3.3: Public/Community Health Nursing Practice
By the end of this section, you should be able to:
- Identify how the public health system interfaces with nursing care.
- Explain the nurse’s role in public/community health.
- Describe how public/community health nurses facilitate the core functions of public health.
- Explain why public/community health nursing is essential to promoting and protecting the health of communities.
Using the Community/Public Health Nursing Competencies as a guide, nurses in this specialty significantly impact the health of populations. Public/community health nurses collaborate with clinicians across the care continuum to bridge the gap between care that is offered or available and care that is needed or accessed. Health promotion and education, social prescribing, community assessments, advocacy, and disease and disaster response are several examples of essential public/community health nursing interventions that promote and protect the health of community members.
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.
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.
In this video, Dr. Deboki Chakravarti of the American Public Health Association (APHA) shares information about unintentional injuries as a public health issue. Unintentional injuries are another example of a non-communicable category that presents an opportunity for public health and clinical care to interact.
Watch the video, and then respond to the following questions.
- Dr. Chakravarti shares information about public health initiatives aimed at addressing injuries across age groups. She discusses unsafe sleeping conditions for infants, drowning for young children, car accidents for teens, and workplace injuries for adults. What are some components of clinical care that work in concert with public health interventions to address these accidents?
- Since the video has been published, new evidence has emerged that names gun violence as the leading cause of death in children (Goldstick et al., 2022). Can you think of the public health and clinical care interventions that can address this public health crisis?
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.
Health Promotion and Education
Public/community health nurses educate clients, families, and communities on health topics and conditions, preventative measures , and approaches to wellness . For example, nurses in this specialty may teach caregivers of toddlers about nutrient-dense foods that picky eaters may enjoy or hold a weekly session to help seniors on a fixed income create recipes based on the local grocery store’s weekly sale flyer. Nurses may employ many teaching methods, including conducting live and in-person class sessions, holding Zoom meetings, or distributing printed material. Nurses can create their own teaching material informed by current research, best practices, or clinical guidelines or may access freely available toolkits. Toolkits are often developed by health departments, colleges and universities, or national health organizations. For example, teaching toolkits are available for HPV vaccination , substance-use prevention , healthy sleep , hypertension , interpreting nutrition labels , and many other health topics.
Health promotion efforts also involve screening for conditions and diseases so that the public/community health nurse can make appropriate and early referrals for care. A nurse may offer monthly vision and hearing screening s to alert community members to the need for sensory aids. Preventing diseases before they occur through education and other health promotion activities helps communities reduce disease prevalence, incidence, and impact. This is important for the health of the population but also decreases the burden and spending on the health care system and resources of the community. In fact, one study of a nurse-led community-based clinic in which clients could receive nonurgent health care and guidance demonstrated a $34 savings to society for every $1 invested (Bicki et al., 2013). While there is some rhetoric regarding the utility and cost of nurse-led clinics, a comprehensive review determined that these clinics do not increase health care costs and have improved client satisfaction with and access to health services (Connolly & Cotter, 2023). Ongoing rigorous research regarding the role of nurse-led initiatives is needed to reach additional conclusions regarding their impact on population health.
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? .
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.
Community Assessments
Nurses in community health can assess communities or groups within communities to determine health problems, health risks, and the need for teaching or other interventions. Creating a Healthy Community describes community assessment s in depth. Community assessments can also reveal problems or areas of opportunity related to health equity. Nurses in community health address health disparities, promote equity, and facilitate justice.
Health Advocacy
Using results of community assessments and professional experiences with addressing the health needs of the community, the public/community health nurse can advocate for services and programming that the community needs to achieve health. Additionally, public/community health nurses can engage in proactive advocacy. Public/community health nurses participate in safeguarding (e.g., tracking medical errors), empower clients and families with information about their health condition and possible alternatives to care plans, liaise between families and providers, and champion social justice (Abbasinia et al., 2020). Advocating for Population Health discusses the nurse’s role as advocate in depth.
Read the scenario, and then respond to the questions that follow.
As you have gotten to know the Lee family, you have also improved your public/community health nursing skills. You are interested in employing health education, social prescribing, and health advocacy in your professional role to address some of the health concerns of the Lee Family.
- What health advocacy could you conduct to address the Lee family’s lack of access to clean water?
- What health education could you provide, and to whom, to support Sunshine’s safety given her life-threatening allergy?
- What social prescriptions might you make to the entire family?
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.
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.
| Essential Public Health Service | Example Supporting Dental Health in Children |
|---|---|
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A public/community health nurse receives a report from a school nurse that many elementary-school children have obvious and painful dental caries. They collect data on the number of dental offices in the county, the cost of attending a dental appointment, and methods of accessing the dental offices. They also collaborate with the school nurse to identify any dental education efforts in the school setting. |
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The public/community health nurse determines that there are only two dental offices in the county that provide care to children, a visit costs 30 percent of the average weekly salary for families, and public transportation options to access the dental offices are limited. The school has limited education on healthy teeth, brushing, and flossing for first-grade students. The nurse has identified issues in access to dental care for children and preventive teaching and will work to address these gaps in health care. |
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The public/community health nurse discusses methods of increasing dental health education in the school with the school nurse, teachers, and principals. They use funds available to purchase a toothbrush, toothpaste, and flossers for every child in the county elementary schools. They collaborate with the school team to develop a short video and flyer for parents about dental health in children. |
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The public/community health nurse builds a relationship with the dental offices in the county to determine the feasibility of offering dental services to the children while at school. |
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The public/community health nurse communicates findings about unaddressed dental caries in children to the county and state lawmakers. They propose a funding initiative to subsidize the cost of dental visits for children to the two offices offering pediatric services and funding for a mobile dental unit that could visit each school once per month to carry out dental exams and fillings. |
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The public/community health nurse contacts the county water department to ensure that water is being adequately fluoridated per state law. |
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The public/community health nurse files a formal request with the public transportation bus unit to develop additional routes that include stops proximal to the dental offices so families without reliable transportation may access the dental office. |
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The public/community health nurse involves community members with diversity in experiences, gender, race, and dental health history by recruiting older students from the high school to serve as interns three hours per week to mentor the elementary-school students on dental care. |
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The public/community health nurse collects data on the number of children evaluated and treated in the mobile dental van and increases in dental office visits with the newly added bus routes. They determine that the new bus routes are underutilized for dental office visits, so they request public funds be re-allocated from the new bus routes to funding additional dental van days at each elementary school. |
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The public/community health nurse will maintain and develop new partnerships with dental and health-focused organizations in the county and beyond and will continue to collect data to support the ongoing need for supplies and funding to ensure dental caries are prevented, identified, and addressed in elementary-school children. |
Healthy People 2030 has set a goal to increase the proportion of children and adolescents who have received dental sealants on one or more primary or permanent molar teeth. Dental sealants are coatings that are painted on teeth and can prevent tooth decay. This preventive intervention can help children avoid cavities for years. School-based dental programs are one way to ensure all children have access to dental sealant regardless of race/ethnicity or income, two determinants with noted disparities in access to this component of care.
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.
| Topic |
Assessment
Collecting and analyzing data to: |
Policy Development
Collaborating with local legislators, businesses, schools, and other organizations on policies supporting: |
Assurance
Providing: |
|---|---|---|---|
| Asthma | Identify the prevalence of asthma, common triggers, and temporal patterns in exacerbations | Asthma-friendly environments and improved air quality | Hands-on teaching regarding the use of asthma medications and devices |
| Sexually transmitted infections (STIs) | Determine STI rates, high-risk populations, and trends in transmission | Access to confidential and affordable testing and treatment | Education and counseling on prevention and treatment, confidential partner notification and contact tracing |
| Headache disorders | Describe the prevalence and impact of headache disorders | Headache-friendly workplaces and school/work attendance flexibility | Support groups for community members with chronic headache disorders |
| Diabetes | Identify community members at risk for diabetes | Affordable access to diabetes supplies, exercise, and nutrient-dense foods | Self-management education programs |
| Food safety | Evaluate food-handling practices of local restaurants and eateries | Food safety training and outbreak prevention | Guidance and case triage of community members impacted by an outbreak |
| Violence | Explore the availability and content of violence prevention programs and resources | Gun-safety legislation and trauma-informed care practices | Support and counseling for those affected by community violence |
| Immunization | Monitor immunization rates among community members | Vaccine requirements for school attendance | Immunization clinics and health promotion education regarding vaccine uptake |
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.
| Topic | Primordial | Primary | Secondary | Tertiary |
|---|---|---|---|---|
| Cardiac health in older adults | Implements community programming that promotes good general health, such as physical activity and stress reduction | Leads a fitness walking group for attendees of the senior center without cardiac health conditions | Conducts weekly blood pressure screenings for seniors | Leads a fitness walking group for attendees of the senior center with cardiac health conditions |
| Teen pregnancy | Provides mandated comprehensive sex education programs to all students in grades 9 to 12 | Facilitates access to barrier methods of contraception in schools and additional contraceptive services at the local health clinic | Offers pregnancy testing and prenatal counseling to teens | Delivers quarterly parenting and child development seminars for pregnant teens and partners |
| Seasonal influenza | Implements public awareness campaigns regarding handwashing and respiratory hygiene | Administers influenza vaccines each fall to students enrolled in city schools | Provides accessible testing to facilitate early diagnosis | Counsels ill individuals on supportive care measures and facilitates access to antiviral medications as appropriate |
| Smoking cessation | Enforces comprehensive tobacco control policies | Educates community members on the health risks and implications of smoking | Provides individual and group counseling to smokers | Offers relapse prevention services for community members who have successfully quit |
| Road accidents | Supports legislation for clearly designated bike lanes and crosswalks | Teaches young children about walking and pedestrian safety | Coordinates efficient systems for rapid emergency services responses to scenes of accidents | Ensures community access to rehabilitative services following a road accident |
| Suicidality | Promotes mental health awareness and antistigma education | Trains caregivers, teachers, and other community members on suicide prevention and intervention techniques | Establishes community crisis hotlines | Coordinates support groups for individuals and families affected by suicide |
| Substance use disorder | Develops mandate for prescribers in community to engage in safe prescribing practices education | Educating community members on healthy coping skills | Provides screening and referral for middle and high school students | Facilitates access to prescribers of medication-assisted treatment as a recovery support |
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.
| Setting/Specialty | Example of Actions Performed |
|---|---|
| School |
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| Corrections |
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| Camp |
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| Occupational health |
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| Home health—continuous services |
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| Home health —skilled visits |
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| Hospice |
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| Parish/ faith |
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| Ambulatory care |
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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.
This video follows a nurse as she contemplates different ways to contribute to health and well-being via roles in community health. Community-based and hospital-based nurses can collaborate and serve equally important roles in bridging client transitions across the care continuum to ensure safe and supportive care.
Watch the video and visit the Johnson & Johnson nursing specialty website, and then respond to the following questions.
- Thinking about the Lee family, which community health nursing roles or specialties could help promote health and reduce risk for the family?
- What kinds of community health nursing jobs or roles are of interest to you in the future?