Nurses and Nursing in Community

Article / Research Article

Siniša Franjić

Advisor Doctor, Baghdad Medical City and Iraqi Ministry of Health, Iraq

*Corresponding author :

siniša Franjić Independent researcher E-mail:
Submitted : 6 July 2020 ; Published : 10 Aug 2020


The goal of health care is to prevent illness, maintain health, help the sick and disabled person, as well as alleviate and prevent suffering from serious illnesses. Nurses who provide health care provide assistance to the individual, family, and community. The attitude towards the patient is completely holistic, which means that the patient’s health condition is fully considered. The nurse is not only focused on actions related to illness and other health difficulties that need to be addressed around the patient, but also turns to his physical, mental, social, economic and cultural condition.

Keywords :

Nurse, Nursing, Health, Community, Patient


Community nurses face many challenges within their evolving roles [1]. The transition from working in an institutional setting to working in the community can be somewhat daunting at first. As a student on community placement or a newly employed staff nurse, it soon becomes apparent that there is a wide range of factors influencing the planning and delivery of community healthcare services. Within the home/community context, those issues that impact upon an individual’s health are more apparent. People are encountered in their natural habitats rather than being isolated within the hospital setting. Assessment is so much more complex in the community, as the nurse must consider the interconnections between the various elements of a person’s lifestyle. In addition, community nurses are often working independently, making complex clinical decisions without the immediate support of the wider multidisciplinary team or access to a range of equipment and resources as would be the case in a hospital or other institutional healthcare environment. It is recognised, for example, that district nurses are frequently challenged with managing very complex care situations which require advanced clinical skills, sophisticated decision making and expert care planning.

Any attempt to analyse the series of complex processes that makes up a living community without the participation of local residents/consumers is a fairly fruitless exercise. In gathering information from a large community population, a variety of methods may prove useful. An approach entitled Participatory Rapid Appraisal has been described elsewhere and involves community members in the collection of information and related decision making. Originally used in developing countries to assess need within poor rural populations, it has been employed in deprived urban areas. A wide variety of data-collection methods is used and Participatory Rapid Appraisal involves local agencies and organisations working together. By working in partnership with local residents, action is taken by community members who have identified issues of local concern/interest and discussed potential solutions. Clearly, Participatory Rapid Appraisal could be used to help tackle specific issues as well as large-scale assessments.

Health professionals’ attention to community-based approaches to promote health and prevent disease has dramatically increased in recent years [2]. The increased emphasis is due to many factors, including a greater understanding of the complex etiologies of health problems, an appreciation of the relationship of individuals with their environment, and recognition of the limitations of focusing only on individual behaviors to promote health. A greater understanding of the role of the sociocultural, physical, and political environments in achieving health has resulted in multiple approaches to promoting wellness. Individual approaches to health promotion identify a finite number of lifestyle areas that can be quantified and targeted for intervention. Community-based models move beyond individual lifestyles to distal factors that influence health, such as working and living conditions. In a community-based view, the social, political, institutional, legislative, and physical environments in which behavior occurs can be targeted to promote health. Community approaches emphasize populations and communities as clients and acknowledge that the greater environment influences individual health behaviors.
Although health care professionals recognize that attention to the social, physical, and political environment is necessary for health promotion, community-based models are not intended to neglect the individual. Individuals make up communities, so although the community may be targeted, individuals play a critical role in providing leadership. Community-based strategies for health promotion are community-led strategies, as control is placed with individuals who reside in the community.

District Nurses
District nurses (DNs) can trace their roots back to the mid-1800s at least, and the historical development of the service is well recorded [1]. They used to work in relative isolation but are more likely nowadays to work within a team. The role of the district nurse has evolved over time in response to political influences and the changing needs of the populations served. Although it is acknowledged that the role of the district nursing service is not clearly defined, it involves the assessment, organisation and delivery of care to support people living in their own homes.

With the current pressures on health and social care, there has been renewed attention on the pivotal role of the DN in leading and managing complex care at home. The value of the DN’s role in caring for patients at home, avoiding unnecessary hospital admissions, cannot be underestimated. Equally, DNs are central to ensuring effective discharge planning. The King’s Fund Report entitled ‘Understanding Quality in District Nursing Services’ highlights the dissonance between the policy incentive to promote care in community settings and the capacity problems being experienced in district nursing services, and, among its recommendations, proposes the development of a rigorous framework to assess and monitor the quality of care in the community. Ongoing work by the Queen’s Nursing Institute (QNI) on what constitutes a safe caseload to protect staff well-being while also ensuring high-quality and safe patient care – comprising holistic care and care continuity – within current resources will further inform the debate.

Health and Well-Being
As healthcare practitioners who foster a holistic approach to care assessment and delivery it is important to understand what health, well-being and public health are and the differences between them [3]. The community practitioner should also have knowledge and understanding of the relationship of cause and effect and how it impacts on care delivery, treatment and outcome.

The World Health Organization (WHO) defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
While the word ‘complete’ might render the definition as idealistic and perhaps unattainable, the definition does acknowledge that health is a multidimensional issue, with well-being as an integral part, including the physical, mental and social aspects. Subsequent WHO publications have contextualised the definition and presented it in light of the importance of recognising underpinning health determinants and influencing factors such as income, education and social exclusion/inclusion.

When reading the WHO definition of health above is it noteworthy that the concept of well-being is integral. Well-being as a notion applies to all individuals, regardless of their physical or psychological state. The term ‘well-being’ was analysed by the Sustainable Development Research Network, who conclude that the term encompasses the concepts of life satisfaction (happiness, quality of life), physical health, income and wealth, relationships, work and leisure, personal stability and lack of depression. You may wish to consider at this point whether one of those mentioned is more significant to well-being than another, or whether and how they relate.

The idea of health and well-being being closely related is embedded in government policy. The Organization for Economic Co-operation and Development report that lower income countries do well in relation to subjective perceptions of well-being and overall work-life balance, while higher income counties struggled with work-life balance and within these higher income counties poorer educated and low income populations do less well – resulting in poorer health and social isolation. Why would this be? The role of expectation and perception links clearly to the emotional well-being of populations and their emotional health.
Health is a value judgement that individuals make based on their goals, beliefs and aspirations and shaped by their social and cultural experiences [4]. Health can be seen as having the following components:

  • Physical health that is concerned with the physical functioning of the body, including certain aspects of fitness such as strength and stamina, characteristics such as body size and shape, susceptibility to infection and ability to recuperate.
  • Mental health refers to the ability to learn, to grow from experience, to think clearly and coherently and the ability to solve problems.
  • Social health that includes the ability to make and maintain satisfying interpersonal relationships, respond appropriately in various social situations and fulfil a role in society.
  • Emotional health refers to the ability to express emotions such as joy, fear and grief appropriately in terms of both manner and place, cope with stress and deal with other emotional reactions and tensions.
  • Spiritual health includes the feelings of unity with others, principles of behaviour and personal values and, for some people, religious beliefs and practices.
    Health is not just the absence of disease and illness. It is also about an improved quality of life.

Promotion of Health
Health promotion as a concept came to the fore in the 1980s [3]. The WHO succinctly defined health promotion as ‘the process of enabling people to increase control over and to improve their health’. This definition is still relevant today and relates to the concept of empowerment and the nurse as a leader and educator. The definition underpins current government policy, actively placing the individual at the center of care and encouraging their involvement in the decision processes in order to take control of health decisions: ‘No decision about me without me’. Public health clearly encompasses health promotion. It can be concluded that health promoters (such as community nurses) should aim to enhance participation, equity and fairness to improve the health of individuals, families and communities.

Nurses are involved in public health activity through their day-to-day contact with patients, clients, families and carers; delivering health promotion activity, planned or unplanned by providing information, education, facilitating motivation and empowerment. Community nurses are in a strong position to promote health and well-being. Their knowledge of the local community and access to clients and their families in their own homes enables community nurses to develop a deep understanding of the factors that influence the health of individuals, families and communities. Their ability to influence the care received by individuals and to influence local health policy development is high.

Health promotion has been viewed as an effort to prevent disease and illness [5]. Most sources cite three levels of prevention: Primary prevention is the prevention of disease; secondary prevention consists of early screening and detection of disease; and tertiary preventionis the restoration of health after illness or disease has occurred. Focusing health-care efforts on all three levels of prevention is important to promoting health, but during the last two decades, the focus on primary prevention has become the ultimate goal of health promotion.
The focus in health care during the first half of the 20th century was on care for the patient who was already ill. The prevailing belief at the time was that patients should seek health care when they were ill. During this time, most health-care practitioners cared for patients at the tertiary level by (1) preventing further insult or injury after the disease or illness had occurred, by stabilizing the patient’s condition to prevent deterioration; (2) helping patients to recover from the current illness or disease through treatment; and (3) whenever possible, to help restore patients to their previous state of health.

Advancements in technology during the second half of the 20th century contributed to better diagnostic testing, helping to shift the focus of health care to secondary prevention. Providers became savvier about the importance of screening “at risk” patients during appropriate intervals for known diseases and illnesses. A focus on secondary levels of prevention led healthcare providers to encourage early detection and treatment.

With the focus on screening and early detection, treatment could be instituted before overt signs and symptoms appeared, thereby preventing some of the long-term sequelae associated with illness and disease. For example, blood pressure would be checked in a patient with no symptoms of hypertension, and if elevated, a plan of treatment would be instituted. The goal was and is maintaining the patient’s blood pressure within normal limits and hopefully minimizing the development of catastrophic complications such as stroke or myocardial infarction. Certain circumstances must exist for a screening test to be useful.

Family Care
Women and their families receive most of their health care, both well and ill care, in the community setting [6]. During the past several years, the health care delivery system has changed dramatically. With a focus on cost containment, people are spending less time in the hospital. Clients are being discharged “sicker and quicker” from their hospital beds. The health care system has moved from reactive treatment strategies in hospitals to a proactive approach in the community. This has resulted in an increasing emphasis on health promotion and illness prevention within the community.

Nurses play an important role in the health and wellness of a community. They not only meet the health care needs of the individual but also go beyond that to implement interventions that affect the community as a whole. Nurses practice in a variety of settings within a community, such as clinics and physician offices, shelters, churches, health departments, community health centers, and homes. They promote the health of individuals, families, groups, communities, and populations and promote an environment that supports health.

Family-centered cares refers to the collaborative partnership among the individual, family, and caregivers to determine goals, share information, offer support, and formulate plans for health care. Key elements in the provision of family-centered care include demonstrating interpersonal sensitivity, providing general health information and being a valuable resource, communicating specific health information, and treating people respectfully. The philosophy of family-centered care recognizes the family as the constant: the health of all the family members and their functional abilities influence the health of the client and other members of the family. Family-centered care works well in all arenas of health care, from preventive care to long-term care. Family-centered care enhances the confidence of all those involved about their skills and helps to prepare individuals for assuming responsibility for their own health care needs. It is vital for the nurse to assess how much knowledge the family already has about the client’s health or illness.

The focus of health care initiatives today is on people and their needs, strengthening their abilities to shape their own lives. The emphasis has shifted away from dependence on health professionals toward personal involvement and personal responsibility, and this gives nurses the opportunity to interact with individuals in a variety of self-help roles. Nurses in the community can be the primary force in identifying the challenges and implementing changes in women’s and newborn’s health for the future.

Nursing interventions involve any treatment that the nurse performs to enhance the client’s outcome. Nursing practice in the community uses the nursing process and is similar to that in the acute care setting, because assessing, performing procedures, administering medications, coordinating services and equipment, counseling clients and their families, and teaching about care are all part of the care administered by nurses in the community.

Family Violence
Family violence, in all its forms, is a crime in every state in the United States [7]. Regardless of whether it is child abuse, dating violence, intimate partner violence, elder abuse, or the abuse of vulnerable people with cognitive, mental health, or physical disabilities, it is a crime to push, slap, punch, kick, or injure anyone. Many forms of familial or institutional neglect are also potentially criminal in nature. Nurses encounter individuals who have experienced family violence. Some of these acts of violence may be investigated by law enforcement.

Forensic nurses address health care issues with a legal component. Forensic practice is part of holistic care by adding the legal issues that surround victims, perpetrators, and their families and significant others. Forensics pertains to the law and the courts; however, it is not limited to the criminal courts. While not every nurse is a trained forensic nurse, many nurses routinely encounter forensic issues in their practices. Nurses who work with survivors of family violence throughout the life cycle may be asked to collect evidence for and testify in a variety of courts, including criminal, family, guardianship, juvenile, and probate courts.

The role of the forensic nurse includes three broad areas: (1) provide thorough, competent, and compassionate care to patients who have experienced violence; (2) collect evidence and document findings in a manner that that allows for the use of the evidence and findings in the investigation and adjudication of a criminal case; and (3) testify about the facts of the case and as an expert. To some extent, these aspects of the forensic role can be in conflict with each other. For example, the nurse’s role as patient advocate could impair the nurse’s ability to provide unbiased testimony in a criminal trial. Forensic nurses can best address the possibility of conflict in these roles by providing high-quality, patient-centered care and remaining as objective as possible. Forensic nurses should not think of themselves as “victim advocates” and should refer to the person for whom they are providing care as a patient, not a victim or survivor of violence. Competent nursing care always requires that nurses act in the best interests of their patients (not just forensic patients), so serving as a patient advocate does not present any conflict with other aspects of the nurses’ role. Nurses must collect evidence with the knowledge that this evidence will serve the criminal justice system, not just the prosecutors, remaining as objective and neutral as possible in their handling of the evidence and documentation of the findings. Finally, forensic nurses with a history of providing objective testimony in court, whether their testimony benefits the prosecution or defense in a particular case, will be seen as more credible than nurses biased in favor of the prosecution. Carefully objective, thoughtful forensic nursing care at all stages will ultimately provide the greatest benefit to survivors of violence.

Mental Health
The genetics of cognitive abilities, mental functioning, social attitudes, psychological interests, psychiatric disorders, learning disorders, behavior, addiction, mood, and personality traits have long been of interest to geneticists [8]. This interest has been complicated by the complexity of brain function as well as the social, ethical, legal, and political implications of research in this area. Also complicating study is the tendency for such conditions to be too broadly defined, thus perhaps diluting the possible gene associations. For example, it is more fruitful to look for a specific type of genetic variation connected with a more narrowly defined communication disorder such as expressive, mixed, phonologic, and so on rather than the broadly used term.
With the new NHS system focusing on identifying the needs for local services and on primary prevention with health improvement programmes, practice nurses are ideally placed to screen for drug misuse and for those with at- risk alcohol consumption, to deliver health information and brief interventions [9]. There is some evidence suggesting that 13% of men and 2.5% of women having an alcohol use disorder consult their general practice.

Community mental health nurses are exposed to a wide range of clients with varying degrees of psychiatric disorders and substance misuse. Community drug and alcohol teams may include community psychiatric nurses. Their work may cover the recognition of substance misusers, liaison with primary health care workers, for example general practitioners, in detoxification, motivation and relapse prevention, counselling, alcohol, drug and HIV (human immunodeficiency virus) education, and other harm minimisation work.

District nurses usually encounter patients at different stages in their illness and are responsible for the provision of total nursing care. They too have a role to play in prevention and harm reduction in relation to substance misuse.

The misuse of psychoactive substances in the workplace is one of the major concerns of management, professional organisations and occupational health staff. There is evidence to suggest that a policy on tobacco smoking or alcohol use can lead to reduced absenteeism, improved safety performances, lower maintenance costs, lower air-conditioning and ventilation costs, increased productivity, improve morale among non-smokers, fewer accidents and a lowered risk of losing skilled employees through premature retirement or death.

Primary care mental health workers provide additional, specialist services in primary care settings for people with mental health needs. One of the key functions is to help facilitate the transition towards primary care becoming the major arena of community mental health care and to facilitate the supply of basic therapeutic interventions such as cognitive behavioural therapies.

A patient has a right to withhold consent for examination or treatment, or withdraw it at any time [10]. Consent is important in the law because of its connection with trespass to the person, that is, assault or battery. An assault is any act which causes in the person subjected to it an apprehension of the immediate infliction of a battery. A battery is the physical contact with another’s person. To have obtained informed consent is a defence against an accusation of assault and/or battery.

Consent may be express, when it is oral or written down, and this is the usual practice for surgical procedures. It is implied, for example in compliant actions such as raising one’s arm for an injection. Implied consent may be adequate for minor procedures.

The most important element in consent is the patient’s understanding of what is going to be done. Obtaining valid consent involves giving an explanation of the nature of the examination or treatment, of any substantial risks involved, of any side-effects and consequences for the life of the patient, mentioning alternatives, and giving all this information in a form which is comprehensible to the patient. Of course, the patient may be advised about a course of action, but it is important to back up this advice with the reasons.


The common goal of medicine and health care is to improve, preserve and restore health. Medicine studies the human body from the point of view of disease, and health care from the point of view of basic human needs. Medicine performed by a physician deals with the detection of a disease or injury by making a diagnosis. The diagnosis is determined on the basis of anamnesis, physical examination and on the basis of medical and technical documentation. Based on the diagnosis, the treatment of the disease or injury, the correction or prevention of complications in a particular organ or organism is also directed. With nursing care, nurses make a nursing diagnosis together with a patient or a team of nurses and it can relate to an individual, group, or community. Nursing diagnosis refers to the satisfaction of basic human needs and is made on the basis of nursing history. Here, the tasks are aimed at meeting the patient’s individual needs for health care and training, if possible, for self-care.

  1. Chilton Sue (2018) Nursing in a community environment in Chilton S Bain, H. (eds): A Textbook of Community Nursing. Second Edition 4: 16 -17.
  2. Pender N J, Murdaugh C L, Parsons MA, (2015) Health Promotion in Nursing Practice, Seventh Edition , Pearson Education, Inc., Upper Saddle River 56.- 57.
  3. Baguley F (2018) Public health and the promotion of well-being in Chilton, S.; Bain, H. (eds): „A Textbook of Community Nursing, Second Edition“, Routledge, Taylor & Francis 25: 27-34.
  4. Close A (2003) Advanced Practice and Health Promotion in McGee P Castledine G (eds) Advanced Nursing Practice, Second Edition“ Blackwell Publishing Ltd 113.
  5. Thomas DJ, St Pierre, CM (2011) Health Promotion in Dunphy L M Winland-Brown J E. Porter B O Thomas DJ (eds) Primary Care – Art And Science Of Advanced Practice Nursing, Third Edition“, F.A.Davis Company, Philadelphia. 25.
  6. Ricci SS (2009.) Essentials of Maternity, Newborn, and Women’s Health Nursing, Second Edition Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, 25- 26.
  7. Laughon K, Amar A F, Sheridan DJ, Anderson S (2011) Legal and Forensic Nursing Responses to Family Violence in Humphreys J Campbell J C (eds) Family Violence and Nursing Practice, Second Edition Springer Publishing Company, LLC 367- 368.
  8. Lashley FR, (2007) Essentials of Clinical Genetics in Nursing Practice Springer Publishing Company LLC 244.
  9. Rassool G H (2010) Addiction for Nurses Wiley-Blackwell John Wiley & Sons Ltd, Chichester 7.-9.
  10. Taplin D (1994) Nursing and informed consent: An empirical study in Hunt G (ed) Ethical Issues in Nursing-Professional Ethics“, Routledge, Taylor & Francis Group 22.