Learning Objectives
By the end of this section, you will be able to:
- Describe the nurse’s role in community-based health care
- Identify different competencies used by the nurse in community-based health care
- Recognize different at-risk populations within community-based health care
The nurse’s role in community-based health care involves being an educator, caregiver, change agent, collaborator, counselor, and patient advocate. To promote health, prevent disease, and manage chronic conditions, nurses work in collaboration with other healthcare professionals and community members to provide care to individuals, families, and communities in a variety of settings, including clinics, schools, and homes. Some of the key competencies used by nurses in community-based health care include promoting healthy lifestyles, preventing disease and health problems, educating the community, and evaluating the community. Nurses must have strong skills to effectively engage with diverse populations and communicate health information in a way that is easy to understand. There are several at-risk populations within community-based health care, including patients with disabilities, pediatric patients, older adults, individuals from underrepresented groups, people who are under- or uninsured, and patients with low socioeconomic status. Nurses play a critical role in addressing the unique health needs of these populations, such as providing access to healthcare services, education on self-management of chronic conditions, and support for social determinants of health (SDOH). Nurses also work to address health disparities within these populations and promote health equity.
Nurse’s Role in Community-Based Health Care
Nurses play a vital role in community-based health care. They provide a wide range of services to individuals and families in the communities as the first point of contact for patients. Nurses in community-based healthcare settings educate individuals and communities on healthy behaviors, provide disease prevention and screening services, and connect patients with appropriate resources and services. They also work closely with other healthcare professionals to coordinate care and ensure patients receive the support they need to achieve optimal health outcomes. Overall, nurses in community-based healthcare settings are critical members of the healthcare team, working tirelessly to improve the health and well-being of individuals and communities.
Community-based healthcare settings may include outpatient clinics, mobile clinics, home health, and healthcare centers. They can be located in a free-standing building, in a multipurpose room, or even in the basement of a building. The National Association of Community Health Centers provides information on how a community clinic can provide primary health care to patient populations who might otherwise have limited access to care. These patients may not have insurance, may not be able to afford the service, or may have barriers because of distance and language.
Types of Nursing Roles
Nursing roles can be diverse and multifaceted. Nurses serve as educators, teaching patients and families about disease prevention, medication management, and healthy lifestyle choices. Caregiving is also a fundamental nursing role, involving providing direct patient care, monitoring vital signs, administering medications, and supporting patients and families emotionally. As change agents, nurses are responsible for identifying areas of improvement in patient care and developing and implementing strategies to improve patient outcomes (Ten Ham-Baloyi, 2022). Collaboration is also essential for nurses, as they often work as part of a team with physicians, other healthcare professionals, and community organizations to ensure that patients receive coordinated and comprehensive care. Nurses serve as counselors, providing emotional support and guidance to patients and families facing health challenges. Finally, nurses act as patient advocates, ensuring that patients’ needs and preferences are prioritized, and advocating for their rights to receive appropriate care. All the nursing roles are interconnected and critical to ensuring that patients receive the best possible care and that their health needs are met holistically. For example, nursing as a counselor also involves providing education and resources to patients and families (educator) to help them better understand their health conditions and make informed decisions about their care. Nurses as counselors also work with other healthcare professionals (collaborator), such as social workers and psychologists, to provide comprehensive support to patients and families (Table 4.8).
| Role | Description | Example |
|---|---|---|
| Educator | Educating patients and their families about disease prevention, treatment options, medication management, and healthy lifestyle choices; providing education to their colleagues, sharing their expertise and knowledge to improve the quality of patient care; providing health education to schools, churches, and community organizations | A nurse leading a health education workshop about healthy lifestyles for patients |
| Caregiver | Providing direct patient care, monitoring patients’ vital signs, administering medications, and performing various medical procedures; providing emotional support and comfort to patients and their families | A nurse providing the postsurgical care for a patient who has just had a gastrectomy |
| Change agent | Identifying areas for improvement in patient care, developing strategies and implementing actions to bring positive change | A nurse leading a quality improvement project about preventing falls |
| Collaborator | Working as part of a team with other healthcare professionals to provide coordinated and comprehensive care to patients | A nurse working with the physician to implement a care plan for a patient with multiple organ failure |
| Counselor | Providing emotional support and guidance to patients and their families who are experiencing health challenges | A nurse providing diabetic foot care consultant service to a patient with diabetes |
| Patient advocate | Ensuring that patients’ needs and preferences are prioritized and that they receive appropriate care | A nurse suggesting that the physician should talk to a patient who has some questions about his treatment |
Educator
One of the key nursing roles is that of an educator, which refers to their critical role in educating patients and their families about disease prevention, treatment options, medication management, and healthy lifestyle choices. This education helps patients better understand their health conditions and empowers them to make informed decisions about their care (National League for Nursing, 2022). Nurses also provide education to their colleagues, sharing their expertise and knowledge to improve the quality of patient care. Additionally, nurses may serve as educators in community settings, providing health education to schools, churches, and community organizations. Nursing as an educator is essential to ensure that patients and their families have the information needed to manage their health and make informed decisions about their care.
Caregiver
The nursing role as caregiver is fundamental to patient care, where nurses provide direct patient care, monitoring patients’ vital signs, administering medications, and performing various medical procedures. Caregiving also involves providing emotional support and comfort to patients and their families. Nurses spend a significant amount of time with their patients, developing a rapport and building trust. They play a crucial role in assessing patients’ needs and ensuring that they receive individualized care that meets their physical, emotional, and spiritual needs. In addition to caring for their patients, nurses work to prevent complications and promote healing. They monitor patients’ progress and collaborate with other healthcare professionals to develop and implement treatment plans. Nursing as a caregiver is essential to provide high-quality patient care and promote positive health outcomes.
Change Agent
The nursing role as change agent involves identifying areas for improvement in patient care, developing strategies and implementing actions to bring positive change. Nurses are often at the forefront of healthcare delivery and have a unique perspective on the challenges and opportunities for improvement in the healthcare system (Swanson et al., 2020). They play a critical role in implementing evidence-based practice and innovative solutions to improve patient outcomes (Ten Ham-Baloyi, 2022). As change agents, nurses collaborate with other healthcare professionals, patients, and families to identify opportunities for improvement, develop goals and objectives, implement actions, and evaluate interventions (Ten Ham-Baloyi, 2022). They are also responsible for advocating for policy changes that promote high-quality patient care and patient safety. Nursing as a change agent is essential to improving patient outcomes and transforming the healthcare system to meet the evolving needs of patients and families.
Collaborator
The nursing role as a collaborator involves working as part of a team with other healthcare professionals to provide coordinated and comprehensive care to patients (Swanson et al., 2020). Nurses collaborate with physicians, social workers, physical therapists, and other healthcare professionals to develop and implement patient care plans (Swanson et al., 2020). They work together to ensure that patients receive the most appropriate and effective treatments and care that is delivered in a timely and efficient manner (Ten Ham-Baloyi, 2022). Collaboration also involves sharing knowledge and expertise, working together to identify areas for improvement, developing strategies and implementing actions to improve patient outcomes (Ten Ham-Baloyi, 2022). Nurses as collaborators also work with community organizations and other stakeholders to address the SDOH and promote health equity (Swanson et al., 2020). For example, nurses may work as collaborators to identify grants used to provide transportation to health services. To achieve this, nurses may partner with city governments, and public, private, and religious organizations to fund back-to-school initiatives (e.g., dental and vision clinics). They may collaborate with local branches of organizations like Mothers Against Drunk Driving, Alcoholics Anonymous, or the Department of Housing and Urban Development to raise funding or create community outreach programs. Overall, nursing as a collaboration is essential to providing high-quality patient care and promoting positive health outcomes for individuals and communities.
Counselor
The nursing role as a counselor involves providing emotional support and guidance to patients and their families who are experiencing health challenges. Nurses serve as trusted advisors and advocates, providing a listening ear, offering practical advice, and helping patients and families cope with the stress and anxiety that can accompany illness and treatment (Swanson et al., 2020). Overall, nursing as a counselor is essential to promoting patients’ emotional well-being and supporting their overall health and recovery.
Patient Advocate
The nursing role as a patient advocate involves ensuring that patients’ needs and preferences are prioritized and that they receive appropriate care. Nurses serve as the primary liaison between patients and the healthcare system, advocating for patients’ rights to receive high-quality care that meets their individual needs (Abbasinia et al., 2020). Patient advocacy involves supporting patients in decision-making, providing information and resources, and helping patients and families navigate complex healthcare systems (Abbasinia et al., 2020). Nurses as patient advocates also work to identify and address barriers to care, such as financial, cultural, or linguistic barriers (Nsiah et al., 2019). They work collaboratively with other healthcare professionals and community organizations to promote health equity and ensure that all patients receive the care they need to achieve optimal health outcomes (Nsiah et al., 2019). Overall, nursing as a patient advocate is essential to promoting PCC and ensuring that patients’ voices are heard and that their needs are met.
Link to Learning
Review the story of Florence Nightingale who is a role model for nurses today. In her life, she worked as an educator, caregiver, change agent, collaborator, counselor, and patient advocate.
Competencies Utilized in Community-Based Health Care
Nurses who work in diverse community-based healthcare settings must possess a unique set of competencies to effectively care for patients. These competencies include the competencies for promoting healthy lifestyles, preventing diseases and health problems, educating the community, and evaluating the community. Nurses who possess these competencies are essential to providing high-quality care in community-based healthcare settings.
Link to Learning
This article describes critical thinking skills that are necessary for community-based nursing.
Promoting Healthy Lifestyles
Nurses play a vital role in promoting healthy lifestyles and preventing disease. To effectively promote healthy lifestyles, nurses must possess a range of competencies, including knowledge of health promotion and disease prevention, communication skills, assessment skills, and counseling skills. Nurses must be knowledgeable about healthy lifestyle practices, such as proper nutrition, exercise, and stress management, and be able to communicate this knowledge effectively to patients and communities (Kris-Etherton et al., 2021). Assessment skills allow nurses to identify patients’ health needs and develop individualized plans of care that promote healthy behaviors (Kris-Etherton et al., 2021). Counseling skills enable nurses to effectively motivate and support patients to make positive health choices and change unhealthy behaviors. Nurses must also possess skills in behavior change theories and motivational interviewing techniques to effectively support patients in making lasting behavior changes. Overall, nurses who possess competencies in promoting healthy lifestyles are essential to improving the overall health and wellness of individuals and communities.
Preventing Disease and Health Problems
Nurses play a crucial role in preventing disease and health problems. To effectively prevent disease, nurses must possess competencies in health promotion and disease prevention, assessment, communication, and education (Frenn & Whitehead, 2021). Nurses must have a strong understanding of the risk factors for various diseases and the strategies to reduce those risks. They must also be able to assess patients’ needs and develop tailored plans to prevent or manage diseases (Frenn & Whitehead, 2021). Communication and education are essential competencies for nurses to teach patients about healthy lifestyles, provide information on screening tests and vaccinations, and explain the importance of medication adherence (Greiner & Knebel, 2003). Nurses must also have knowledge of infection control and be able to identify and respond to outbreaks or other public health emergencies.
Educating the Community
Nurses play a vital role in educating the community on a range of health-related topics. To effectively educate the community, nurses must possess communication, cultural, and community outreach competencies. Nurses must be able to communicate health information in a clear and understandable manner and use appropriate teaching methods to reach diverse audiences. The ability to respect and understand one’s own beliefs and values as well as how these values and beliefs may differ between cultures is cultural competence. This is essential in health care, as nurses must understand the unique cultural beliefs and values of the community to effectively communicate health information to best provide care and educate accordingly (Nair & Adetayo, 2019). Community outreach is another essential competency, as nurses must be able to establish and maintain relationships with community organizations, government agencies, and other healthcare providers to effectively reach and educate the community. Overall, health education competencies or skills enable nurses to develop and implement community health programs that promote healthy lifestyles and disease prevention. Nurses who possess competencies in community health education are essential to improving the overall health and well-being of communities.
Evaluating the Community
Nurses play a crucial role in evaluating the health status and needs of communities. To effectively evaluate communities, nurses must possess competencies in data collection, analysis, assessment, and program evaluation. Nurses must be able to collect and analyze data on the health status and needs of the community to identify health disparities and areas for improvement. Assessment skills allow nurses to identify the specific health needs of the community, and program evaluation skills enable nurses to assess the effectiveness of community health programs and interventions. Nurses must also possess knowledge of health policy and be able to advocate for policies that address the health needs of the community. Effective collaboration and communication skills are also essential, as nurses must work with community members, healthcare providers, and other stakeholders to develop, implement, and evaluate community health programs. Overall, nurses who possess competencies in community health assessment and program evaluation are essential to improving the health and well-being of communities.
At-Risk Populations Within Community-Based Health Care
Nurses play a critical role in caring for at-risk populations within community-based healthcare. An at-risk population includes individuals who face barriers to accessing healthcare services, have limited access to health care, or are marginalized. These populations include patients with disabilities, pediatric patients, older adults, individuals from underrepresented groups, people who are under- or uninsured, individuals with low incomes, immigrants, people experiencing housing insecurity, sexual and gender minority groups, and those with mental health or substance use disorders. Nurses must be able to identify and address SDOH, such as poverty and housing instability, which contribute to poor health outcomes among at-risk populations. Overall, nurses who possess competencies in caring for at-risk populations are essential to improving the health and well-being of marginalized communities.
Patient Conversations
Identification of Patient Needs
Scenario: Nurse Barbara Rosencrantz works at a homeless shelter and has a patient named Delroy Barnes. Mr. Barnes is 29-years-old and has recently immigrated from Jamaica and is staying with his older brother. He is Rastafarian and wears a cloth wrap over his hair.
Nurse: Hello, Mr. Barnes. How are you?
Patient: Hello, Nurse. Please call me Delroy.
Nurse: Okay, Delroy. I was told that you wanted to speak to me. Are you looking for a bed for the night?
Patient: No, ma’am. The pastor at my sisters’ church sent me here.
Nurse: Okay (nodding gently).
Patient: I’m not homeless, but I need information about work and other things.
Nurse: I see. I can definitely help you with that, but I need more information about exactly what your needs are.
Patient: Well, it’s like this. I want to work, but every time I look for work, I have to do some paperwork. And I can’t do the paperwork.
Nurse: I see. Delroy, in order to help you, I need to ask you some questions. I’m not trying to be intrusive, but I need some detailed information about you. Are you okay with that?
Patient: Go ahead, ma’am.
Nurse: Can you read and write, Delroy?
Patient: Oh yes, I can read and write. That’s not the problem (laughing and nodding). The problem is that it’s a lot of paperwork with fine print. Back home when I looked for work, I didn’t have to do all this paperwork. Now I have to fill out these packets (raises his hands to show two packets of paper), and I can’t read them.
Nurse: But Delroy, you just told me that you can read. Can you try to read one page for me?
Patient: That’s the problem. I can read, but I can’t read these papers because I can’t see the words. It’s too small, and my glasses don’t work on these.
Nurse: Oh, I see. You need an eye exam from our eye clinic. So, Delroy, at this shelter we have a vision clinic every Tuesday and a dental clinic on Wednesdays. The service is free, and we provide glasses too.
Patient: Okay, I need to come on Tuesdays and Wednesdays then. Because I need glasses, and I need my teeth looked at. Can you tell me what else you have here? I don’t have insurance, and I don’t want to be a problem to my brother, you know.
Nurse: Definitely. I understand. So let me tell you about our schedule. We are a homeless shelter at night, but during the day we do the vision and dental clinics. We also do regular doctor visits like checkups. Dr. Martin will prescribe medications too if needed. Most of the medications are free or at a reduced price because the city and the department of health help support this program financially. We have job fairs twice a month to support employment opportunities.
Patient: Thank you so much, Ms. Barbara. I will come back tomorrow for the eye clinic then. Thank you!
Patients With Disabilities
Nurses play an important role in caring for patients with disabilities, ensuring that they receive the highest quality care possible. According to the Americans with Disabilities Act (ADA), an individual with a disability is defined as “a person who has a physical or mental impairment that substantially limits one or more major life activities, a person who has a history or record of such an impairment, or a person who is perceived by others as having such an impairment” (ADA, 2020, para. 3). Caring for patients with disabilities requires nurses to possess competencies in PCC (Bezyak et al., 2020). Patient-centered care involves recognizing and respecting the unique needs and preferences of each patient and ensuring that their care is tailored to those needs. Nurses must be knowledgeable about the various types of disabilities and their impact on a patient’s physical and mental health, as well as any accommodation that may be needed to provide optimal care (Bezyak et al., 2020). Some disabilities are invisible, meaning they are not immediately apparent or visible. Nurses must be aware of such disabilities and create an environment where patients can share about these disabilities. Nurses must respect visible and invisible disabilities and should work to support these patients in their healthcare and lifestyle needs. Nurses must also be able to educate patients with disabilities and their families on self-care management and promote the patient’s independence and autonomy. Overall, nurses who possess competencies in caring for patients with disabilities are essential to ensuring that patients receive the highest quality care possible and achieve the best possible health outcomes.
Patient Conversations
Discharging a Patient With a Disability
Scenario: Mr. Smith, a 38-year-old, has just had an amputation after a car accident. He is going to be discharged later today. The morning shift nurse walks into his room and begins their conversation.
Nurse: Good morning, Mr. Smith. How are you feeling today?
Patient: Hi, I’m feeling okay. I’m just a bit frustrated with my amputated leg.
Nurse: I understand that it can be frustrating at times. As your nurse, I want to make sure that I’m supporting you in the best way possible. How can I assist you today?
Patient: Well, since I am going to discharge today, I have some concerns that I want to discuss with you. I have been having some trouble with my mobility since the surgery, and I’m not sure what I can do to improve it. I feel like I’m not getting the same level of care as someone without a disability.
Nurse: I hear your concerns, and you’re right that people with disabilities can face unique challenges. However, as your nurse, I’m here to make sure that you receive the best possible care regardless of your disability. I can work with you to come up with a care plan that takes into account your specific needs and limitations.
Patient: That sounds good. What can we do to start?
Nurse: Well, first, let’s talk about your mobility concerns. Are there any particular activities that you’re having trouble with?
Patient: Yeah, I’m having trouble with walking longer distances, and I’m worried that I won’t be able to get the exercise I need to stay healthy.
Nurse: I understand. One thing we can do is to work with a physical therapist to develop an exercise plan that is tailored to your specific needs and abilities. We can also explore assistive devices like wheelchairs to help you move around more easily.
Patient: That sounds like it could help. But what about when I come to the clinic for appointments? I feel like I struggle to get around the clinic, and it can be challenging for me to get into the exam room.
Nurse: I can help with that too. We can make sure that your appointments are scheduled in an accessible exam room that is easy for you to get into. We can also work with you to make any necessary accommodations, such as providing a wheelchair or a helper.
Patient: Thank you. That would be really helpful. I appreciate that you’re taking my disability into consideration.
Nurse: Of course. It’s my job to make sure that you receive the best possible care. If you have any other concerns or questions, please don’t hesitate to ask. I’m here to support you.
Pediatric Patients
Nurses play a vital role in caring for pediatric patients, from newborns to adolescents. Caring for pediatric patients requires nurses to possess competencies in PCC, family-centered care, communication, and developmental assessment. As noted earlier in this chapter, patient-centered care involves recognizing and respecting the unique needs and preferences of each pediatric patient. This remains true in the pediatric population, where developmental stage and current needs underscore each decision made for the patient. Furthermore, in the pediatric population, family-centered care is most effective to meet the needs of the patient and family. This family-centered care involves recognizing and respecting the role of the family in the pediatric patient’s care, including their preferences and priorities for their health decisions (Cincinnati Children’s Hospital Medical Center, 2023). Effective communication skills are essential for nurses to communicate with pediatric patients and their families effectively, especially when providing education or discussing complex medical information. Developmental assessment skills allow nurses to evaluate and monitor the physical, cognitive, and emotional development of pediatric patients and intervene appropriately when necessary.
Life-Stage Context
Considering Developmental Age in Pediatric Patients
While considering developmental level for all patients is important, it is foundational for success in pediatric nursing. Age often does not link directly to the developmental level of the patient, so the nurse must be able to assess each patient individually and cater care accordingly. For example, pain assessment will look different for each patient and may vary for the patient at different moments in time. While the numeric pain scale of 0 to 10 is generally approved for anyone over six years old, there are many patients over six years old who would benefit from an alternative pain assessment. Children who are nonverbal or are not able to understand the numeric system may utilize a visual scale system (such as the Wong-Baker FACES Pain Scale) instead. Additionally, the nurse can assess pain via vital signs and physiological changes in the patient.
Nurses must also be knowledgeable about pediatric illnesses and their management, including medication administration, pain management, and psychosocial support. Overall, nurses who possess competencies in caring for pediatric patients are essential to providing high-quality care and achieving positive health outcomes for children and their families.
Older Adults
Nurses play a critical role in caring for older patients, who require specialized care to address the unique physical, cognitive, and social needs that come with aging (Kim & Oh, 2020). Caring for older patients requires nurses to possess competencies in geriatric assessment. Geriatric assessment skills allow nurses to evaluate and monitor the physical, cognitive, and social function of older patients and intervene appropriately when necessary, such as addressing fall risk or managing chronic diseases like dementia or diabetes. Nurses must be knowledgeable about age-related changes in health and medication metabolism, as well as common geriatric syndromes such as delirium and frailty. Nurses must also communicate effectively with older patients and their families, especially when providing education or discussing complex medical information (Kim & Oh, 2020). Overall, nurses who possess competencies in caring for older patients are essential to ensuring that older patients receive high-quality care and achieve the best possible health outcomes in their later years.
Individuals From Underrepresented Groups
Nurses play a crucial role in caring for individuals from underrepresented groups, who may experience disparities in health outcomes due to SDOH, including racism, poverty, and inadequate access to health care. Nurses who work with individuals from underrepresented groups must engage with the community to understand the community’s health needs and work collaboratively with other healthcare providers to promote health equity. They must provide patient education that is culturally appropriate and address any barriers to accessing care, such as language or transportation barriers (Joo & Liu, 2020). Nurses must also advocate for policies and programs that address health disparities and ensure access to high-quality care for all patients, regardless of their race or ethnicity (Joo & Liu, 2020). Overall, nurses who possess competencies in caring for individuals from underrepresented groups are essential to reducing health disparities and promoting health equity for all patients.
Underinsured/Uninsured
Nurses play a critical role in caring for people who are under- or uninsured, who may lack access to adequate health care due to financial barriers. Caring for these groups requires nurses to possess competencies in PCC, resource management, and advocacy. Patient-centered care involves working with persons who are under- or uninsured to develop affordable care plans that meet their needs. Resource management skills are essential for nurses to help patients access resources, such as medication assistance programs, community health clinics, and financial assistance programs. Nurses must also advocate for policies and programs that address healthcare access and affordability for all patients, regardless of their insurance status. Nurses can refer patients to appropriate and cost-effective resources for their care, focusing on preventive care. They must work collaboratively with other healthcare providers, social workers, and community organizations to ensure that patients receive comprehensive care that addresses their physical, emotional, and social needs. Nurses must also provide patient education that is tailored to the patient’s insurance status and address any barriers to accessing care (e.g., a transportation barrier). Overall, nurses who possess competencies in caring for patients who are under- or uninsured are essential to promoting access to high-quality care and improving health outcomes for at-risk patients.
Socioeconomic Status
Nurses play a crucial role in caring for people with lower incomes, who may experience health disparities due to SDOH, such as poverty, lack of education, and inadequate access to health care. Nurses must consider the financial situation of people with lower incomes and help them access affordable resources, such as financial assistance programs, community health clinics, and social services, to promote health equity. They must work collaboratively with other healthcare providers, social workers, and community organizations to ensure that patients receive comprehensive care that addresses their needs. Nurses must also provide culturally appropriate patient education that is tailored to the patient’s socioeconomic status. For example, nurses should never assume patients can safely afford prescribed medication or treatment tools. Instead, they should outline what will be needed, help assess any barriers for the patient to obtain or maintain access to these items, and work with the interdisciplinary team to develop solutions. Overall, nurses who possess competencies in caring for people with lower incomes are essential to promoting health equity and improving health outcomes for at-risk patients.