareness among the public about the
hazards and help them to reduce such hazards, so that
the problem may not become a social issue.
Cost, access and quality issues over health care system
• Public health care should be easily accessible to all and
should be maintained following high standards of quality.
Such programmers will require high cost of maintenance,
else such programmes will fail.
• Failure of such good programmes would lead to negative
impact on the minds of people regarding the feasibility of the
system.
• Hence, the main responsibility of a community health nurse
is to find adequate resources to ensure that they provide
easily accessible and quality health care to people.
Socio-cultural issues:
• The numerous global, social, demographic, economic, and
political changes in recent years have alerted health care
professionals to the need to provide attention to the increasing
diversity in our society and the effect of that diversity on
people’s health.
• Nepal is one the most culturally diverse nation in the world.
• Culture influences our expectations and perceptions of
symptoms, the way we label sickness. Health and illness are
shaped by cultural factor; socio-cultural influences affect not
only the individual’s health status but also the entire health
system.
Nursing has traditionally been a female dominated
profession.It is clear that nurses must be sensitive to cultural
differences to be able to provide the best possible care to
individuals, families and communities.
• Learning about different cultures helps to prepare community
health nurses to competently care for clients from diverse
cultures.
• The needs of clients vary based on variable, such as age,
education, religion and socioeconomic status, each client
should be assessed to determine his/her specific cultural
needs.
• Nurses should complete a cultural assessment on every client
with whom they interact.
• Cultural competence means that the nurse has attained
cultural awareness, has cultural knowledge, uses cultural
skill and has cultural encounters with culturally diverse
clients.
• A major trend in this category is the rise of social conscience.
Health as a right rather than a privilege has become an issue.
• National health insurance is another issue.
• Description of benefits provided. These includes provisions
for hospitalization, ambulatory care and health maintenance.
• The redefinition of health as a positive state rather than the
absence of disease.
• Increasing use of mass communication techniques.
Challenges
• Nurses’ mindset that the proper role of a nurse is at the
bedside or at the client’s side, the direct care role.
• The structures within which nurses work and the process of
role socialization that occurs within those structures.
• Relatively few nurses receiving graduate level preparation in
the concepts and strategies of disciplines basic to community
health (e.g. epidemiology, biostatistics, community
development, service administration, and policy formation).
• With few exceptions within the graduate programs in
community health nursing, there is no aggressive effort to
develop population focused skills commensurate with the need.
The bias of many nurses seems to be that these skills are less
important than clinical skills.
• Greater life expectancy of individuals with chronic and acute
conditions is challenging the health care system’s ability to
provide efficient and effective continuing care even after being
discharged from hospitals in their own homes.
• The public is becoming better informed and more assertive
about health services, sometimes challenging the
professional decisions. At the same time, concerns with
human rights, equity, accountability and ethical issues will
come to the forefront of debate and action.
• Changing disease pattern and challenges of infectious
diseases, chronic and non-communicable diseases, injuries
and violence, new or re-emerging conditions is challenging
today’s nurses to think and react in sophisticated way.
• Greatly reducing the burden of excess mortality and
morbidity suffered by the poor. This means shifting the ways
in which governments all over the world use their resources.
It also means focusing on those interventions that enable the
greatest health gain possible with the available resources so
that the diseases that disproportionately affect the poor, like
tuberculosis, malaria, and HIV/AIDS, can be less of a
burden.
• Countering the potential threats to health resulting from
economic crises, unhealthy environments, or risky behaviors.
Stable economic growth throughout the world, environments
with clean air and water, adequate sanitation, healthy diets,
safer transportation, and the reductions in risky behaviors,
such as tobacco use, will go a long way in creating a healthier
world.
• Developing more effective health systems. The
goals of these systems should be to improve
health status, reduce health inequalities, enhance
responsiveness to legitimate expectations,
increase efficiency, protect people from financial
loss, and enhance fairness in the financing and
delivery of health care.
• Investing in the expanding knowledge base. The increased
knowledge base of the 20th century did much to improve
health. The search for new knowledge must continue because
it benefits all humanity. Two areas that need special attention
are infectious diseases that overwhelmingly affect the poor,
and information that will help shape future health system.
References:
• Stanhope, M., Lancaster, J. Community Health Nursing Process and
Practice for Promoting Health. The C.V. Mosby Company. P 29, 810, 811
• Gulani, K.K. (2008). Community Health Nursing. Kumar Publisher House.
P 82-84
• Lucita, M. (2006). Public Health and Community Health Nursing in the
New Millennium. B.I. Publications Pvt. Ltd. P 20-23
• Rao, K.S. (2000). Community Health Nursing. B.I. Publications Pvt. Ltd. P
1-4, 274, 280-286
• Clark M. J. (1992). Nursing in the Community. USA. Appleton and Lange.
P 27 - 29