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COMMUNITY
INTRODUCTION

The word community has been derived from two Latin words, namely ‘com’ means together and
‘munis’ means to serve. This community means to serve together. It means the community is an
organization of human beings framed for the purposes of serving together.

DEFINITIONS

“Community consists of population with several group of people living in a definite area
representing various religions, 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 other. It function within a particular
social structure and exhibits and create certain norms, values, and social institutions. The
individuals belongs to the border society through his family and community.” (WHO)

Types of Community

Homogenous Community: Share same interests, same activities, same background, and live in
same community, so that there is a social interaction between them.

Heterogenic Community: Live in a same locality are made of different types of people who do
not have the same background and interest.

Characteristic of Community

 The community is a contiguous geographical area

 It is composed of people living together
 People co-operate to satisfy their basic needs
 There are common organization e.g. markets, schools, banks, hospitals etc.

Community Health

Community health is more than the health of its members. It broadens its focus to concentrate on
families, groups and community at large, their life styles, environment and resources which are
available and affecting their health. It is a systematic way of studying the health and disease
present in a community and the patterns of delivery of care, both of which influence amount
nature of disease.

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According to WHO, 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 for
the community.

COMMUNITY HEALTH NURSING

Community health nursing is one of the professions which operates within the domains of
community health and helps in meeting health and nursing needs of the community. It plays a
very important and challenging role in promoting and protecting health of people. Unlike other
specialities of nursing, CHN lays major emphasis on primary level prevention and focuses on the
entire community.

DEFINITIONS

“Community health nursing is the 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 Nurses’ Association)

Community nursing is defined as nursing practice which occurs outside a hospital and in a
variety of practice settings. Community nursing encompasses autonomous and collaborative care
of individuals of all ages, whether sick or well by promoting, improving and restoring health.
According to the International Council of Nurses, key nursing roles include advocacy, promotion
of a safe environment, research, participation in shaping health policy, health systems
management, and education (International Council of Nurses [ICN]

Goals /Aim of Community Health Nursing

According to the American Nursing Association (ANA), public health nursing is the practice of
promoting and protecting the health of populations using knowledge from nursing, social and
public health sciences (Waldorf, 1999).

The primary goal of community health nursing is to help a community protect and preserve the
health of its members, while the secondary goal is to promote self-care among individuals and
families. In the health-care reform environment, the community health nurse will probably
continue to care for individuals and families, particularly high-risk clients and those with
communicable diseases. Community health nursing involves the identification of high-risk
aggregates in the community, and the development of appropriate and workable policies and
interventions to ensure accessible services for all groups of the population.

The aim of community health nursing practice is:

 To promote health and efficiency

 To prevent and control diseases and disabilities

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 To prolong life by providing need based, well balanced comprehensive healthcare

services to community at large through organized community efforts.

OBJECTIVES OF COMMUNITY HEALTH NURSING

 To increase capability of community to deal with their own health problems

 To strengthen community resources
 To control and counteract environment
 To prevent and control communicable and non-communicable disease
 To provide specialized service for mothers, children, adults, workers, elderly,
handicapped and eligible couples etc.
 To supervise, guide and help health personnel to function in community for community
health services
 To conduct research and contribute to the further refinement and improvement of
community health nursing practice.

Characteristics of Community health Nursing

Six important characteristics of community health nursing are particularly salient to the practice
of this specialty.

 It is a specialty field of nursing

 Its practice combines public health with nursing
 it is population focused.
 it emphasizes on wellness and other than disease or illness
 it involves inter-disciplinary collaboration
 it promotes client’s responsibility and self-care

PRINCIPLES OF COMMUNITY HEALTH NURSING

1. The community health nursing agency has clearly defined objectives and purposes for its
services.
2. An active organized citizens group, representative of the community is an integral part of
the community health programme.
3. Community health nursing services are available to the entire community regardless of
origin, culture or social and economic resources and it also should be available to people
irrespective of age, sex, creed, nationality, political affiliation.
4. Community health nursing recognized the family and community as units of service.
5. Health education and counseling for individual, family and community are the integral part
of community health nursing.

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6. Recipients of health care should participate in planning relating to goals for the attainment
of health.
7. The community health nursing service should be based on the needs of the patient and there
should be proper continuity of services to patients.
8. The community health nurse directs the patient to appropriate community resources for
necessary financial and social assistance.
9. The community health nurse should not accept gifts and bribes from the patients.
10. The community health nurse should not belong to any one section or any political group.
11. The community health nurses should maintain professional relationship with all the leaders
in the community and maintain ethics at all times.

Community health Nurse

A European conference on nursing administration (1959), define a public health nurse as the
nurse most directly concerned with giving health education and care to individual and families in
the community.

Qualities of a community health nurse

 Intelligent, Cheerful, Honest, Well balanced, Disciplined, Courageous, Creative,

Healthy, Friendly/helpful, Good Listener

Roles of CHN

 Client oriented role: Care-giver, Educator, Counselor, Referral Resource, Role model,
Advocate, Primary Care Provider, Case Manager
 Delivery Oriented Role: Co-ordinator, collaborator, liason, discharge, planner
 Group Oriented role: Case finder, leader, change agent, community care agent,
researcher

STAGES OF EVOLUTION OF COMMUNITY HEALTH NURSING

1. The early home care nursing stage

This is a prototype of community-based nursing. It focuses to reduce suffering and promote

healing. This began with religious and charitable groups. Babies were delivered at home by
midwives with little or no training. Midwifery programs started in France and England in 1720 &
1741 respectively. The Industrial revolution created epidemics, high infant mortality,
occupational diseases, increasing mental illness in Europe and USA. Hospitals and dispensaries
were built and only the least respectable women pursued nursing.

2. The district nursing stage (visiting nursing)(1850-1900)

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Modern CHN laid by Florence Nightingale was founded in this era. During the Crimean war she
established competent nursing care +kitchens and laundries that saved 100s of lives. She
demonstrated how population-focused nursing works (CHN).

3. The public health nursing stage (1900-1970)

Role of the district nurse expanded during this stage. Lillian Wald was the first to use the term
“public health nursing” and promoted rural nursing and family-focused nursing and was the first
president of The National Organization for Public Health Nursing

1902- School nursing started in New York

1905- 200 organizations providing public health nursing for about 440 nurses.

1912- National Organisation for Public Health Nursing formed with Lillian Wald as first
president. National League for Nursing Education started

By the 1920s public health nursing was acquiring a professional status in comparison to its
earlier association with charity. The institutional base moved from charitable organisations to the
government. Industrial nursing expanded during this stage as well

1934- Survey of Public Health Nursing published by National Organisation of Public Health
Nursing

1942- American Association of Industrial Nurses established

4. The community health nursing stage (1970 to present)

The distinction between public health nursing and community health nursing was done by the US
Department of Health in 1984. Community health nursing refers to all nursing practicing in the
community regardless of their educational preparation. Public health nursing is a part of
community health nursing and is a generalist practice for nurses prepared at the Baccaleaureate
level with basic public health content with specialization at the Masters level

1978- Established Association of Graduate Faculty in Community Health Nursing / Public

Health Nursing (later became Association of Community Health Nursing Educators)

In 1980- the ANA developed a Conceptual Model of Community Health Nursing. Both
American Nurses Association and American Public Health Association developed statements on
the role and conceptual foundations of community health nursing

1990 Association of Community Health Nursing Educators publishes Essentials of

Baccalaureate Nursing Education

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Community Health Nursing in Nepal

History of Community Health and Community Health Nursing in Nepal before 1972 AD

History of community health is no longer in Nepal. During the time of Jung Bahadur Rana,
Royal family and PM family got immunization against small pox. The record shows that one
post was created as Director General of Local Health Service, later on this local health service
was changed into public health service. Modern health services started since 1933 starting with
the establishment of department of health services.

During the first five year plan (1956-61) malaria eradication project was established. During
the Second Plan (1962-65) as part of the overall health program, emphasis was placed on both
preventive and curative medicine for the first time. Although many of the health related services
still focused on the provision of curative activities, the concept of preventive medicine had
become fairly well established in the planning and budgeting process in the third five year plan.
(1965-70) Separate project was formed to address existing disease e.g. leprosy control project,
TB control project, smallpox eradication project, FP/MCH project. In 1970, the Community
Health and Integration division was established to help deal with overlaps in services and to
make the health programs more cost-effective. To do this, the Division experimented with the
process of integrating the vertical projects under one administrative body, district health office.

Health Personnel before 1972 AD (2028/29 B.S.)

Before 2010 B.S., there was no provision of public health nursing in Nepal, later a team of
nurses were sent to India and Bhutan for public/community health service. Some of those nurses
were: Rup Kumari Gurung, Jimmi Tamsang, Rebika Ragain, Barnadeti Rai.

2015 B.S.: When Jimmi Tamsang and Barnadeti Rai returned from India, they started
Community Health Service in Nepal especially in Chitwan and Makwanpur.

2017 B.S.: In support of WHO, department of health services sent some nurses to India and
Lebanon for Public health nursing study. When Bharatpur hospital was established, home
visiting service was started by health workers along with the public health nurses. They had to
work in community and hospital as well.

2028 B.S. : After the integration of all vertical projects, ANM were appointed in each health post
and Public health nurses in district public health office. Public health nurse (PHN) is responsible
for supervising the ANM and their activities in the HP.

1971 A.D.: Zonal public health nurse post was created and allocated PHN in each zone and
started public health nursing activities.

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History of Community Health Nursing after 1972 AD (2028/29 B.S.)

1978 A.D.: The concept of Primary Health Care was developed. The slogan of Health for all by
the year 2000 A.D. was passed in Alma Ata Conference in 1978.

1987 A.D.: Post basic bachelor in community health nursing was started in Mahabouddha
nursing campus and prepared the community health nurses to work in community according to
the plan of Nepal Government.

1989 A.D.: Changed the political system in the country (from autocratic to democratic). New
health care system defined the health care services to be provided by each level of health system.
MoHP is responsible for policy making whereas health posts are responsible for service
provision.

1993 A.D.: Organogram was changed, various division including Nursing Division and
Community Health Division were dissolved. Implementation of all the health service including
community health and training are run through various division and centers within the DoHS.

1996 A.D.: Job description for public health of various level of health care system was prepared
by national health training centre (NHTC).

2008 B.S.: BPKIHS, Dharan started M.Sc. Nursing, a 3 yrs course with speciality in community
health nursing.

Scope of Community Health nursing

1. Promotion of health of people in the community

The nurse works with the community and subgroups to identify health needs and to
motivate self-help in groups, increase utilization and development of resources, set
priorties of community health problems.

2. School Health Services

Nurses provide health screening, individual or group education, referral and follow-up to
both students and faculty.

3. Occupational health
CHN may work as an occupational nurse in industry and assess the health of worker and
provide needful assistance.

4. Immunization services
They are provided for vaccine preventable diseases, influenza, and tuberculosis
screening/referral/follow-up to all age groups. The nurse provides immunizations according
to the Advisory Committee on Immunization Practice for preventable diseases, markets and

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assists in elimination of barriers to assure age appropriate immunizations. The nurse

conducts tuberculosis screenings per guidelines for individuals or groups with referral and
follow-up of abnormal findings.

5. Family Planning services

Nurses counsel, educate, and provide provisions for contraception to those individuals seeking
family planning services. Nurses complete on-site physical examinations under contractual
agreements with physicians or mid-level practitioners. Prenatal Risk assessment, prenatal
education, and case management are provided. Nurses complete a standard risk assessment on
all pregnant women and provide ongoing education, counseling, and assessment of the women
during pregnancy. Referrals to other health and medical resources are done as needed.
¨Postpartum visits, counseling and education are provided. Nurses conduct postpartum home
visits, assess mother and newborn, provide appropriate education and counseling, and make
referrals to other appropriate services.

6. Education
CHN can get involve in education of nursing students by acting principal, professor, lecturer etc.
She can contribute to the development of educational and professional career of students.

7. Administration
CHN can also get involve in the administrative activities by acting as a district public health
officer, primary health care nurse, public health officer etc.
8. RESEARCH
Community health provides platform for conducting various researches. It provides new
opportunities to lead and participate in research areas. Previous researches can be reviewed
and re-conducted and can work on the need based projects of the assigned community.

DIFFERENCES BETWEEN HOSPITAL NURSES AND COMMUNITY NURSES

HOSPITAL NURSES COMMUNITY HEALTH NURSES

UNIT OF Focus: individual patient Focus: individual and family
SERVICE
HEALTH On the t/t and care of the sick and Focus is multiple- promoting health,
FOCUS on restoring the individuals maintaining balance on health, early
balance towards health. detection of disease and care measures
(restorative, habilitation and
rehabilitation), assessment of socio-
economical and cultural factors.
RANGE AND Works with disease classification Works with the entire spectrum of
VARIABILIT in different hospital units. health and illness conditions from
Y OF WORK Problems are identified and nurse optimal health to minor or severe
works with identified disease on conditions.
priorities. Works in all kinds of settings-home,

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Nurses works with actual ill school, clinic, industry etc. variability
patients. in one day may include all age groups
Variability is restricted to one and services cut across all areas of
ward or service. living, not just mental or physical
health.
Co-ordination It must be achieved between all It must be achieved among a variety of
personnel responsible for patient medical and non-medical personnel
care within the institution. within health agency and with those
outside.
Autonomy Physician is the medical authority. Medical authority may be delegated to
The nurse narrates the patient’s nurses. They represent medical
condition to him. authority in home, school etc.
Nurses are assigned Nurses have autonomy in planning and
responsibilities for several patients implementing nursing care measures
or for certain tasks for a large for patients. They have extensive
number of patients, such as giving authority for making decisions and for
medication or certain treatments. developing initiating various health
and group activities in the community.
Predictability Depends on treatment of the Multiple factors like socio-economic,
of Events patient. physical, emotional, climate and
cultural background.
Sphere of The hospital setting are an The home is the most private of life
intimacy artificial environment and limits where intimate relationship may be
the nurse observation of family directly observed.
relationships or other indicators of
health
Scope of The nurse relationships is limited Nurse has professional relationships
professional to hospital personnel and few with people in various disciplines other
relationships others. than medical.

Changing concepts in public health

In the history of public health, four distinct phases may be demarcated:

a. 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, for want of the
needed technical knowledge. However, these measures vastly improved the health of the people
due to disease and death control.

b. Health promotional phase (1920-1960)

At the beginning of the 20th century, a new concept, the concept of "health promotion" began
to take shape. It was realised that public health had neglected the citizen as an individual, and
that the State had a direct responsibility for the health of the individual. Consequently, in
addition to disease control activities, one more goal was added to public health, that is, health

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promotion of individuals. It was initiated as personal health services such as mother and child
health services, school health services, industrial health services, mental health and rehabilitation
services. Public health nursing was a direct offshoot of this concept. Public health departments
began expanding their programmes towards health promotional activities.

c. 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. However, as old problems were solved, new health problems in the form of
chronic diseases began to emerge, e.g., cancer, diabetes, cardiovascular diseases, alcoholism and
drug addiction etc. especially in the affluent societies. These problems could not be tackled by
the traditional approaches to public health such as isolation, immunization and disinfection nor
could these be explained on the basis of the germ theory of disease. A new concept, the concept
of "risk factors" as determinants of these diseases came into existence. The consequences of
these diseases, unlike the swift death brought by the acute infectious diseases, was to place a
chronic burden on the society that created them. These problems brought new challenges to
public health which needed reorientation more towards social objectives. Public health entered a
new phase in the 1960s, described as the "social engineering" phase. Social and behavioural
aspects of disease and health were given a new priority. Public health moved into the preventive
and rehabilitative aspects of chronic diseases and behavioural problems.

d. Health for All phase (1981 -2000 AD)

As the centuries have unfolded, the glaring contrasts in the picture of health in the developed
and developing countries came into a sharper focus, despite advances in medicine. 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 per, cent 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, and the life expectancy is 30 per cent lower than in the
developed countries. The global conscience was stirred leading to a new awakening that the
health gap between rich and poor within countries and between countries should be narrowed
and ultimately eliminated. It is conceded that the neglected per cent of the world's population too
have an equal claim to health care, to protection from the killer diseases of childhood, to primary
health care for mothers and children, to treatment for those ills that mankind has long ago learnt
to control, if not to cure. Against this background, in 1981, the members of the WHO pledged
themselves to an ambitious target to provide Health for All by the year 2000, that is attainment of
a level of health that will permit all peoples "to lead a socially and economically productive life"

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