Figure 1-4 is a useful illustration of the arenas of practice. Becausemostnursesworkinginthecommunityandmanystaff public health nurses, historically and at present, focus on providing direct personal care servicesincluding health educationto persons or family units outside of institutional settings(eitherintheclientshomeorinaclinicenvironment), suchpracticefallsintotheupperrightquadrant(sectionB)of Figure 1-4. However, specialization in public health nursing is population-focused and focuses on clients living in the com- munityandisrepresentedbytheboxintheupperleftquadrant (sectionA).
Therearethreereasons,inadditiontothepopulationfocus, thatthemostimportantpracticearenaforpublichealthnursing is represented by section A of Figure 1-4, the population of free-livingclients: 1. Preventive strategies can have the greatest impact on free-
living populations, which usually represent the majority of acommunity.
2. Themajorinterfacebetweenhealthstatusandtheenviron- ment (physical, biological, sociocultural, and behavioral) occursinthefree-livingpopulation.
FIG 1-4 Arenas for health care practice.
Community based nursing
Public health nursing staff or nurses working in the
Clients living in the community
Clients in institutional settings
(e.g., hospital, nursing home)
Secondary-Individual and/or family focus
Focus of practice
Location of client
16 PART 1 Influencing Factors in Health Care and Population-Centered Nursing
There is a need and a place for a nursing specialty in the community; the nurse in this specialty is more than a clinical specialistwithamastersdegreewhopracticesinacommunity- based setting, as was suggested by the Consensus Conference more than 25 years ago. Although in 1984 these nurses were referredtoascommunityhealthnurses,todaytheyarereferred toasnursesincommunity-basedpractice(seedefinitionsinthe inside cover of this text). Those who provide community- oriented service to specific subpopulations in the community and who provide some clinical services to those populations may be seen as nurse specialists in the community. Although such practitioners may be community-based, they are also community-orientedaspublichealthspecialistsbutareusually focused on only one or two special subpopulations. Preparing for this specialty includes a masters or doctoral degree with emphasisinadirectcareclinicalarea,suchasschoolhealthor occupational health, and ideally some education in the public health sciences. Examples of roles such specialists might have indirectclinicalcareareasincludecasemanager,supervisorin ahomehealthagency,schoolnurse,occupationalhealthnurse, parish nurse, and a nurse practitioner who also manages a nursingclinic.
ROLES IN PUBLIC HEALTH NURSING In community-oriented nursing circles, there has been a ten- dencytotalkaboutpublichealthnursingfromthepointofview ofaroleratherthanthefunctionsrelatedtotherole.Thiscan be limiting. In discussing such nursing roles, there is a preoc- cupationwiththedirectcareproviderorientation.Evenindis- cussions about how a practice can become more population focused,thefocusisfrequentlyonhowanindividualpractitio- ner, such as an agency staff nurse, can adopt a population- focused practice philosophy. Rarely is attention given to how nurseadministratorsinpublichealth(oneroleforpublichealth nursingspecialists)mightreorienttheirpracticetowardapop- ulationfocus,whichisparticularlyimportantandeasierforan
Staff public health nurses or clinical nurses working in the communitynurses,whoarecommunity-based,whomaybe clinicallyorientedtotheindividualclient,andwhocombine someprimarypreventivepopulation-focusedstrategiesand direct care clinical strategies in programs serving specified populations(sectionBofFigure1-4)
Sections C and D of Figure 1-4 represent institutionalized populations.Nurseswhoprovidedirectcaretotheseclients in hospital settings fall into section D, and those who have administrative/managerial responsibility for nursing ser- vicesininstitutionalsettingsfallintosectionC. Figure 1-4 also shows that specialization in public health
nursing,asithasbeendefinedinthischapter,canbeviewedas aspecializedfieldofpracticewithcertaincharacteristicswithin the broad arena of community. This view is consistent with recommendations developed at the Consensus Conference on theEssentialsofPublicHealthNursingPracticeandEducation (USDHHS,1985).Oneoftheoutcomesofthehistoricalconfer- ence was consensus on the use of the terms community health nurseandpublic health nurse.Itwasagreedthatthetermcom- munity health nurse could apply to all nurses who practice in the community, whether or not they have had preparation in publichealthnursing.Thusnursesprovidingsecondaryorter- tiarycareinahomesetting,schoolnurses,andnursesinclinic settings(infact,anynursewhodoesnotpracticeinaninstitu- tional setting) could fall into the category of community health nurse.Nurseswithamastersdegreeoradoctoraldegree who practice in community settings could be referred to as community health nurse specialists, regardless of the area of nursinginwhichthedegreewasearned.Accordingtothecon- ferencestatement:Thedegreecouldbeinanyareaofnursing, such as maternal/child health, psychiatric/mental health, or medical-surgical nursing or some subspecialty of any clinical area(USDHHS,1985,p.4).Thedefinitionsofthethreeareas ofpracticehavechanged,however,overtime.
In1998theQuadCouncilbegantodevelopastatementon thescopeofpublichealthnursingpractice(QuadCouncil,1999 [revised2005]).Thecouncilattemptedtoclarifythedifferences betweenthetermpublic health nursingandthetermintroduced into nursings vocabulary during health care reform of the 1990s:community-based nursing.Theauthorsrecognizedthat the terms public health nursing and community health nursing had been used interchangeably since the 1980s to describe population-focused,community-orientednursingpracticeand community-based practice. However, the Council decided to make a clearer distinction between community-oriented and community-based nursing practice. In contrast, community- basednursingcarewasdescribedastheprovisionorassurance ofpersonalillnesscaretoindividualsandfamiliesinthecom- munity, whereas community-oriented nursing was the provi- sionofdiseasepreventionandhealthpromotiontopopulations andcommunities.Itwassuggestedthattherebetwotermsfor the two levels of care in the community: community-oriented careandcommunity-based care.(seethelistofdefinitionspre- sentedinBox1-5).
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