3.3 Public/Community Health Nursing Practice

Interface of Public Health with Nursing Care

Public health and clinical care can interact on a daily basis to support health across populations of clients. Some interactions are more visible than others, such as during times of a global pandemic. Despite increases in the visibility of and focus on public health during the COVID-19 pandemic, collaborations between public health and clinical care have been longstanding and ongoing. Such collaborations support both communicable and noncommunicable health concerns.

During the COVID-19 pandemic, public health efforts such as global, national, county, or city-specific disease surveillance and reporting played a crucial role in guiding clinical care decisions. Such efforts helped hospitals and other care facilities predict the need for services, directed policies on physical distancing and whether businesses and other community centers were open to the public, and helped clients and families evaluate the risk of socializing with those from other households. Public health efforts such as requiring masks when in public helped individuals, families, and essential workers avoid spreading or contracting COVID-19 (Cowger et al., 2022; Kociolek et al., 2022). Places that implemented public health policies to facilitate distancing, such as mandating quarantine and isolation when ill, school closures, household confinement, and limiting social gatherings, coincided with fewer COVID-19 cases and lower disease transmission rates than in places that did not implement such procedures early or stringently (Zweig et al., 2021). As public health efforts in prevention, screening, and later vaccination aimed to reduce the clinical care needed across the globe, clinical care efforts were supported by public health initiatives (Figure 3.6). Clinical care included treatment of active infection, but also testing and diagnosis in established care centers and drive-through operations. Public health efforts also supported the availability of needed medications, supplies, and equipment to treat active infections in hospitals and homes. Once a vaccine was developed, clinical care included vaccine administration. At the same time, public health initiatives determined priority groups for vaccination, established vaccine clinics across communities, and promoted vaccines as a method of health promotion and disease control.

Figure 3.6 A public health worker in Hawaii distributes at-home COVID-19 testing kits at a drive-through distribution event in March of 2022. Throughout the COVID-19 pandemic, public health organizations across the globe orchestrated accessible, convenient, and safe drive-through events for obtaining point-of-care COVID-19 testing, vaccines, and home test kits. (credit: Navy Medicine/Flickr, Public Domain)

Infectious disease response and control presents an opportunity for public/community health frameworks to guide clinical care and for nursing care to support public/community health goals. However, public/community health and nursing care also work in concert to address noncommunicable diseases and health concerns. Addressing the population’s mental health is a key example. Mental health impacts people of all genders, races, ages, occupations, parenting status, and education levels. In fact, 25 percent of youth experience depressive symptoms, 35 percent of adults aged 45 years and older feel lonely, and the suicide rate among all nurses is 18 percent higher than the U.S. general population, with female nurses having twice the risk of dying by suicide than the general population (Blazer, 2020; Lee and Friese, 2021; Office of the Surgeon General [OSG], 2021). Public health agencies may develop promotional campaigns to reduce the stigma surrounding mental health disorders and educate the public on signs that indicate help is needed for a mental health concern. Clinicians provide comprehensive mental health care that can include similar education personalized for the client. Public health agencies may work with clinicians to implement standard mental health screening tools into every preventative health encounter and then provide referral sites where other clinicians can offer expert mental health care and counseling. Clinicians may also engage in public health data sharing, making relevant public health agencies and organizations aware of the rates of mental health concerns in a community or nationally. Such sharing supports proper funding of programs to support mental health for all and treat mental illness among affected clients.

Remember that efforts across clinical and health areas might address upstream or downstream factors. As discussed in What Is Population Health? upstream factors involve actions and initiatives that address the root causes of health issues, whereas downstream factors include responses to health issues without focusing on solving or preventing the health problem. Thinking about how to create meaningful change in upstream factors can be overwhelming and is much more labor-intensive than, say, teaching a client about the safe administration of medications. Importantly, it is not the responsibility of one nurse to change upstream factors or to move an entire health system to a focus on prevention over treatment. Working with individual clients who have diagnosed conditions is, of course, important to their health and quality of life and is a duty of nurses. However, nurses also have a duty to support meaningful upstream change for their clients and the community at large. Nurses can contribute to advancing this area through advocacy and activism, which are detailed in Advocating for Population Health. Nurses are well positioned, and have a professional duty, to leverage their personal, social, and political capital (Florell, 2021) as members of a highly trusted profession to engage in nursing activism and advance health equity through upstream change.

The Role and Significance of the Community Health Nurse

As frontline clinicians on whom community members rely for health care and guidance, public/community health nurses play a crucial role in sharing health information, promoting health through education and counseling, and implementing preventative care activities. Public/community health nurses meet the needs of community members seeking health guidance and health care through several key roles and responsibilities.

Social Prescribing

Social prescribing involves referrals to community resources other than those traditionally considered directly related to the health care setting. Social prescribing is a cost-effective way to support clients and families with chronic conditions with symptom management and health promotion (Husk et al., 2020). Public/community health nurses may facilitate connections to community agencies that support health and social needs, such as financial planning, a walking group, or a community garden (Figure 3.7). Activities like ballroom dancing, volunteering, seeing plays, or visiting museums can benefit clients’ emotional health, social connectedness, and feelings of empowerment (Chen, 2022). Social prescribing interventions can engage the diverse population in social and health-promoting experiences that also decrease utilization of formal health care services and prevent development of chronic conditions (Howarth et al., 2020). To learn more about this topic, watch the video What is social prescribing?.

Figure 3.7 Clarence Webb proudly displays a bunch of kale grown at the community garden Grow Dat Youth Farm in New Orleans. Community members who learn to grow food here have opportunities to explore and practice sustainable agriculture, engage in community leadership, and support food security and food justice. Referrals to community agencies like community gardens go beyond the conventional boundaries of nursing care and exemplify the concept of social prescribing. (credit: Kirsten Strough/USDA/Flickr, Public Domain)

Healthy People 2030

Food Insecurity

Food insecurity refers to limited or uncertain access to food. Income, employment, race/ethnicity, and disability may all be contributing factors. Neighborhood access to grocery stores impacts food security, given the limited options and higher prices at smaller convenience stores. Additionally, lack of personal transportation or access to public transportation to travel to a faraway grocery stores can precipitate food insecurity. The Healthy People 2030 program aims to reduce household food insecurity and hunger, eliminate very low food security in children, and increase the consumption of fruits and vegetables among people ages 2 and older.

Disease and Disaster Response

Public/community health nurses prevent the spread of diseases across communities through the following by:

• Administering immunizations
• Screening for infectious and communicable diseases
• Providing education on infection control
• Educating community members on disease mitigation and self-assessments

Public/community health nurses are at the forefront of response efforts during natural disasters, mass casualty incidents, and other crises. These nurses provide immediate, on-site care to those affected physically and emotionally by disasters. They also coordinate resources, connect community members to needed resources, and support those affected in efforts to rebuild or return to predisaster levels of functioning. Importantly, public/community health nurses collaborate with public services (e.g., police and fire) to develop plans for responding to disasters in the community. Addressing disasters and engaging in disaster planning helps the public/community health nurse build community resilience. Through building confidence in the community’s ability to respond to a disaster, creating networks of support, and expertly managing health needs in an evolving situation, these nurses minimize the negative health impact of actual or potential disasters.

The professional services public/community health nurses offer and roles they fill are essential to promote and protect the health of communities. Such nursing efforts largely focus on prevention and early intervention to address health issues before they develop or contribute to disability and decreases in quality of life. With a focus on prevention and health promotion rather than reacting to diagnoses, public/community health nurses can empower individuals, families, and communities to make informed decisions about health and be involved in their own care and needs. Through assessments and related advocacy, nurses facilitate additional community empowerment, as community members may be involved in local health decision-making processes and be invested in participating in health programming. Finally, emergencies, disasters, and disease outbreaks significantly compromise a community’s health. Public/community health nurses establish response plans, coordinate and mobilize resources during a disaster, and ensure that resources needed to stay safe and healthy are available in times of crisis (Figure 3.8). Principles of Disaster Management discusses this topic in more detail.

Figure 3.8 A community health worker distributes water, diapers, personal care products, and other essential supplies to community members of St. John, USVI, following a natural disaster. Resource management and supply distribution following natural disasters such as floods, fires, and hurricanes pose significant challenges due to co-occurring infrastructure collapse and logistical constraints. Public/community health nurses can manage and organize the distribution of medical and essential supplies and ensure equitable distribution of resources following a disaster. (credit: Jocelyn Augustino/FEMA/Flickr, Public Domain)

Public/Community Health Foundations and Nursing Practice

Nurses provide services to clients, families, groups of people, and the larger community in a specific place. The place may be a school or school district, health center, prison, or memory care facility, as only a few examples. Public/community health nurses may set goals related to each of the essential services and core functions, implement interventions, and lead aspects of care in the community to meet the public’s health needs and broad population health goals. They provide direct care, education, and assessments and fill other duties to promote health, prevent disease, reduce risk, and support the health of the determined community. Regardless of the activity or step of the nursing process addressed, providing care to communities, and not just in the community, is an important consideration when thinking about what role a nurse may be filling. To provide care to the community, public/community health nurses guide their practice with the core functions of public health, the 10 Essential Public Health Services, and the levels of prevention.

Foundations of Public/Community Health discussed the 10 Essential Public Health Services that all communities should use to protect and promote health in communities. The core functions of public health are carried out via these activities. Table 3.2 connects the 10 Essential Public Health Services with an exemplar regarding public/community health nursing care supporting children’s dental health.

Thinking back to Foundations of Public/Community Health, recall that the essential services align with the three core functions of public health: assessment, policy development, and assurance. Please see Table 3.3 for examples of how community/public health nurses implement the core functions of public health across a variety concerns and conditions affecting the health of the public.

Public/community health nursing activities can be categorized by the five levels of prevention below. Foundations of Public/Community Health provides more details on each level.

• Primordial prevention
• Primary prevention
• Secondary prevention
• Tertiary prevention
• Quaternary prevention

Table 3.4 provides examples of nursing activities across the levels of prevention and related activities that support the core functions of public health. Because quaternary prevention concerns what public/community health nurses and other professionals should avoid (Martins et al., 2018), this level is not included in the table.

Health Across the Community Helps Clients and Families

Public/community health nurses may work in specialty roles as school nurses, street nurses, occupational health nurses, home care nurses, correctional nurses, or clinic nurses. Caring Across Practice Settings describes several of these nursing roles. Nurses in public/community health provide direct-care services, promote health, reduce risk, and prevent disease within communities. They apply the nursing process to identify the community’s health needs, create and disseminate interventions, engage in advocacy efforts, and collaborate with community members to support the overall health of the community. These nurses provide the care and services that support population health goals in the community.

Note that the term “community nurse” may have a different meaning globally. For example, outside of the United States “community nurse” or “district nurse” may refer to nurses who provide direct care in client homes.

Public/community health nurses apply a community-focused lens to their professional practice. This lens provides a broader view of health and captures more of the community members in their professional efforts. Their work will involve promoting public health practices and preventing disease among large groups, such as those in schools, prisons, or community care centers. Table 3.5 provides examples of public/community health nurse care settings and nursing actions performed. Additionally, the Johnson & Johnson Nursing website details 96 different nursing specialties, many of which are community-based.

While the community is the client, individuals and families can be recipients of care. Public/community health nurses also provide direct care to individuals and families outside of acute-care centers, such as in personal homes and clinics. Individuals and families may need direct nursing care and support to address their conditions and personalized health concerns. Public/community health nurses help individuals and families learn to manage conditions and can administer ordered care and treatments.

When a public/community health nurse cares for a client, family, or group, the benefits of such care extend to the community at large. The individual or family benefit from direct nursing care; and the community at large may experience reductions in communicable diseases, amelioration of health care disparities, lowered health care costs, and other benefits. To address health needs in the community, public/community health nurses may mobilize existing resources or develop new programs that will benefit clients and families across the community. They work with community members to determine their health priorities and align programs and initiatives with the community’s needs. This requires analysis of community member input and community-level health data.