Unit 1- Concept of community and community health nursing

Community
Community consists of population with several group of people living in a definite
geographical area representing various religious, values, goals, believes, interests
and practice. The group and people include male and female, children, adults, both
healthy and ill rich and poor, thus community represents the society at large.
- K.S. Rao
A community is a social group determined by a geographical boundaries and/ or
common values and interests. Its members know and interact with each others. Its
functions within a particular social structure and exhibits and create certain norms,
values and social institutions. The individual belongs society through his family
and community -WHO

Types of Community :
Homogeneous community : Share same interests, same activities, same
background and live in same community, so that there is a social interaction
between them.
Heterogeneous community : Live in a same locality are made of different types
of people who do not have the same background and interest.
Characteristics of a community:
 The community is a contiguous (closet or nearby) geographic area.
 It is composed of people living together.
 People cooperate to satisfy their basic needs.
 There are common organization e.g markets, schools, banks, hospitals etc.
Community Health
Community health refers to the health status of the members of the community, to
the problems affecting their health and to the totality of health care provided to the
community.
The state of health of all the members of the community, problems affecting this
health & health care services available in the community.
WHO expert committee
Community health deals with preventive, curative & promotional services and its
focus is health problems of the community.
Community Health Nursing:
Community health nursing is a field of nursing practice for which there exists a
body of knowledge and related skills which is applied in meeting the health needs
of communities, families and individuals in their normal environment such as at
home, at school and at place of work.
American Nurse’s Association

Community health nursing comprises the skills of nursing programs for the
promotion of health, the improvement of conditions in the social and physical
environment, the prevention of illness and disability and rehabilitation.
WHO expert committee
CHN is a synthesis of nursing practice and public health practice applied in
promoting and preserving their health of the population.
ANA1973

Community Health Nursing is a synthesis (combine) of nursing and public health

practice applied to promoting and preserving the health of people. The practice is
general and comprehensive. It is not limited to a particular age group or diagnosis,
and is continuing, not episodic.
Community health Nurse is responsible for family centered care rather than to only
individual. It is concerned with the people who are sick as well as the healthy,
young and old, male and female.
Definition of Public Health
Public health refers to all organized measures ( whether public or private) to
prevent disease, promote health and prolong life among the population as a whole.
Its activities aim to provide conditions in which people can be healthy and focus on
entire population, not individual patients or disease. WHO
Thus, public health is concerned with the total system and not only eradication of a
particular disease.
Public health is the Science and Art of preventing disease , prolonging life,
promoting health and efficiency through organized community effort.

The three main public health functions area:

 The Assessment and Monitoring of the health of communities and
population at risk to identify health problems and priorities.
 The formulation of public policies designed to solve identified local and
health problems and priorities.
Difference between community health and public health
Community health
Community health nursing is a synthesis of nursing and public health practice
applied to promoting and preserving the health of populations. Treat “ Population
as a Whole” Focus on individual, family, groups, community. Utilizing Health
promotion, health maintenance, health education, and management, coordination,
and continuity of care for meeting population needs.

Public health
Public health is the Science and Art of :preventing disease, prolonging life,
promoting health and efficiency through organized community effort.
Community Health Nurse mainly focused in 4 areas:
 Prevention of premature death .
 Prevention of diseases, illness and disability.
 Promotion and maintenance of health.
 Rehabilitation
Goal of Community Health:
 To promote and preserve health.
 To restore health when it is impaired.
 To minimize suffering and distress.
  To promote quality of living.
 To develop self care abilities
Aim of Community Health:
The aim of community health nursing practice is
 To promote health and efficiency.
 To prevent and control diseases and disabilities.
 To prolong life by providing need based, well balanced comprehensive
health care services to community at large through organized community
efforts.
Objective of Community Health:
 The objective of community health is
 To provide need based comprehensive services which include the following:
 To assess the need and priorities of vulnerable group like pregnant mother,
children, children and old age persons.
 To provide health care services at every level of community.
 To make community diagnosis.
 To evaluate the health programme and make further plans.
 To prevent disabilities and providing rehabilitation services.
 To provide referral services at various health care levels.
 To increase life expectancy.
 To enhance the standard of nursing profession through-
 Conducting nursing research
 Providing quality assurance in community health nursing.
 Performing the role of nurse epidemiologist
 Teach and demonstrate healthy ways of living.

 Assist in the prevention and control of communicable disease. Visit people

in their own homes and village to identify health needs and priorities and
deal with effectively.
 Promote the health of school children through the health services.
 Promote the health of the worker- occupational health.
  Maintain and promote the health of the elderly and handicapped
 Work in close cooperation with government and other local organizations to
promote the health and welfare of individuals, families and communities.
Principles of CHN:
 Recognize needs and functioning within the total health programme.
 Clearly defined objectives and purposes for it’s services
 As active organized citizens group of the community group is an integral
part of the community health programme.
 Community health nursing services are available too the entire community.

 Community health nursing recognized the family and community as units of

service.
 Health education and counselling for the individual, family and community
are the integral part of community health nursing.
 Participation in planning relating to goals for the attainment of health.
 The community health nurse should qualify as full- fledged nurse.
 Based on the needs of the patient and there should be proper continuity of
services to patients.
 Periodic and continuous appraisal and evaluation of health situation.
 The community health nurse should function/ serve as an important member
of the health team.
 There should be provision for qualified nurse to make supervision for
community health services.
 The CHN directs the patient to appropriate community resources for
necessary financial and social assistance.
 Should not accept gifts or bribes from the patient.
 The CHN should not belong to one particular section or political group.
 CH agency should provide a continuing education programme for nurse.
 The nurses assume responsibilities of their own continuing professional
development through acquiring higher and higher education and forming and
strengthening the professional associations.
  The CHN services should develop proper guidelines, in maintaining records
and reports.
 There should be proper facilities and job conditions.
 The CHN should maintain professional relationship with all leasers in the
community and maintain ethics at all times.

Scope of community health nursing

 Home care
 Nursing home
 MCH and family planning
 School health nursing
 Community health nursing
 Industrial health nursing
 Domiciliary nursing services
 Mental health nursing
 Rehabilitation services
 Geriatic health nursing
Home Care:
Providing nursing care to the actual situation of home .History taking, physical
examination, assess the characteristics of illness, provide nursing care & treatment,
providing health education to the family
Nursing Home :
Provides health care mainly medical & nursing care to the individual & family.
They provides the facilities more than other hospitals & charges less fees
MCH And Family Planning:
Periodic care is provided to the mother & child during antenatal, perinatal &
postnatal period
School Health Nurse:
Nurse provides care to the school going children. she provides following care
immunization, first aid, detection of diseases, sanitation health records
Community Health Nurse:
She provides care to the whole community through PHC & clinics.
Industrial Health Nursing:
First aid care during emergency care, periodic health check up, care during
sickness period etc
Domiciliary nursing services: She provides care to the mother & child during the
home delivery
Mental health nursing : She provides care to the mentally ill persons mainly in
psychiatric hospitals.
Rehabilitation services: Community health nurse works in rehabilitation centre
& rehabilitate the patient who are physically & mentally ill.
Geriatic health nursing: She provides care to the old people mainly in medical &
nursing care.

Functions of community health

 Home visiting
 Running child welfare clinic
 Running family planning clinic or assisting
 Assist in running ANC and PNC
 Conducts school health services
 Carries out or assist the PHN in inspection of day care centers.
 Collection of information or data from the community.
 Health education.
 Record keeping
Changing concept of Community/ Public health
 Disease Control Phase (1880-1920)
 Health Promotional Phase (1920-1960)
 Social Engineering Phase (1960-1980)
 Health For All Phase (1981-2000)

1)Disease Control Phase (1880-1920)

Public health during the 19th century was largely a matter of Sanitary legislation
and Sanitary reforms aimed at the control of man’s Physical environment, e.g.,
water supply, sewage disposal, etc.
Clearly these measures were not aimed at the control of any specific disease.
However, these measures vastly improved the health of the people due to disease
and death control.

2) Health Promotional Phase (1920-1960)

At the beginning of the 20th century, a new concept, the concept of "Health
Promotion" began to take shape.
Mother and child health services
School health services
Industrial health services
Mental health and
Rehabilitation services.
Since, the state has direct health responsibilities two great moments were initiated
for human development.
Provision of “Basic Health Services” through the medium of PHC’s and Sub
centres, for rural and urban areas. Establishment of health centers for providing
integrated curative and preventive services given the highest priority to the
establishment of health centers
Second great movement was the community development programme to promote
village development through the active participation of the whole community and
on the initiative of the community

3 Social Engineering Phase (1960-1980)

With the advances in preventive medicine and practice of public health, the pattern
of disease began to change in the developed world. Many of the acute illness
problems have been brought under control.
Old problems were solved and new health problems in the form of chronic disease
began to emerge. Such as diabetes, cancer, cardiovascular disease, alcoholism and
drug addiction etc.

These type of problems could not talked by the traditional approach to public
health, such as isolation, immunization and disinfections, nor could these be
explained on the basis of the “germ theory of disease”.
A new concept, the concept of “risk factor” as determinant of these came into
existence.
Public health entered a new phase in 1960 as “social engineering phase”.

Public health entered a new phase in the 1960s, described as the "social
engineering phase”.
Public health moved into the preventive and rehabilitative aspect, preventive
medicine, preventive disease, promotion of health and prolongation of life.

4) Health For All Phase (1981-2000)

Most people in the developed countries, and the elite of the developing countries,
enjoy all the determinants of good health - adequate income, nutrition, education,
sanitation, safe drinking water and comprehensive health care.
In contrast, only 10 to 20% of the population in developing countries enjoy ready
access to health services of any kind.
Death claims 60-250 of every 1000 live births within the first year of life.
Life expectancy is 30% lower than in the developed countries .
Large no. of the worlds peoples, perhaps more than half, have no access to health
care at all, and for many of the rest, the care they receive does not answer the
problems they have”.
In 1981 WHO pledged “Health For All” by 2000 to bridge the gap between
developing and developed countries.
To lead a Socially & Economically productive life.
Historical development of community health and community health nursing:
International level
Before mid 1800s-Home Care which focus on Sick and Poor individual.
Orientation: curative
Agencies: religious orders
Mid 1800s to 1900
District Nursing with focus on Sick and poor individual.
Orientation: curative/less in prevention
Agencies: voluntary & some government

Before one can fully grasp the nature of community health or define its practice, it
is helpful to understand the roots and influencing factors that shaped its growth
over time.
Community health nursing development has been influenced by changes in
nursing, public health and society that is traced through several stages.
Community health nursing development has been influenced by changes in
nursing, public health and society that is traced through several stages.
Early Home Care Stage (Before Mid 1800s):
For many centuries female family members and friends attended the sick at home.
The focus of this care was to reduce suffering and promote healing (Kalish and
Kalish, 1986). The early roots of home care nursing began with religious and
charitable groups.
District Nursing (Mid 1800s to 1900)
The next stage in the development of community health nursing was the formal
organization of visiting nursing (Phoebe, 58AD) or district nursing. Although
district nurses primarily care for the sick, they also thought cleanliness and
wholesome living to their patients, even in that early period. Nightingale referred
to them as “health nurse”. This early emphasis on prevention and health nursing
became one of the distinguishing features of district nursing and later of public
health nursing as a specialty.
Problems of district nursing:
 Increased number of immigrants
 Increased crowded city slums
 Inadequate sanitation practices.
 Unsafe and unhealthy working conditions.
Nevertheless, nursing educational programs at that time did not truly prepare
district nurses to cope with their patients, multiple health, and social problems.
Public Health Nursing Training (1900-1970)
By the turn of the century, district nursing had broadened its focus to include the
health and welfare of the general public, not just the poor.
Lillian D. Wald’s contributions to public health nursing were enormous. Wald’s
emphasis on illness prevention and health promotion through health teaching and
nursing intervention as well as her use of epidemiological methodology established
these actions as hallmarks of public health nursing practice
Community Health Nursing (1970 to present)
The emergence of the term community health nursing heralded a new era while
public health nurses continued their work in public health by the late 1960s and
early 1970s.
Many other nurses, not necessarily practicing public health, were based in the
community. Their practice settings included community based clinics, doctor’s
office, work sites, schools, etc, to provide a label that encompassed all nurses in
the community.
The confusion was laid in distinguishing between public health nursing and
community health nursing.
The terms were being used interchangeably and yet, had different meanings for
many in the field in 1984 the division of nursing convened a consensus conference
on the essentials of Public Health Nursing practice and education in Washington
DC (1985).This group concluded that community health nursing was the broader
term referring to all nurses practicing in the community regardless of their
educational preparation.
Public health nursing, viewed as a part of community health nursing, was
described as generalist practice for nurses prepared with basic public health content
at the baccalaureate level and a specialized practice for nurses prepared in the
public health at the master's level or beyond.
The debate over these areas of confusion continued through the 1980’s with some
issues unresolved even today. Public health nursing continues to mean the
synthesis of nursing and public health sciences applied to promoting and protecting
the health of populations.
Community health nursing is used synonymously with public health nursing and
refers to specialized population focused nursing practice, which applies public
health sciences as well as nursing services.

A possible distinction between the two terms might be to view community health
nursing as a beginning level of specialization and public health nursing as
advanced level. Whichever term is used to describe this specialty, the fundamental
issues and defining criteria remain as:
The specialty of Community Health Nursing
The two characteristics of any specialized nursing practice are: Specialized
knowledge and skills, and Focus on a particular set of people receiving the service.
These two characteristics are also true for community health nursing. Community
health nursing is grounded in both public health and nursing sciences, which makes
its philosophical orientation and the nature of its practice unique.
The Nepal (National Level)
Before and during the rana regime from 1903 to 2002 BS, no public health nursing
service was available in Nepal.
In the year 2010/2011 BS one post was created for the director general of local
health services and Dr.Raghubir Vaidya was assigned to take that post.
A team of nurses from india and Bhutan was invited to work in Nepal for
providing public health care service.
Some of the nurses in that team were:
Ms. Namdel
Ms. Rebika Ragain
Ms. Jimmi Tamsang
Ms. Barnadeti Rai
Ms. Rup Kumari Gurung
In 2015 BS( 1958 AD) Ms. Jimmi Tamsang and Rebica Ragain came from India
and started the community health nursing services an ANM schools in the
Narayani Zone.
Jimmi tamsang was assigned at the central level offices for public health NSg.
Administration with the help of WHO nurse Ms. Andrenwala from india.
From 1960 onwards the Department of Heath services selected some staff nurses
foe public health nursing services and they were sent to Beirut, Lebanon and India
for public health nursing training (one year diploma) every year with the help of
Who and USAID.
In 2019 BS, Bharatpur Hospital was established. The health workers, including the
public health nurses, used to visit homes in the morning time, and in the afternoon
they used to work in the hospital.
A team including a sanitation/ hygiene expert, a nutrition expert, a health education
and a public health nurse went to Bharatpur to provide health care service. The
team used to stay in a tent. After a period of time a wooden house was built with
the support of USAID.
The team started their services providing vaccinations- especially for cholera and
small pox as in that period there was an epidemic of these diseases.
At that time the community services were provided through vertical projects like
small pox eradication project and the FP/MCH project by the support of donor
agencies.
Ms. Laxmi Malla was appointed by MOH in 2022 BS to work as a Public health
nurse.
Later on she did an MSc. In Community Health from Women’s University,
Bombay.
She has worked in National Health Training Centre (NHTC) since Falgun 2056 BS
to 2058 BS Falgun as a director.
In 1971 AD, posts for Zonal Public Health Nurses were created in 7 zones, and
Zonal Health Offices were filled up by Zonal Public Health Nurses.
In central level in Kathmandu, public health nurses were assigned in MCH/FP
projects to provide community health nursing services focusing on Mother and
Child Health Care and Family Planning services.
In 2027/28 BS, the new approach of Integrated Health Services was developed. All
the services provided through various projects were put together under the
umbrella of HMG Community Health Services as a pilot project
In 2029/20 BS two district, Bara from the Terai region and Kaski from hilly
region.
In 2039/40 BS a separate body for the integrated Health Pilot Project was
established in the central level and the Community Health Division was established
later on.
At present many PHNs and ANMs are working in various area like HMG,
Educational institutions, INGOs, NGOs and local NGOs from central to grass roots
levels to provide the various community health nursing services in Nepal.
Roles and functions of community health nurse
1) Care provider: She provides a continuous and comprehensive are to the
family, group of people and community at large. She emphasizes more on
promotive and preventive health care.The community health nurse
approaches the family and persuades them to implement promotive and
preventive measures. Care during illness is beneficial gaining acceptance,
trust and confidence. She also provides care during illness for which usually
the family members come forward to seek help. As care is given the nurse
educates and helps the family members to develop their abilities and
overcome their barriers so that they can take care of their health and nursing
needs, promote their health and prevent illness.The care is provided at home,
clinic, school, work place etc.
This function is referred to as “CARE PROVIDER ROLE”
2) Health Educator
The community health nurse educates the individual, family, groups of people and
the community at large. Health education thus given focuses on promoting health,
preventing illness and aspects related to care during illness and rehabilitation &
disability prevention.
The nurse conducts planned health education sessions for organized community
groups e.g., school children, antenatal mothers, eligible couples, elderly etc.,
Health education for the family is planned and implemented as part of the family
care plan.
The community health nurses is involved in giving incidental/casual/spontaneous
health education according to the situation. (washing of hands before a child eats)
Thses functions refer to as “HEALTH EDUCATOR ROLE”
3) COUNSELLOR
The community health nurse helps individual, families and the community at large
to recognize and understand their problems to be solved, find solutions with-in
resources and implement feasible and acceptable solutions.
4) RESOURCE PERSON
The community health nurse explores community resources in terms of money,
manpower, material, agencies etc. • She makes use of these resources in helping
individual, family groups and community to meet their health and nursing needs.
5) Observer
The community health nurse makes observations of any untoward change in health
behaviour and health status of the community, people, their surroundings, unusual
occurrence of disease & take action accordingly.
E.g : Providing information, health education to people to improve their behaviour
and health status, working with the family and providing direct care during illness,
notification to health authority about communicable disease.
6) ADVISOR
The community health nurse gives some suggestions on practical situation which
requires immediate actions and where there is little scope of health education.
E.g, In case of a client with diabetes mellitus, the community health nurse advices
with concern on the foods to be included and avoided. (according to the socio –
economic condition of the individual & family)
7) PLANNER
The community health nurse while giving comprehensive care to family and
community makes a plan on the basis of identified health problems and health &
nursing needs.
She plans with other team members to provide appropriate care, which is referred
to as planner role.
8) CARE MANAGER
The community health nurse implements the care which is planned for the family
and community.
She directly provides the care with the active participation of family and
community members.
She makes use of family and community resources.
She guides the family and community and refers when required. She maintains a
record of the care given to families and the community.
The community health nurse evaluates the effectiveness of care given in terms of
change in health status, health behavior, reduction in illness, improvement in clinic
attendance-immunization & rate of utilization of the community health services
9) Researcher
The family nurse should identify practice problems and find the best solution for
dealing with these problems through the process of scientific investigation.
10) Role model
The family nurse is continually serving as a role model to other people through his
or her activities. A school nurse who demonstrates the right kind of health in
personal self-care serves as a role model to parents and children alike.
11) Case manager
Although case manager is a contemporary name for this role, it involves
coordination and collaboration between a family and the health care system. The
case manager has been formally empowered to be in charge of a case
12) Case finder and epidemiologist:
The family nurse gets involved in case finding and becomes a tracker of disease.
13) Coordinator, collaborator, and liaison:
The family nurse coordinates the care that families receive, collaborating with the
family to plan care.