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Community Health Nursing
Report of a
WHO Expert Committee
Technical Report Series
558
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World Health Organization, Geneva
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WORLD HEALTH ORGANIZATION
TECHNICAL REPORT SERIES
No. 558
COMMUNITY HEALTH NURSING
Report of a WHO Expert Committee
WORLD HEALTH ORGANIZATION
GENEVA
1974
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First impression, 1974
Reprinted, 1975, 1982
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ISBN 92 4 120558 X
© World Health Organization 1974
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WHO EXPERT COMMITTEE ON COMMUNITY HEALTH NURSING
Geneva, 30 July - 5 August 1974
Members:
Dr Esther Ammundsen, formerly Director-General, National Health Service, Copen
hagen, Denmark (Vice-Chairman)
Professor J. K. E. Amorin, Department of Preventive and Social Medicine, Ghana
Medical School, Accra, Ghana
Dr Rebecca Bergman, Professor of Nursing, Tel-Aviv University, Israel (Rapporteur)
Mr I. C. Boubacar, Assistant Director, School of Public Health, Niamey, Niger
Miss M.-F. Collidre, Public Health Nursing Programme, International School of
Advanced Nursing Education, Lyons, France
Dr Ines Durana, Visiting Professor, Mahidol University, Bangkok, Thailand (Chair
man)
Mrs Kyung-sik Lee, Assistant Professor, School of Public Health, Seoul National
University, Seoul, Republic of Korea
Miss Vadlamani Subhadra, Public Health Nursing Supervisor, All-India Institute of
Hygiene and Public Health, Calcutta, India
Representatives of other organizations:
Christian Medical Commission
Miss Nita Barrow, Associate Director, Geneva, Switzerland
International Committee of Catholic Nurses and Medico-Social Assistants
Miss G. Lauretti, Office of Hygiene and Health, Rome, Italy
International Confederation of Midwives
Miss A. Ebbs, Deputy Secretary, London, England
International Council of Nurses
Miss Adele Hcrwitz, Executive Secretary, Geneva, Switzerland
League of Red Cross Societies
Miss B. Yule, Chief Nursing Adviser, Geneva, Switzerland
Secretariat:
Dr Aleya El Bindari Hammad, Scicntist/Nursing and Public Health Officer, Division
of Strengthening of Health Services, WHO (Secretary)
Dr K. W. Newell, Director, Division of Strengthening of Health Services, WHO
Dr Doris E. Roberts, Chief, Nursing Practice Branch, Division of Nursing, United
States Public Health Service, Bethesda, Md., USA (Temporary Adviser)
Dr Magdalena Sokolowska, Chief, Department of Medical Sociology, Institute of
Philosophy and Sociology, Polish Academy of Sciences, Warsaw, Poland (Tem
porary Adviser)
4
COMMUNITY HEALTH NURSING
Report of a WHO Expert Committee
A WHO Expert Committee on Community Health Nursing met in
Geneva from 30 July to 5 August 1974. The meeting was opened by Dr
W. H. Chang, Assistant Director-General, who welcomed the participants
on behalf of the Director-General. The Committee was composed of mem
bers representing multiple disciplines in order to have the benefit of varied
and broad backgrounds, opinions, and approaches to future health care
delivery.
Dr Chang said that the objectives of the meeting were to clarify the
contribution of nursing to the improvement of the health of communities,
to define the function and tasks of the community health nurse and her role
in the health team, to consider the education of personnel in terms of local
needs, and to make recommendations that would promote those objectives.
There was an urgent need for peripheral health services, and communities
must become involved in developing them. Health workers had to be trained
for, and properly utilized at, all levels of the health service. Appropriate
safeguards of nursing practice must be instituted and an effort made to
develop innovative approaches to the problems involved in establishing
and developing community health nursing services. Dr Chang described the
community health nurse as a generalist, capable of functioning in a health
team, of communicating with and motivating people, and of working
effectively with educational, social, and other workers within thecommunity.
1.
1.1
INTRODUCTION
Concepts of health care
The Committee considered that the acceptance of health as a basic
human right and of health care as an important means of protecting that
right are fundamental to the effective delivery of community health care.
It follows naturally that health care should be accessible to all the population,
the word “ accessible ” being used in its broadest context to mean available
when needed, free of economic barriers, unlimited by social or cultural
distinctions, and within reasonably easy reach.
The term “ health care ” implies a broad spectrum of services including
primary health care, the integration of preventive and therapeutic services,
5
health education, the protection of mothers and children, family planning,
and the control of environmental hazards.
A system of health care delivery is essential to the provision of community
health care, and that system must reflect certain inherent characteristics
of the community. It must, for example, evolve from the community it
serves; it should involve the community in all aspects of its organization,
such as in the planning, delivery, and evaluation of care; it must be inter
related with other operating social systems within the community; and it
must support as well as be supported by the community for which it exists.
Moreover, the health system must be flexible in its approaches to health
care; those responsible for operating it should be aware that the primary
avenue to health may be through education, economic progress, legislation,
or other aspects of society rather than through organized health structures.
Given these characteristics, all countries and all communities, even the
most rural and impoverished, will find it feasible to develop effective health
care. In spite of this, health services have been noted more for their gaps,
deficiencies, and poor utilization, especially among rural populations,
than for effective and efficient improvement in community health. In order
to change this situation, the factors influencing community health must be
considered jointly with the modifications required in the health care system.
1.2
Determinants of community health and health care
The health status, disease patterns, and health expectations of the people
are the major determinants of community health needs. In addition, the
social, economic, and cultural environments influence the health, health
behaviour, and health perceptions of groups, both positively and negatively.
Thus it is often possible to make major improvements in the health of a
population through relatively modest changes in cultural behaviour,
economic standards, or social institutions. In countries where malnutrition
is prevalent, the identification of a ready source of protein or the intro
duction of soil fertilization can lead to a considerable reduction in the
incidence and severity of communicable diseases. Similarly, clean water
supplies and insect control are well-known means of reducing mortality
rates. In the more developed countries the steadily increasing prevalence of
cardiovascular diseases, cancer, mental illness, and accidents could be
reduced by drastic changes in behaviour with regard to the sedentary way
of life, excessive eating, alcoholism, smoking, and the generation of mental
stresses.
Rapid population growth and urbanization contribute to the health
problems in developing countries and constitute additional challenges to
community health programmes.
6
General education, improvements in communications, and technological
developments produce changes in people’s perception of health, in their
definitions of illness, and in their demands on the health care system. They
also alter family and community life, changing both the nature of the
relationships between individuals and the patterns of social relationships in
family and community groups. In some instances these processes are
beneficial to health; in others they cause conflicts and stress with detrimental
health effects.
Community resources and their allocation to health services (or to
services related to health) directly determine the scope and composition of
health care delivery systems. Per capita income, literacy rate, and educa
tional and occupational opportunities are only a few of the other factors
influencing the number and type of health personnel available, the adminis
trative framework of the health system, and the possible strategies for care
that may be implemented.
The acceptance of traditional providers of health care enlarges the
potential health resources of the community and simultaneously promotes
the integration of desired health practices into the accepted social and
cultural behaviour of the local population. The importance of this is
universally recognized, yet health professionals have been slow in bringing
the traditional providers of health care into the health system. The readiness
of health planners to acknowledge the influence of birth attendants, healers,
and similar people on the health of communities may be an important
factor in the eventual success of the health programme. The training and
utilization of traditional health workers enables community health services
to be provided in the context of accepted norms and encourages traditional
culture-bound patterns of health care to become more scientific.
1.3
The community and community health
The Committee agreed on the following meanings of the terms used in
community health nursing.
Community
A community is a social group determined by geographical boundaries
and/or common values and interests. Its members know and interact with
each other. It functions within a particular social structure and exhibits
and creates certain norms, values, and social institutions. The individual
belongs to the broader society through his family and community.
7
Human health
Individual and group health is determined by human biology, the
environment, the ways of life of the community, and the health care system,
as shown below.
Health care
system
WHO 40712
The implementation of a health programme leads to a change in in
dividual and group behaviour. This process, as shown below, can be
influenced by members of the principal social institutions in the country,
Health services
(scienti fi c/tradi I ional):
Education
Industry
and agriculture
Legal
institutions
Religious bodies
Government
Mass media
WHO 40713
Community health
Community health refers to the health status of the members of the
community, to the problems affecting their health, and to the totality of
health care provided for the community.
The assessment of health requires an understanding of the general
population to be served. Major categories of information on health are
outlined in the following paragraphs.0
“ These paragraphs are based on: WHO Technical Report Series, No. 481, 1971 >
pp. 33-36.
8
(1) Demographic data
— present and projected population according to age, sex, location
— population density
— migration
— life expectancy
— probable birth rates
— literacy rates
community health CELL
326, V Main. 1 Block
Koramongala
Bangalore-560034
India
(2) Environmental characteristics
— housing conditions
■— working conditions
— educational opportunities
— sources of water supply, water quality
— waste water disposal and water pollution control
— solid wastes management, including sanitary handling and dis
posal
— vector control and the control of alternative hosts of disease
— environmental pollution
— climate
■— structural organization and administration of environmental
health services
(3)
Economic information
— occupational characteristics
— patterns and tendencies regarding personal or family income
— health sector income and expenditures
•— national income and expenditures
— costs of providing health services and of maintaining the different
categories of health manpower
— cost/effect information for selected health problems
(4)
Health needs
— mortality and morbidity data according to major causes, age, sex,
geographic distribution
— the extent to which the principal diagnostic categories result in a
demand for health care and in disability
9
(5)
1.4
Utilization of health care services by the population
— health services actually utilized (“ met ” demand): number, types,
quality, effects
— characteristics of those who use services, including their attitudes
and knowledge regarding the use of health services and of the
health system that provides them
— “ unmet ” demands or needs for health services
— approximate volume of services desired (or needed) that are not
obtained, according to type of service
— characteristics of those who desire (or need) services
— reasons for not obtaining the desired (or needed) services.
The family and family health
The family is one of the oldest and strongest social institutions. Its
members share genetic traits, environment, general attitudes, and life styles.
Through their interactions and mutual dependencies, the family functions
as a unit; factors impinging on one member affect all other members to
some degree.
The state of health of one member and his response to illness influences
and is influenced by physical and psychological support mechanisms
operating within the family. A child’s growth and development reflects the
interaction of genetically determined biological factors and the family
environment. Poor housing, overcrowding, inadequate food, and in
adequate education affect all members of the family, and behaviour patterns,
including those governing health care, are shared by the family. It is
logical, therefore, to consider the health needs and problems of the family
as a whole and to deal with individual health problems within the frame
work of a comprehensive family health programme.
1.5
Family and community health nursing
The Committee expressed considerable concern that renewed emphasis
on the role of nursing in community health might, through misunderstand
ing, diminish the importance of family health nursing. There was unanimity
on the importance of planning, organizing, and evaluating nursing services
in terms of the health needs of the whole community, but at the same time
the Committee considered it essential to clarify its position on family health
nursing. It therefore drew up the following statement, which represents
the consensus of the Committee :
10
Family health nursing is based on the concept of the family as a unit and is directed
towards meeting the health needs and concerns of the family by encouraging it to use its
own resources, both human and material, and by indicating the best way to use available
health services.
Developments taking place in modern life have led to changes in health needs and
demands for wider service coverage than has ever been envisaged. Illness, disability, or
other events such as unemployment can disturb the equilibrium of the group and affect
the mental and physical health of its members.
In many countries, the shortage of health personnel limits the wider use of home
visiting services intended to reach all families needing care; such visits often have to be
reserved for selected families only. Thus, other methods must be employed to provide
family health care. Possible approaches are to work with small groups of families and to
organize consultations in a family-centred clinic.
Community nursing includes family health nursing but is also concerned with identify
ing the community's broad health needs and involving the community in development
projects related to health and welfare. It helps communities to identify their own problems,
to find solutions, and to take such action as they can before calling on outside assistance.
1.6
Midwifery and community health nursing
Another concern of the Committee related to the place of midwifery
in community nursing services. In this instance there was agreement that
maternal and child health services, including midwifery, were basic com
ponents of family and community health care. For this reason, midwifery
is not mentioned specifically in discussions of nursing services but is con
sidered to be implicit throughout.
2.
THE SITUATION
The vastness of the world’s health problems is difficult to realize, and it
is even more difficult to design strategies that will cope with the situation
in the foreseeable future.
Hundreds of millions of people have little or no access to essential health
services. The seriousness of the problem is indicated in a few vital statistics.
In 1970, for example, the infant mortality rates in some countries were
officially reported to be as high as 146 per thousand live births." Studies
and surveys indicate that the infant mortality rate in some populations may
be as high as 300 per thousand and in some subgroups even higher. The
officially reported life expectancy figures range from 74.5 years in Sweden
to 35 years and less in some African countries.1’
“ World Health Organization World Health Statistics Annual, 1970, Vol. 1: Vital
statistics and causes of death, Geneva, 1973, pp. 10-11.
b United Nations Compendium of social statistics: 7967, New York, 1968 (Statistical
Papers Series K, No. 3), Table II, p. 158.
The ratio of all nursing and midwifery personnel in various countries
illustrates the wide disparity in these services throughout the world. In 1970,
Indonesia reported there were 1.7 nurses, midwives, and other nursing
personnel per 10 000 population, while Czechoslovakia reported a figure
of 54.5 per 10 000.“ These statistics do not, however, show the
distribution of nursing personnel within the country, which may be even
more disparate when rural and urban areas are compared or when different
social, economic, or cultural groups are considered separately.
The major characteristics of rural and semi-rural populations, which
comprise 80% of the world’s population, are :
— geographical isolation and poor communications
— an unfavourable environment with exposure to communicable diseases
and malnutrition
— inadequate health facilities and lack of sanitation
— poor educational opportunities.
In spite of the above realities, health services and the education of health
personnel have been centred on the hospital. Nursing has followed this
pattern and most, if not all, basic nursing education prepares the nurse for
hospital work rather than for service in the community, where most of the
needs for health care and protection occur.
Fig. 1 illustrates the distribution of nursing services in many developing
countries. It demonstrates that although the sick in hospitals represent the
the smallest proportion of the population needing care, they receive a
large proportion of the nursing service available. Populations cared for
in urban health centres receive the second highest proportion of nursing care,
while those in villages and rural communities have little or no nursing
coverage. At these local levels there are vast areas not covered by any
organized health service. Birth attendants and other practitioners of
traditional folk medicine are frequently the only providers of health care
available. It is thus apparent that the “ care ” pyramid is inverted in
relation to the “ need ” pyramid.
The diagram also shows the discrepancies in nursing education in
relation to community needs for service. A preponderance of the educational
experience of nursing students is obtained in the care of hospitalized patients
with relatively little practice in community nursing. In fact many of the
nurses employed in public health have had no community health nursing
preparation. This situation is particularly acute in rural peripheral areas
of the world, where the provision of care tends to be more challenging and
complex and at the same time lacks administrative direction or consultation.
a World Health Organization World Health Statistics Annual, 1970, Vol, III: Health
personnel and hospital establishments, Geneva, 1974, p. 57.
12
FIG. 3. EXISTING NURSING SERVICES RELATED TO COMMUNITY NEED AND
EDUCATIONAL EXPERIENCE
The failure to give personnel adequate preparation for service as primary
health workers or community health nurses in rural and peripheral areas,
consistent with population needs and resources, represents a serious de
ficiency in health manpower development today. Schools of nursing, like
schools of medicine, have focused attention on theory and practice relevant
to care of the sick in hospitals, often ignoring the need for disease prevention,
health maintenance, and health promotion. Training courses even neglect
the care of the sick and disabled who are not institutionalized, in spite of the
fact that they far outnumber the hospitalized patients in any community.
Personnel trained in hospital-based institutions are often the only staff
available for community health services, for which they have little or no
preparation. Where postbasic education programmes have been established,
the aim has been to prepare administrators of hospital nursing services,
public health/hospital supervisors, researchers, and teachers. The prepara
tion of nurses to provide community health care in its full sense, or to feel
responsible for meeting the health needs of communities, is lacking in many
instances.
There are further constraints that make work at the periphery difficult.
In many countries nurses are not accepted as team leaders or coordinators
of health care although they are often the personnel most able to assess the
13
needs and to see that appropriate interventions are carried out. The problem
is further aggravated in many societies where nursing personnel are not
legally allowed to diagnose and treat patients although they are the only
practitioners available. This is especially true in peripheral areas. Not
infrequently nursing personnel are instructed to refer patients for diagnosis
and treatment to the next echelon in the health structure, but the persons
consulted may be even less qualified than the nurse concerned.
Owing to the traditional approaches adopted by nursing and other
health education programmes, health personnel tend to provide stereotyped
patterns of services instead of trying to adapt the health programme to the
community, taking the differing needs of people into consideration. More
over, inadequate assessment of existing community resources may impose
unnecessary limitations on the scope of health services so that they cannot
approach major community needs.
Too often health personnel are so preoccupied with establishing a health
structure within each community, without questioning its relevance to the
existing situation, that their real objectives become clouded. In many
instances more rapid progress toward health could be made by developing
health services in conjunction with other established programmes, delaying
the development of the health organization itself until the community is
ready and able to support it. Community developments such as agricultural
development, irrigation, transportation, and other health related pro
grammes offer a natural base for health services. The use of these avenues,
geared to the expressed needs of the people, provides a solid foundation for
the health programme and gives it some chance of success.
Another major constraint needs to be mentioned. In an attempt to close
gaps in the health service, workers are often hastily recruited from rural or
peripheral communities, narrowly trained, and employed to carry out a
varied range of functions. Their job titles and rewards also vary considerably
and are often unrelated to their training or actual work. They are frequently
assigned to the peripheral health services as primary health workers or for
other nursing work in villages. This practice has created conflicts and abuses.
The health workers have been expected to carry out tasks for which they
have little or no training, the nursing personnel have not been trained to
direct or supervise them, and the communities served have been disappointed
and critical of the continued gaps in service in spite of the marked increase
in the number of personnel.
A well organized nursing system responsible for the education and
practice of nursing personnel is needed in every country to cope with these
problems. It should be accountable for the nursing services provided and
should participate in the planning of the preparation and utilization of all
staff recruited for community health.
14
3.
THE CHALLENGE
In considering the magnitude of the problems of effective community
nursing practice, the Committee put forward the following list of questions
that it felt must be answered by nursing action, functioning alone or in
concert with other groups responsible for community health service.
(1)
Can we close the gaps
— where no service exists?
— where personnel exist but are badly distributed?
— where service is inefficient?
— where service is ineffective?
(2)
Can we change
— the medical value system ?
— the nursing value system?
— the disease orientation ?
— the educational focus?
— rigidity in planning health services?
— the isolation of health from other sectors?
— priorities from individual to community health ?
— the low status of providers of direct nursing care?
(3)
Can we provide
— motivation for community involvement?
— new models of nursing education ?
— personal accountability for practice?
— effective coordination of resources for care?
(4)
Can we remove barriers
— to effective team leadership and function ?
— to open communication ?
— to continuity and cohesiveness within the health system ?
— to full collaboration of national, international, governmental and
nongovernmental agencies for health ?
The Committee was ready to accept these challenges and believed that
nursing educators, administrators, and practitioners, once they were aware
15
of the situation, could, through their concerted efforts, make a dramatic
impact on the present indefensible state of community health throughout
the world and most particularly in the developing countries.
4.
THE PROPOSAL
To provide guidance for those involved in implementing the changes
necessary in nursing and the health care system in order to meet the chal
lenges set forth, the Committee proposed the following areas where change
is fundamental for sound progress.
4.1
Change in the conceptual framework
The scope and complexity of the health needs of populations and the
limited impact of service and educational programmes in meeting these needs
point to deficiencies in the underlying concepts of present health care.
These concepts must undergo major changes in order to move away from
traditional patterns, attitudes, and stereotyped services and to improve the
results of nursing practice. The new or revised concepts should be based on :
(1) a health system encompassing the total population rather than
focusing on limited groups such as hospitalized patients, self referrals, or
other ready utilizers of available services. This broader coverage should be
easily identified in all phases of the health programme, i.e., in the planning,
provision, and evaluation of services. It would be demonstrated by the
proportion of individuals and families served out of the total population
(or the appropriate subgroup of the population). Breadth of coverage
would not necessarily imply an even distribution of care, since special
efforts would be made to protect the vulnerable groups within the total
population.
(2) the acceptance of the community itself as the major determinant of
health care, its members being stimulated to recognize and express their
needs and expectations and to participate actively in the development,
implementation, and evaluation of the health service and health educa
tional programmes. The community should be encouraged to mobilize
and to use all available resources in the development of health services,
which should be so directed as to indicate that they are provided by, rather
than for, the community. Thus, community selection of health workers
(particularly primary health workers) and of people involved in volunteer
services and related activities should be encouraged and respected.
16
(3) the possibility that community health may be approached other than
through an organized health system. The approach should be made through
whatever social activity is most significant to the community at its given
stage of development. Thus, if health does not have priority, the health
worker should first help the community to achieve its other aspirations.
The resources generated by such activities and the confidence won by the
health worker in participating in them will greatly assist in the creation of a
health service. Moreover, other activities frequently have a health com
ponent, which the health worker can promote to the maximum extent.
(4) the development of nursing as a system of care rather than as a
specialized occupation. Such a system would include the spectrum of
health care functions from intuition to expertise. It would comprise mem
bers of the community, primary health workers, community health nurses
and midwives, teachers, clinical specialists, administrators, and research
workers. Between all these people there should be a continuous exchange
of views and experience.
(5) the philosophy that people in a community have a potential for
continued individual development and are capable of dealing with most
of their own problems if they are given health education and encouraged
by example. This philosophy is in direct contrast with traditional concepts
in which health services are imposed on the community and operate through
the medium of health professionals who are not involved in the community,
thus creating a feeling of dependency in the people served.
(6) the need to construct nursing educational programmes that embrace
all aspects of human life (biological, socioeconomic, and cultural) and that
are intimately related to community needs and health practice. Such pro
grammes would compel faculties to train and examine students in a practical
setting and would require both teachers and students to cope with the
problems of providing health care in a real community. It would also place
on them the responsibility for implementing changes in the health and health
behaviour of groups.
4.2
Change in nursing education
The implementation of the above concepts will necessitate major changes
in nursing education and service. The inferences for nursing education go
beyond modifications in technical content or methods of teaching. They
call for basic changes in the theory of nursing coupled with the reformulation
of curricula, the reshaping of methods and concepts of learning, and the
redefinition of the roles of all persons involved according to the functions
that they will perform. These changes should be aimed at achieving:
17
(1) a curriculum that is people-oriented not institution-centred and that
emphasizes health rather than disease. Such a curriculum would produce
graduates with knowledge of the basic and behavioural sciences, with
clinical skill in diagnosing illness and other deviations from health, both
physical and emotional, and with the ability to prescribe preventive, curative,
and rehabilitative therapy. The graduate nurse would be able to adapt
health care to the family and community setting, using medical and other
referral services for the greatest benefit to patient and family.
(2) a reversal of traditional nursing education, starting with healthy
families in their social and community life, moving to the development
of disease, disability and social dysfunction, and so to treatment, cure and
rehabilitation.
(3) the participation of students and faculty in community health
through the examination of health needs and through working with the
community in planning and providing health care, analysing its effects, and
studying ways of improving the pattern of care.
(4) opportunities for students to understand community life, its manner
of functioning, and the efiects of this on health or illness within the popu
lation. Given such opportunities, students would learn from a number of
experiences of varying complexity among different social and cultural groups
in their natural environments. They would also learn to work competently
with others, to develop self-reliance in themselves and to encourage this
quality in others and in the community.
(5) the imparting to students of a knowledge of life processes, which
would enlarge their understanding of human life in general, of value systems,
and of society’s formal and informal support mechanisms.
(6) a fundamental orientation of the student towards a dynamic con
ception of life and human relationships, in which disease and hospital care
are regarded as mere episodes within the life span.
4.3
Change in nursing services
The implementation of a community approach to the provision of
community nursing services calls for a change in basic attitudes on the part
of many health workers. There is need to change traditional modes of
thinking in regard to the providers and recipients of care, to alter longlasting habits in the provision of care, to stimulate new thinking among
health administrators, and to substitute flexibility for fixed notions of
community health. More specifically, these changed concepts of community
health require :
18
(1) a commitment to the accountability of the nursing service for the
effective and efficient provision of basic health services including preventive,
diagnostic, therapeutic, and rehabilitative care in all communities and for
all populations. It is necessary to move aggressively towards this goal.
(2) the adaptation of the health services to the health needs and operat
ing social systems of the community. Such adaptation must, of course, be
commensurate with the resources of the health service and the level of social
development of the community.
(3) the development of a community orientation that takes account of
the various social strata and of the different ways in which the members of
those strata cope with health problems. Nurses must help the community
and its subgroups to assess their health needs, determine priorities, and
establish realistic objectives.
(4) the sharing of responsibility between the nursing service, the com
munity, and health educational institutions for the selection, preparation,
and appropriate utilization of health personnel at all levels and areas of
function, the recognition of the individual needs and strengths of staff, and
the promotion of career mobility. This sharing of responsibility would
demonstrate the interdependence of service and education.
(5) the enlargement of the pool of personnel available to supplement
nursing services by the inclusion of indigenous groups. These groups
should be properly trained and should work under the direction and super
vision of the nursing service.
(6) the active promotion of community self-help in all aspects of its
social structure (e.g., educational, legislative, and industrial).
5.
APPROACHES TO STRENGTHENING COMMUNITY
HEALTH NURSING
Each country and each community must decide for itself what methods
can be used and what steps can be taken to develop a sound, vigorous,
and effective health programme. Therefore it was considered pointless and
inappropriate for the Committee to describe ways of implementing the
concepts it had advanced for the improvement of nursing in the com
munity health care system in local, national, or world settings. The Com
mittee did, however, describe the fundamental characteristics of a com
munity nursing service as the encompassing of the whole community with
19
a system of basic health care, the services being so organized as to ensure
continuous, comprehensive, coordinated, accessible, and relevant services
to all.
In addition, the Committee considered a variety of suggestions for
strengthening community nursing services. These suggestions dealt with
the expansion of health manpower resources, concomitant changes in roles
and functions of personnel, the educational implications, and evaluation
processes.
5.1 Expansion of manpower resources for community health
The provision of primary health care for all segments of the population
is perhaps the most crucial health problem of most communities of the world
today. Various attempts have been made to cope with this problem. In
developed countries primary health care is provided by physicians, dentists,
nurses, physiotherapists, and similar health professionals. In response to
the increasing need for primary care, schools preparing these professionals
are expanding enrolments, new schools are being established, and all groups,
especially nurses, are being prepared to extend their roles in providing
diagnostic and therapeutic care.
In the developing countries, where the problem is excessive and resources
sparse, other approaches are being taken. Indigenous healers, village
health workers, birth attendants, and similar groups within the community
are looked to for health care. These lay personnel, in the role of primary
health workers, provide the first contact with the community at the peri
pheral level. They carry but simple curative functions and “ front-line”
measures for the protection and promotion of health.
Although these primary health workers have arisen out of a critical need
of populations for primary health care, they are often not included in the
health care delivery system of the country. Consequently they lack proper
training, supervision, and support and the essential referral or backup
system is not available to them. In spite of these handicaps they have
shown their potential for supplementing health resources in their com
munities.
To the problem of providing health care services to the millions of people
who are not at present covered, the promotion of primary health care
workers—members of the community trained within the community, and
supported by it—offers a realistic and effective solution, especially in rural
and peripheral communities. But in order to guide and supervise their
activities and to increase their efficiency and effectiveness primary health
workers must be recognized and integrated into the health care system of
the country. Because their functions are among those provided by nursing
20
services, the inclusion of the primary health worker in the community
nursing system is not only logical but essential to ensure the safe and
appropriate care of the populations served. This means that the community
health nurse will have to assume responsibility for the training of primary
health workers, for helping them to develop the necessary health services,
for providing the support needed, and for serving as the link between the
primary worker and the rest of the health system.
If the primary health worker is responsible for giving direct health care
to communities in the areas of communicable disease control, maternity
care, child health, the treatment of common diseases, and home and village
sanitation (alone or in conjunction with other personnel), the role and
function of the community health nurse also will have to change.
5.2 Changes in roles and functions of nursing personnel
Each country and each community within the country is encouraged to
develop its pattern of community nursing services in accordance with its
unique needs and available resources. However, all workers included in
this service pattern should be part of the total nursing system of the country
and of the community health nursing system in particular. Similarly,
the classification of personnel within the nursing system depends on the
local situation and on the national development plan for health manpower.
In most countries at least three levels of function are reflected in personnel
classification systems—the local or peripheral level at which direct care is
given to the community, the intermediate level at which guidance and
supervision are given to local staff, and the central or administrative level
at which overall direction, consultation, and managerial support arc provided
for the total community health programme. These three distinct groups of
nursing personnel are interdependent and their functions interrelated.
It should be emphasized that all personnel are involved in decision-making
and in the implementation of services but with varying degrees of pro
gramme responsibility.
The scope of functions of each group depend on the size and complexity
of the community, the number and preparation of personnel, the public
acceptance of and policy regulations governing health practice, and the
organizational health structure. As an example, a general description of a
few representative community health nursing functions at the peripheral
level is given below.“ These functions might be provided by primary health
workers, family health visitors, and/or community health nurses.
“ Asterisks against a number of these functions indicate that the peripheral health
worker may be aided by others, including, for instance, patients, family members, other
health and non-health workers or community representatives., ..
..
! Y Hh’ALTH (
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Nursing process
Peripheral level functions
Assessment
Participates * in the examination of individual, family, and
community health states and health behaviours, including the
knowledge, attitudes, and perceptions of groups regarding
health and illness. Describes and analyses resources available
and patterns of utilization.
Problem identification
In accordance with the assessment process, identifies * health
problems in individuals, families, and community groups,
determines basis for each problem, and draws inferences for
appropriate nursing action.
Points out gaps or deficiencies in community resources and
assists in developing plans to meet these needs. Develops *
service priorities and plans for intervention based on above
analysis, community expectations, and accepted standards of
practice.
Implementation
Implements * the “ agreed upon ” services to individuals,
families, and community groups which may include : direct
therapeutic and curative care; health education; the planning of
care with family members; referral to appropriate service or
health professionals ; case-finding; instruction and services to
high risk groups ; community health promotion and health
education ; and establishments of needed resources. Devel
ops * specific activities for promotion and general main
tenance of health which may include: demonstrations in home
gardening, water purification, the building of wells, and the
safe disposal of wastes ; and the development of individual,
family, and community competence to cope with and to take
responsibility for their health needs.
Evaluation
Develops * service objectives in terms of problems identified
above; determines measures to be used to reflect attainment of
objectives and of safety and quality of care ; ensures that
necessary evaluative data are collected accurately and sys
tematically ; monitors health services for desired quality;
analyses the results of service in relation to the proportion of
population served and programme objectives reached.
In order to attain the goal of community health services for all, major
changes within the present roles of all health personnel are essential. As
indicated in section 5.1, with the greater use of indigenous groups as health
manpower resources and the delegation of many services traditionally
performed by nurses, physicians, health educators, and others to this group,
there will have to be a marked upward shift at all other levels of responsi
bility.
Perhaps the most dramatic change in the roles and functions of com
munity health nurses will be seen in the additional diagnostic and thera
peutic responsibilities required of them. First, they will be expected to teach
primary health workers many of the functions traditionally performed by
22
nurses and guide these new personnel in case-finding, disease prevention,
patient and family care, community programme development, health educa
tion, and curative and related functions. An even more demanding re
sponsibility of the community nurse will be the fulfilment of roles usually
ascribed to general medical practitioners. These include examining the
sick and disabled, determining the source of the problems presented, and
treating acute conditions as well as the major prevalent diseases in the
community. As the nurse becomes more competent in these and associated
nursing skills, her role as teacher, supporter, and consultant of the primary
health worker will also expand.
Throughout this pattern of care, the community health nurse is seen
as a generalist, able to work in a team, to teach and encourage other health
workers, to communicate with and motivate population groups, and to
interrelate community nursing with other systems. Since leadership of the
team is determined by the nature of the presenting problem and not by
professional status, the community nurse is expected to be able to provide
team leadership but also to share the leadership role with the primary health
worker, health educator, agriculturist, or other team member, depending
on the area of concern and major functions to be carried out.
Fundamental to this plan and to the provision of safe, appropriate,
effective, and efficient community health services is a dependable referral
and support system at every level of function. Thus the primary health
worker needs the direction, supervision, guidance, and assistance of a
competent, readily available community health nurse. The community
health nurse similarly needs the support of medical referral services to
examine and treat patients and families with unusual or complicated condi
tions. Advisers, consultants, and clinical experts in other fields will also be
needed to review programme plans, analyse presenting problems, assist in
evaluation procedures, and recommend possible approaches for improving
services in the community.
The administrator of nursing services also needs support—from experts
in administration, community planning, and programme analysis, from
behavioural scientists, educators, and clinical specialists, and from many
other peer groups. Such assistance is necessary to maintain high quality
programming in all aspects of service throughout the community nursing
structure.
Implementation of health programmes with role formulation and staff
development along these lines is envisaged as having a far reaching effect,
resulting in the extension and strengthening of health services to all groups.
23
5.3
Implications for nursing education
Directors of schools of nursing and their faculties will be required to
translate the new concepts of community nursing into action. The educa
tional system will need to be reorganized so that learning starts in the
community, a process that will help students to understand the working of
community life, the nature of social structures, and the contribution of each
to individual, family, and community function. Nursing education must
emphasize health, the process of normal growth and development, and those
individual, familial, and social forces that promote health as well as those
that cause deviations from health. Educational objectives will have to be
redefined to respond to community needs and health aspirations.
The unqualified acceptance of community nursing as the foundation
of all nursing practice is implicit in the new concepts. This kind of prepara
tion will thus be seen as essential for all nurses, and curricula should be
revised accordingly. Care of the sick at home, following the development
of skills in health maintenance and disease prevention, prepares the student
for care of the sick in hospitals and other institutions. From this logical
sequential pattern of learning, students understand why the sick behave
as they do, why they become sick, and what factors influence their return
to health. They gain knowledge of various styles of home life, of values,
behaviours, and environmental influences, and of variations among social
strata. Such experiences will guide students in nursing hospitalized patients
and help to close the gap between hospital care and family and community
life.
Developing curricula in which basic learning occurs in a practical setting
is another test of faculty ingenuity. The broad base of primary health care
is the area in which most effort will be required. The development of
community practice sites, the adaptation of content and educational methods
to the wide variety of persons to be trained as primary health workers,
and the construction of a programme that provides the scope and quality
of learning experiences desired all demand keen imagination and inno
vation.
But perhaps the most difficult aspect of the Committee’s proposal for
nursing educators is the essential expansion of programmes to prepare the
numbers and types of nurses required and in as short a time as possible.
This means that every graduate nurse must be prepared to teach other
nursing and health personnel. A great many teachers arc needed to instruct
primary health workers, others to prepare all nurses in community health,
and still others to teach specialities such as clinical subjects, hospital care,
administration, and research. To reverse the diagram shown in Fig. I
(page 13) and to align nursing service with health care needs will call for a
24
vast expansion and profound reorientation of education. At the same time
such changes offer an opportunity for nursing to make an unprecedented
impact on world health and the delivery of health care.
5.4
Evaluation
In line with its proposed new concepts and approaches to community
nursing, the Committee considered various mechanisms of programme
evaluation and made suggestions concerning basic elements to be included
in the evaluation process.
Evaluation is seen as an integral part of the community health nursing
programme at every level of care. It is as important to the work of the
primary care worker and community health nurse at local and peripheral
levels as it is to the administrator and health planner at the central level.
Just as communities need to be involved in setting their goals for com
munity health services, in determining priorities, and in outlining plans of
action, so must they be involved in the assessment of these services. In this
way the people of the community not only share in planning and implement
ing their health care system but are an important force in assessing the
quality of care and the type of services provided, in identifying the successes
and failures, and in planning corrective actions as indicated.
The assessment of services depends first of all on drawing up rational
objectives of health care and developing methods of determining the quality,
safety, and appropriateness of care. This preliminary work should be done
by the community itself, with the assistance of technical health personnel.
Technical assistance is important since goals decided on by the community
alone might be too limited to ensure optimum community health. Once the
objectives have been formulated, it is possible to select methods of measuring
the extent to which they are being met and to develop ways of collecting the
necessary information. The jointly reached objectives and their rationale
should be communicated to the administrative centre of the health service,
which can ensure self-consistency in the subsequent collection, reporting,
and analysis of evaluative data. When applied in various districts, this
procedure also helps to ensure the collection of comparable data, which are
needed for describing the health status of the country as a whole. The
overall picture thus obtained helps the government to determine national
priorities and the allocation of resources for health.
The strengthening of health services requires a knowledge of the major
health problems and patterns of care in the community, in major subgroups
of the population, and in groups at high risk. This information provides a
baseline for determining the extent of the need and for guiding the com
munity and technical health planners in developing the community prog
25
ramme. Through the systematic periodic collection of these data it is
possible to examine the effects of the health programme in moving toward
community goals. It is also possible to determine the efficiency of the
programme by analysing costs in terms of community utilization of ser
vice and in terms of programme effectiveness. Changes can then be made
in the light of these analyses.
Measures have been suggested for evaluating the need for and the
effectiveness of basic health services throughout the world. They include
population coverage, immunization status, individual growth and develop
ment, nutritional status, disability, selected morbidity and mortality rates,
and consumer utilization of services.3
All these measures provide some evidence of the need for community
health care and, analysed over time, show the changes in the health status
of populations. They therefore give clues to the effects of health services
in concert with other influences—social, biological, and environmental.
Population coverage is an important index that has been poorly collected
and reported in the past. It is a basic index of the extent to which services
are actually reaching those groups in need and for whom they are intended.
The Committee agreed that it will be of even greater importance to com
munity health nursing programmes in the future, for it will provide the one
essential measure of the degree of progress attained in the provision of
health services to all communities.
6.
RECOMMENDATIONS
The Committee recognized the urgency of the health needs and lack of
health services in communities throughout the world and recommended
that the following plans of action be made to bring about the necessary
changes as rapidly as possible.
(1) Decisions should be taken to initiate and further develop community
health nursing services that are responsive to the needs of the community,
encompass primary health coverage for all the population, and provide
assurance of the safety and appropriateness of the services rendered.
In order to implement this recommendation, it will be necessary to :
(a) establish an organized nursing service within the context of com
munity health with joint participation of community and health groups.
“ See: WHO Chronicle, 27 : 333 (1973).
26
(i>) incorporate the primary health worker into the nursing and health
care system.
(c) develop the community health nurse as a provider of primary health
care and as the first level of support of the primary health worker.
(rf) provide preventive, therapeutic, and rehabilitative care based on a
family-centred approach.
(e) organize a system of support that includes referral for specialized
services and consultation, educational guidance of health workers at all
levels, and administrative planning and evaluation.
(f) coordinate community health nursing with the other community
development programmes.
(g) establish mechanisms to ensure the safety and appropriateness of
health care, these mechanisms being based on community participation
combined with technical health service judgements.
(A) make available the best-prepared community nursing personnel for
service in the community.
(2) Nursing educational programmes should be developed that make
community health the central objective of basic and continuing preparation.
This may be implemented through :
(a) the development of community-based extramural nursing educational
programmes.
(Z>) a curriculum focused on life processes with emphasis on health,
physical and mental development, and illness, on meeting the needs and
demands of populations, and on the principles of behavioural change.
(c) the preparation of nurses in the biological and behavioural sciences
and in diagnostic and therapeutic processes, which are necessary for
teaching and guiding primary health workers.
(J) the preparation of community-selected primary health workers
through learning cycles built upon their potential and related to com
munity health needs.
(e) the recruitment of students and teachers from the area in which they
will work. The teachers selected from the community should have the
widest possible diversity of skills, knowledge, and experience.
(/) the preparation of nurses and others to develop and guide primary
health workers.
(g) the provision of appropriate, dynamic, continuing education for all
levels of health workers contributing to community nursing.
27
(3) Health manpower, of which nursing manpower is a part, should be
developed within overall national development plans. These plans should
reflect a rational distribution and utilization of personnel to provide com
munity health coverage and essential support systems in the light of present
and projected needs.
(4)
Health care is a component of social policy. Therefore :
(o) health policies and legal and professional constraints that have a
deterrent effect on health care should be reviewed by the communities
involved and by their health workers and steps taken to remove these
constraints.
(h) policies and goals of service and education should be guided by
continuing cooperative relationships between representatives from the
community, service institutions, educational programmes, and pro
fessional groups.
(5)
WHO should :
(a) try to promote the acceptance of the concepts of community health
nursing by Member States and should stimulate and assist in the develop
ment of programmes for training primary health workers to meet the
needs of individual countries. In these tasks nurses should play a
prominent role.
(Z>) promote and assist educational programmes for preparing a cadre
of nurses and others to develop and guide community health workers
at all levels.
(c) make available information on innovative approaches to community
programmes and their impact on health and suggest adaptations where
necessary for national needs.
(J) promote the further development of the work begun by the Expert
Committee on Community Health Nursing towards the effective realiza
tion and implementation of the new concepts, ideas, and orientations
involving the whole range of health professionals and the health system.
COMMUNITY HEALTH CELL
28
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