Medicine

Lect. 9 Roles and Functions of the Community Health Nurse

TERNOPIL STATEMEDICALUNIVERSITY

INSTITUTE OF NURSING

DEPARTMENT OF CLINICAL IMMUNOLOGY, ALLERGOLOGY

AND GENERAL PATIENT CARE

 

Lecture 9

 

Roles and Functions of the Community Health Nurse

 

 

 

After studying this chapter, you should be able to:

 

·        Describe the role of the CHN as Clinician, Collaborator, Manager , and Leader as he/she works in communities with other health care providers

·        Describe the role of the CHN as Educator, Advocate, and Researcher in his/her Community

 

 

Introduction

 

 

Role and Functions of the Community Health Nurse

 

  Community health nurses have always practiced in a wide variety of settings and assumed various roles. In this topic, the seven major roles and six of the most common settings for CHN practice are examined.

 

The seven major roles are:

  • clinician

  • educator

  • advocate

  • manager

  • collaborator

  • leader

  • researcher

 

Clinician

The role of the clinician or care provider is a familiar one for most people. In community health the clinician views clients in the context of larger systems. The family or group must be considered in totality. The community health nurse provides care along the entire range of the wellness-illness continuum; however, promotion of health and prevention of illness are emphasized. Skills in observation, listening, communication, counselling, and physical care are important for the community health nurse. Recent concerns for environment, sociocultural, psychological, and economic factors in community health have created a need for stronger skills in assessing the needs of populations at the community level.

 

Educator

One of the major functions of the community health nurse is that of health educator. As educators, nurses seek to facilitate client learning on a broad range of topics. They may act as consultants to individuals or groups, hold formal classes, or share information informally with clients. Self-care concepts, techniques for preventing illness, and health promotion strategies are emphasized throughout the health teaching process.

A nurse educator is a nurse who teaches and prepares licensed practical nurses (LPN) and registered nurses (RN) for entry into practice positions. Nurse Educators also teach in graduate programs at Master’s and doctoral level which prepare advanced practice nurses, nurse educators, nurse administrators, nurse researchers, and leaders in complex healthcare and educational organizations.

Nurse educators combine clinical expertise and a passion for teaching into rich and rewarding careers. These professionals, who work in the classroom and the practice setting (hospital setting or community setting), are responsible for preparing and mentoring current and future generations of nurses. Nurse educators play a pivotal role in strengthening the nursing workforce, serving as role models and providing the leadership needed to implement evidence-based practice. Nurse educators are responsible for designing, implementing, evaluating and revising academic and continuing education programs for nurses. These include formal academic programs that lead to a degree or certificate, or more informal continuing education programs designed to meet individual learning needs.

Nurse educators are critical players in assuring quality educational experiences that prepare the nursing workforce for a diverse, ever-changing health care environment. They are the leaders who document the outcomes of educational programs and guide students through the learning process. Nurse educators are prepared at the master's or doctoral level and practice as faculty in colleges, universities, hospital-based schools of nursing or technical schools, or as staff development educators in health care facilities. They work with recent high school graduates studying nursing for the first time, nurses pursuing advanced degrees and practicing nurses interested in expanding their knowledge and skills related to care of individuals, families and communities. Nurse educators often express a high degree of satisfaction with their work. They typically cite interaction with students and watching future nurses grow in confidence and skill as the most rewarding aspects of their jobs. Other benefits of careers in nursing education include access to cutting-edge knowledge and research, opportunities to collaborate with health professionals, an intellectually stimulating workplace and flexible work scheduling. Given the growing shortage of nurse educators, the career outlook is strong for nurses interested in teaching careers. Nursing schools nationwide are struggling to find new faculty to accommodate the rising interest in nursing among new students. The shortage of nurse educators may actually enhance career prospects since it affords a high level of job security and provides opportunities for nurses to maintain dual roles as educators and direct patient care providers

A nurse educator is a registered nurse who has advanced education, including advanced clinical training in a health care specialty. Nurse educators serve in a variety of roles that range from adjunct (part-time) clinical faculty to dean of a college of nursing. Professional titles include Instructional or Administrative Nurse Faculty, Clinical Nurse Educator, Staff Development Officer and Continuing Education Specialist among others. Nurse educators combine their clinical abilities with responsibilities related to: Designing curricula developing courses/programs of study Teaching and guiding learners evaluating learning documenting the outcomes of the educational process.

Nurse educators have the unique opportunity to share their clinical expertise in educational settings to shape the next generation of nurses. Current faculty indicates that the most positive aspect of their role is the interaction with students. Nursing faculty may also engage in scholarly inquiry that will further illuminate the nature of teaching and learning and will ultimately shape future educational processes and outcomes

 

Advocate

 In health care the concept of advocacy has become increasingly important over recent years as consumers demand better quality, more responsiveness and easier access to such services. The rise of consumerism through every walk of life has had its influence on expectations of health care, and there is an increasing demand for user-empowerment and public accountability for services.

Two underlying goals in client advocacy are described. One goal of the community health nurse as advocate is to help clients find out what services are available, which ones they are entitled to, and how to obtain these services. A second goal is to influence change and make the system more relevant and responsible to clients' needs.

 

"Nurses must transmit the values of the nursing profession to society, in order that society may change in accord with these values"

(Fowler, 1989, p 98)

 

Four characteristics required for successful advocacy are:

  • assertiveness

  • willingness to take risks

  • good communication and negotiation skills

  • ability to identify resources and obtain results

 

Advocacy has been defined and implemented in many different ways, the major concepts include citizen advocacy; self-advocacy; collective or class advocacy; legal advocacy; and the focus of this paper, the nurse at patient-advocate. The advocate may be the person themselves (self-advocacy); an appointed official employed by a service organisation; an independent person or "befriender"; an "expert" (e.g., legal advocate), or a professional who works closely with the person (such as the nurse as advocate). In any of these different forms and interpretations of advocacy, the nature of the act, the relationship involved, and the goals and outcomes are likely to differ significantly. This proposed is concerned with the nurse acting as the patient’s advocate within his or her professional role, and other formulations are therefore excluded.

Superficially, an advocate may be considered to be one who will always be acting in the person’s "best interest" whatever that might be, and concerned with doing "good", however closer examination of the ethical basis of advocacy suggests that this is a simplistic and perhaps inaccurate portrayal of the role.

In nursing, the concept of the nurse as the patient’s advocate has been a familiar one for a considerable time; it is implied in various nursing codes (e.g., ANA, 1985; UKCC, 1984 & 1992).

There has been a common assumption that advocacy is a major role for the nurse (Marks-Maran, 1993) and for some, advocacy is definitive of nursing (e.g., Gadow, 1980, 1990) or as Murphy (1983) states "the highest order nursing act..." Others, (e.g., Miller etal, 1983; Trandel-Korenchuk, 1983) however argue that nurses cannot act effectively as advocates because of their duties and loyalties to their employers, and the medical profession.

Some nurses who have taken their advocacy role to its full extent have often found themselves in conflict with their employers, other professionals or even their peers when they pursue issues on the behalf of their patients. In some instances (for example Graham Pink, cited by Snell, 1991) this has ultimately lead to disciplinary action and dismissal, even though the nurses professional body had judged that they had not acted outside of their professional code of conduct. Support for advocacy and patient advocates may therefore be more theoretical than actual, and an appreciation of this situation may well inhibit other nurses from full realisation of the patient advocacy role. The dilemmas posed for nurses considering this role are therefore significant. It is arguable that for many nurses advocacy is acknowledged and implemented only within certain limits and boundaries, and it is suggested that nurses often curtail or modify their advocacy activities when conflict with powerful authority figures, within or without nursing, appears to be likely.

 

Models of advocacy:

 

 

The advocate as guardian of patient’s rights

 

This model of advocacy has some parallel with the legalistic definition given above. It is based on the premise that the nurse is able to inform the patient of their rights, and can then enable them to exercise those rights, or intervene to ensure that their rights are respected (Gillette, 1988). Gates (1994) definition of advocacy could be seen as fitting within this model.

Criticisms of this model are that the nurse-patient relationship is not conceived in these terms by either party, and the nurse is not the best skilled or equipped to fulfil this role (Fowler, 1989; Melia, 1987). The legalistic or patient’s rights model may be too narrow a conception to deal with everyday problems experienced by patients and their nurses, for example, treatment and care decisions are rarely as clear-cut as being supported by claiming a right.

Also this perspective tends to pre-suppose a confrontational stance that may prevent nurses from taking an advocacy role.

 

The advocate as conservator of the patient’s best interests

 

The idea that the advocate should be involved in helping the patient receive care or make decisions that are in his or her best interests would at first consideration seem unarguable. The great difficulty with this approach is deciding what the patient’s best interests are, and by whose definition?

Paternalism, described by Gadow (1983) may often be the rationale or motive behind "best interest" decisions. Paternalism is defined by Gadow as:

 

"The use of coercion to provide a good that is not desired by the one whom it is intended to benefit"

                                                                          (Gadow, 1983, p 43)

 

The advocate as conservator of the patient’s best interests

 

An example of this might be the patient who is persuaded to continue with aggressive treatment of terminal illness because they have a theoretical chance of survival. In such an example "good" provided (i.e. potential cure) is defined according to the nurse’s or physician’s values based on cure (Gadow, 1989), however "good" for the patient may relate much more to the care experience in such a situation. In this instance, advocacy as paternalism cannot be defended as offering benefit in relation to the patient’s values, and it also negates the principle of self-determination. The nurse’s actions may be guided by "beneficence" (to do well) or "utilitarianism" (actions that are judged by their social utility, or that offer the greatest good to the greatest number of people (Harman, 1977). The outcomes derived may not coincide with the patient’s self-determined best interests.

 

The advocate as protector of patient’s autonomy

 

Kohnke (1982) is a proponent of this model of advocacy, and identifies two principle tasks for the nurse, informing and supporting. Informing involves providing sufficient information for making informed decisions about health care, and the supporting task which is concerned with reinforcing and upholding the patient’s decision.

This model, however offers little assistance for the nurse caring for patients who are unable to communicate or make informed decisions, and the justification of action (or non-action) based on the client’s right to self-determination may often bring the nurse into conflict with other ethical and legal considerations. Also, Quinn & Smith (1987) argue that respect for autonomy does not presume that the individual will make the best or even safe decisions for themselves, and there is much evidence in daily life that individuals do not do so, although it possible to make arguments such as that a decision to commit a "dangerous" act, say for example misuse of drugs, may be in the persons "best interests" given their own value system. Gadow (1979, 1983, and 1989) is a significant contributor to the advocacy literature with her concept of "Existential Advocacy". She proposes this concept as the philosophical

 

The advocate as protector of patient’s autonomy

 

Kohnke (1982) is a proponent of this model of advocacy, and identifies two principle tasks for the nurse, informing and supporting. Informing involves providing sufficient information for making informed decisions about health care, and the supporting task which is concerned with reinforcing and upholding the patient’s decision.

This model, however offers little assistance for the nurse caring for patients who are unable to communicate or make informed decisions, and the justification of action (or non-action) based on the client’s right to self-determination may often bring the nurse into conflict with other ethical and legal considerations. Also, Quinn & Smith (1987) argue that respect for autonomy does not presume that the individual will make the best or even safe decisions for themselves, and there is much evidence in daily life that individuals do not do so, although it possible to make arguments such as that a decision to commit a "dangerous" act, say for example misuse of drugs, may be in the persons "best interests" given their own value system. Gadow (1979, 1983, and 1989) is a significant contributor to the advocacy literature with her concept of "Existential Advocacy"

 

The advocate as a champion of social justice

 

 This view of advocacy as Fowler suggests, takes the nurse’s role as an advocate from the patient’s bedside to beyond the institutional walls (1989, p 98). There may be an element of advocacy for individual patients, but the focus is on social and political change to deal with inequities and inequalities in provision of care at both macro’ and micro-allocation levels.

 

Manager

 

 The manager's role is common to all nurses. Nurses serve as managers when they oversee client care, supervise ancillary staff, do case management, run clinics and conduct community health needs assessment projects. The nurse engages in four steps of the management process of planning, organizing, leading and controlling evaluation. Each of these functions is described in the text. Specific decision-making behaviours are part of the manager's role as well as human, conceptual and technical skills.

The Nurse Manager plays an essential role in healthcare. She sets the tone of any Healthcare System. The Manager is the backbone of the organization. The quality of patient care, as well as staff recruitment and retention success, rests with this key role. Over time it will be the strength of the nurse manager group that determines the success or failure of nursing leadership, the COO, and even the CEO.

And yet it is rare that nurse managers are given the opportunity to acquire the operational, financial, and management skills essential to their success – and the success of their organization.

As critical as it is to develop those concrete and pragmatic skills noted above, there is also a delicate subtle art to being a Nurse Manager... to balancing the tensions between quality and cost ... to dealing with multiple stakeholders, presenting conflicting agendas ... to dealing with stress and pressure every day ...to implementing processes needed to ensure that individualized compassionate care is provided consistently in the most efficient and effective manner possible...and we show you a system to succeed.

There are three keys to succeeding as a Nurse Manager

 

·        A Complete and Comprehensive Understanding of the Nurse Manager Role and Access to Best Practices

·        A Comprehensive System for Success;

·        A Toolkit to Succeed

 

 

Nurse Managers keys :

 

 

 

 

 

1.

 

They balance the many pressures they face every day: budget challenges; dealing with multiple stakeholders; managing up, down, and across; handling labour issues and shortages; and, of course, finding time to provide excellent care for patients.

2.

 

They set themselves apart as stellar performers in your organization and enjoy greater recognition, respect, and career success.

3.

 

They exhibit increased confidence in their role.

4.

 

Work becomes more professionally gratifying.

5.

 

The organization enjoys enhanced productivity, as well as improved patient and staff satisfaction.

 

 

 

Description:

The goal of a nurse manager is to facilitate and deliver quality nursing care as well as to coordinate and manage the environment in which the care is delivered. The first-line manager/head nurse assumes responsibility for the personnel, resources, and patient care on a nursing unit. A nurse supervisor is often responsible for several nursing units or all units for a particular function such as staffing or a shift, such as night supervisor. A manager directs and promotes the development of nursing staff assigned to the unit. Nurse administrators establish and control the budget and support the implementation of standards of nursing practice and guidelines of care

Settings:

Hospitals, long-term care, ambulatory care, or community/public/home health agencies

Characteristics:

Personal satisfaction, power, recognition, prestige, and economic gain; opportunities for promotion

Drawbacks:

Scope of responsibility, pressures of competition, hard work, and high degree of flexibility; consumer issues, economy, politics, manpower, and technology

Desirable skills:

Fact finding, analyzing, advice seeking, listening, negotiating, and collaborating; risk-taking, tolerance for ambiguity, assertiveness, self-reliance, and achievement orientation; human relations, coaching, and compassionate approach

Education:

RN with BSN, MSN, or doctorate

 

Collaborator

 

 Collaboration with clients, other nurses, physicians, social workers, physical therapists, nutritionists, attorneys, secretaries, and other colleagues is part of the role of the community health nurse. Collaboration is defined as working jointly with to hers in a common endeavour to cooperate as partners.

 

Skills required for successful collaboration are

 

·        Communication skills,

·        Assertiveness,

·        Consultant skills.

 

 

Leader

 

 

The role of leader is distinguished from the role of manager. As a leader, the community health nurse directs, influences, or persuades others to effect change that will positively affect people's health. Acting as a change agent and influencing health planning at the local, state and national levels are elements of the role of the leader.

 

Characteristics of an Effective Leader

A good leader must be:

• A lifelong learner

• A good communicator with effective interpersonal skills

• Able to look at the whole picture

• A good teacher

• Able to foster growth in others by mentoring and providing opportunities

• A model for effective change

• Accountable

• A problem-solver

• A promoter of collaboration

• Knowledgeable in area of expertise

• Goal-oriented

• A person who seeks opportunities for growth

• Open-minded

• A good time manager

• Able to remain calm when everyone else is not

 

 

Researcher

 

In the role of researcher, community health nurses engage in systematic investigation, collection, and analysis of date to enhance community health practice Research in community health may range from simple inquiries to complex agency or organizational studies. Attributes of a nurse researcher include a questioning attitude, careful observation, open-mindedness, analytical skills, and tenacity.

 

Description:

Involves all aspects of working with pharmaceutical/medical/nursing research

Practice roles:

Clinical data coordinator, clinical research assistant, clinical research monitor, research assistant

Characteristics:

Opportunity to be part of groundbreaking studies, projects

Drawbacks:

Some work is temporary or part time, travel may be required, work can be tedious. Position may rely on availability of grant money

Desirable skills:

Strong observation and analytical skills, detail-oriented. Grant writing experience helpful in some situations

Education:

Varies. BS may be required. Some positions may require MS or higher. Advanced nursing research usually requires PhD

Employers:

Pharmaceutical companies, contract research organizations, teaching and university hospitals, educational institutions, temporary technical placement agencies

 

 

Typical functions:

 

 

The functions performed by employees in this job family will vary by level, but may include the following:

·     · Assesses health status of individuals, families, and communities; develops plans and implements appropriate nursing interventions.

·     · Evaluates and determines health resources necessary to meet individual, family and community health needs.

·     · Delivers professional nursing care in an assigned unit, clinic, home, or other setting.

·     · Educates individuals, families, communities, and members of the health care team about the principles of disease prevention and health promotion.

·     ·Provides supervision to other professional or paraprofessional personnel; collaborates with other professionals in the management of health care.

·     · Delegates tasks as may safely be performed by others, consistent with educational preparation and that do not conflict with the provisions of the Oklahoma Nursing Practice Act.

·     · Assures quality health care through use of various measures such as record review, peer review, direct observation, and assessment of individual, family, and community for the desired outcome.

·     · Performs specialized nursing functions as educationally prepared.

 

 

The role of the nurse needs to be expanded to include protection of women's reproductive potential. Nursing has adjusted to the change in medical care through assistance in regaining of health in acute and extended care facilities, in health maintenance, and in acting as primary care providers in providing information on prevention. Infertility increases with age. The impact of contraceptive choices on fertility is reviewed for barrier contraception, oral contraception, IUDs, sterilization, and new contraceptive methods. At different stages in the life cycle there are methods of contraception that are more appropriate than others. The environmental effects on fertility are noted for diethylstilbestrol (DES), which may result in cell carcinoma and changes in the cervical ectropion, uterine, and tubal anomalies; these effects in turn may lead to decreased fertility or fetal loss. DES may also affect male fertility. Chemicals in the workplace such as lead, ionizing radiation, ethylene oxide, and dibromochloropropane are federally regulated because of deleterious effects on reproduction. Other metals and chemicals that may affect fertility are indicated. The prevention of sexually transmitted diseases has a significant impact on preservation of fertility. Life style choices and counseling at early stages of disease are important considerations. Women who smoke have an earlier menopause, have reduced estrogen levels, and increased vaginal bleeding. Infant mortality is higher among women who smoke. Fetal alcohol syndrome is known, but alcohol's effect on fertility is not well documented. Adolescent drug use may lead to later dysfunction. Marijuana use in adults has been related to decreased levels of follicle stimulating hormone, luteinizing hormone, and prolactin, which appears to be reversible in adults. Exposure to high levels of heat is related to male infertility (sperm quality and number); increased scrotal temperature may be caused by febrile illness, varicocele, hot tub usage, and tight jockey shorts. Fertility impairment may be related to a previous medical or surgical intervention. Options are available for organ preservation rather than outright removal. General health conditions related to infertility are identified. The nurse practitioner as a preconception counselor may screen for potential infertility and collect a routine history and physical examination including testing.

 

 

References

·        Antrobus, S. & Kitson, A., (1999). Nursing Leadership: Influencing and shaping health policy and nursing practice. Journal of Advanced Nursing 29, 746-753.

·        Benefield, L.E., Clifford, J., Cos, S., Hagenow, N.R., Hastings, C., Kobs, A., et al. (2000). Nursing leaders predict top trends for 2000. Nursing Management, 31(1), 21-23.

·        Horton-Deutsch, S.L., & Mohr, W.K. (2001). The Fading of Nursing Leadership. Nursing Outlook, 49, 121-126.

·        Kerfoot, K. (2001). The Leader as Synergist. MEDSURG Nursing, 10(2), 101-103.

·        Laurent, C.L. (2000). A nursing theory for nursing leadership. Journal of Nursing Management, 8, 83-87.

·        Perra, B.M. (2000). Leadership: The Key to Quality Outcomes. Nursing Administration Quarterly, 24(2), 56-61.

·        Porter-O’Grady, T. (1997). Quantum Mechanics and the Future of Healthcare Leadership. Journal of Nursing Administration, 27(1), 15-20.

·        Porter-O’Grady, T. (1999). Quantum Leadership: New Roles for a New Age. Journal of Nursing Administration, 29(10), 37-42.

·        Singhapattanapong, S. (2002, March 11). Nurse shortage hurts UCLAMedicalCenter. UCLA Daily Bruin, p.1.

·        Sofarelli M.. & Brown, R. (1998). The need for nursing leadership in uncertain times. Journal of Nursing Management, 6(4), 201-207.

·        Sullivan, E.J. & Decker, P.J. (2001). Effective Leadership and Management in Nursing (5thed.). Upper Saddle River, NJ: Prentice Hall.