Community Based Nursing Standards

Introduction

The World Health Organization (WHO) (1986) stated in the Ottawa Charter for Health Promotion that it was their hope to achieve health for all by 2000 and continue to maintain that state of health throughout the years to follow. One of the ways they proposed to achieve this is through health promotion and illness prevention which according to the WHO (1986) is giving people the information and skills they need to reach and maintain complete physical, mental, and social wellbeing. Since the WHO made this statement of obtaining health for all there have been significant changes in the field of nursing. In particular the field of Community Health Nursing (CHN), which in 2003 released a set of nursing standards that were designed to help the nurse obtain this goal of global health. These standards were designed to help form the base of practice for CHN's as well as provide a description of what is the best possible outcome for clients (Stamler and Yiu, 2008). The standards include; "1.)Promoting health, this is broken down into A.) Health Promotion, B.)Prevention and health protection, and C.)Health maintenance, restoration, and palliation, 2.)Building individual/community capacity, 3.)Building relationships, 4.)Facilitating access and equity, and 5.)Demonstrating professional responsibility and accountability" (CHNAC, 2008). The CHN also draws on the concept of primary health care (PHC) as a way to better her/his delivery of health care and strive for better health for all. The concept of primary health care was defined by the WHO (1978) as both a philosophy and delivery method of care, that uses five principles of care to help guide the concept, they are; accessibility, public participation, appropriate technology, intersectoral collaboration, and wellness promotion and illness promotion (Munro et al., 2000). The focus for this particular paper will be on the standard of Promoting Health more specifically part A.) Health promotion, the paper will take a close look at this standard as well as the PHC concept of wellness promotion and illness prevention. In order to fully explain these concepts particular examples from clinical experiences will be used to show how these standards are implemented or how they should have been implemented to better the health of the UPEI campus. For my clinical experience I was placed at the UPEI Wellness Center where my clinical coordinator A.M. had a background in kinesiology as opposed to nursing. Although the standards of care are not basic practice expectations for her as they would be for a CHN I still feel that they can be applied to the wellness center setting. Therefore I will discuss the standards and use examples of how what A.M is doing relates to the standards of practice as well as discuss how the center could benefit from the use of the standards more directly. The last component of this paper will be a response to reflective practice questions related to the practice standard and PHC concept discussed

Applying the Practice Standard and Primary Health Care Concept

As mentioned above the focus of this paper will be on the practice standard of health promotion and the PHC concept of wellness promotion and illness prevention. Health promotion is a very dynamic concept that uses a positive and empowering approach to bring a population together to achieve its optimal level of health. The CHN establishes health promotion strategies by looking at the community as a whole as well as its individual components as a socio-environmental system (Stamler and Yiu, 2008). The Community Health Nursing Association of Canada (CHNAC) outlines ten different indicators as a way to assess if the CHN is following the standard of health promotion, for this paper five of those indicators are looked at more closely using current research and clinical examples. There will also be discussion on how the practice standard relates to the PHC concept chosen. Wellness promotion is very similar to the standard of health promotion; wellness promotion is defined as helping clients achieve a higher level of wellness through empowerment, and identifying and building on presented strengths (Munro et al., 2000). While illness prevention is more focused on identifying barriers that prevent a person from reaching their goal, or satisfying their needs. This includes interventions of three levels which are; primary (preventing harm before it happens), secondary (reducing occurrence in at risk populations), and tertiary (minimizing effects after harm occurs).

Assessment of Assets and Needs

This indicator states that the CHN works with the individuals/community to determine what are the community's assets and needs (CHNAC, 2008). The best example that comes to mind for this indicator is the round table group discussions that I was part of during my clinical experience. In these discussions A.M was the group facilitator while I was the recorder. The discussions were based around improving health and wellbeing for faculty and staff on UPEI. The two main themes that I felt were used and used well in these discussions were health promotion as well as empowerment. The groups started with a brief introduction to the health promotion plan then A.M asked the members of the group for their input on things like; what does a healthy environment look like, or what can management do to make your workplace healthier for you. Allowing the faculty/staff to assess their own needs is form of empowerment which has been shown to improve self-determination and increase self-empowerment which is both very important in promoting health (Bjorklund, Sarvimaki, and Berg, 2008). This indicator is also linked to PHC through the concept of empowerment which is mentioned in Munro et al. (2000) as being a process that helps clients gain personal strength, effectiveness and power.

Facilitates Planned Change

For this standard the CHN uses the Population Health Promotion Model to facilitate planned change (CHNAC, 2008). For this indicator there are three parts of the population promotion model that are highlighted, for this paper we will be looking at utilizing different ways to address health issues. A.M has done this in a number of ways including the initiation of Wellness Wednesdays; this is a wellness program that takes place every second to third Wednesday. A.M organizes activities that help to improve all aspects of health including mental health and healthy eating fairs, scrapbooking, and card making. There have also been changes to the campus smoking policy, thanks to A.M there is no smoking permitted within 30 feet of any building on the campus grounds. Another service that the wellness center provides is blood pressure, glucose testing, and bone density scan clinics. This is something that can be related to the illness prevention aspect PHC. More specifically it is a form of secondary prevention because it is screening those who may be at risk for developing health problem for example the bone density scans could detect the early signs of osteoporosis in elderly woman (Munro, 2000). This range of health promotion and illness prevention strategies is exactly what this indicator is referring to and there are others who agree that a healthy setting is one that uses a whole systems approach covering as many aspects of health as possible (Dooris, 2009).

Effectively Implements Health Promotion Strategies

Using the Ottawa Charter for Health Promotion the CHN effectively implements health promotion strategies to the individual or community (CHNAC, 2008). Again this indicator is broken down into two different subcategories. The first one varies the use of varies strategies but the one of concern is creating positive environments. This is seen in the practice of the wellness center through the organization of the Healthy Campus Initiative. As mentioned earlier A.M was a group facilitator for group discussions regarding campus health for faculty and staff. These groups were part of this Initiative, which uses the National Quality Institutes (NQI) (2006) framework of Elements of a Healthy Workplace. In this framework one of the things needed for a healthy workplace is workplace culture and a supportive environment, tying in nicely to this particular standard. Another way that the wellness center is creating a supportive environment is by establishing a proper organizational health support structure. Outlined in Golaszeewski (2008) is a series of eight strategies that follow theoretical concepts to create a supportive work environment. The first being create a health initiative administrative structure, the wellness center has done this by establishing the Healthy Campus Initiative committee, which is composed of members of the campus from varies fields (including nursing). The initiative has also worked towards accomplishing the second strategy which is measuring the current health supportive structure of the workplace. This is being done through the group discussions and A.M hopes to distribute an employing satisfaction survey in the near future as well.

Increasing Knowledge, Influence, and Control

The CHN helps the community reach their optimal level of health by increasing their level of knowledge, influence, and control over the determinants of health that effect that particular community (CHNAC, 2008). A good example of this standard is the education sessions the wellness centers provide for the transition classes at UPEI. I was able to give a presentation on health and wellness to one of the transition classes. The presentation included information on exercise, healthy eating, stress management, the effects of tobacco, use and health and wellness resources available to UPEI students. This is directly related to the determinants of health in particular the determinant of education. It has been shown that higher levels of education can lead to better employment status and increased access to health resources (Johnson and Green, 2009). There are also studies that say higher levels of education are associated with higher levels of subjective health status (Lee et al., 2009).

Evaluates and Modifies Health Promotion Program

The last standard of discussion involves the CHN evaluating the health promotion programs within a community and modifying them as needed (CHNAC, 2008). This is the one practice standard that I feel was not used in the wellness center. It may be due to the fact that I have not been there long enough to take part in proper evaluation of the health promotion strategies in place or it may be that there is no established practice to fit this indicator. Evaluating is a very important part of any process it is key in determining what needs to change and what needs to stay the same for a particular strategy that may be in place. Although there are no current evaluations in place it is A.M hope that she will utilize an employee satisfaction survey in the near future.

Reflective Practice Questions

Initial Impressions

At the beginning of my clinical rotation I was unsure of how I would relate the standards to actual nursing practice. Not having a nurse in the facility was probably the main reason for this and the other being my lack of understanding. However after only my first day of clinical I was able to see the relation. Although my coordinator has no background in nursing there were still parts of the standards visible and I was able to imagine how they would apply to a nurse in her position. For example one of the first things I noticed as large part of her job was the promotion of healthy eating, and as Raine (2005) points out it is very important that the health care provider has an understanding of the determinants of health in order to promote healthy eating. A.M. realized that physical environments is a key determinant (Public Health Agency of Canada, 2001) and is a major part of promoting healthy eating. Therefore she was trying to establish healthy eating on campus by removing the high sugar/calorie (junk) food from the vending machines and replacing it with healthier choices, as well as improving the cafeteria food on campus. Although I was unsure of the relation of the practice standards I was certain that I would see wellness promotion and illness prevention. Just by reading the wellness center website regarding information on bone density scans and blood pressure clinics, illness prevention was a large part of the wellness center.

Barriers to Use of Standards

The reason for the barrier is that there is no actual nurse on staff at the wellness center. Therefore there is no formal obligation for the staff to follow the practice standards of CHN's. However as mentioned before my coordinator does an excellent job of health promotion and a lot of her work could fall under the standards of practice. Even though my coordinator does not fall under the designation of a registered nurse (RN) there is no reason why she could not be made aware of these standards to help her guide her practice like it does for us as nurses. Studies have showed that even as nurses it is important for us to be aware of our regulatory standards as well as our specialty ones. In one particular study by Fuller et al. (2008) they determined that regulatory and CHN standards only had 28% of items in common. So it goes to show that sometimes it is important to step back and look outside your specialty to determine the best standards of care.

Relationship of PHC Concept and Standard

Wellness promotion and illness prevention can very easily be linked to the standard of health promotion. For example they both work towards bettering the overall health of a population by providing that population with the tools they need to better themselves. In other words they strive to empower a population

Use in Future Experiences

The question asks how I will use the knowledge gained in other community health nursing experiences. I would like to start by saying that I will carry the knowledge I learned through this experience to all fields of nursing that I may work in. From reading the study by Fuller et al. (2008) I have learned that just because you belong to a specialty of your field it does not mean you can forget about the regulatory standards of your profession. Also from this experience I learned that just because the standards for CHN are intended for the use of RN's it does not mean that another profession could benefit from their guidance. To answer the question I believe that with the knowledge I gained from this experience I will be able to quickly learn about what that particular facilities strategies are for health promotion. Now that I have seen some strategies used first hand I have a better idea of what to look for.

Change of View

After this experience I can definitely see the relationship between PHC and the standards of practice more clearly. I believe it is particularly easy for me because my standard is so close to the PHC concept that I decided to focus on. Health promotion has many things in common with wellness promotion and illness prevention including empowerment, enhancing knowledge and skills (Munro, 2000) (CHNAC, 2008).

Conclusion

In the end I believe that this has been a very enriching and valuable experience for my especially in terms of my nursing career. Through my clinical experiences I was able to witness firsthand the use of practice standards in area of health promotion. I was able to clearly see the relationship between PHC and practice standards. Even though I was not placed under the mentorship of a RN I still believe that standards of practice can be applied to the UPEI wellness center and I also believe that A.M would benefit greatly if the standards were made aware to her to help guide her in her practice

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