History of Community Health
Before one can fully grasp the nature of community health or define its practice, it is helpful to understand the roots and influencing factors that shaped its growth over time. Community health nursing is the product of centuries of responsiveness and growth. Its practice was adapted to accommodate the needs of a changing society, yet it has always maintained its initial goal of improved community health. Community health nursing development has been influenced by changes in nursing, public health and society that is traced through several stages. In tracing the development of public health nursing, now it is clear that leadership role has been evident throughout its history. Nurses in this specialty have provided leadership in: planning and developing programs; shaping policy; administration; and the application of research to the community health.
Four general stages mark the development of public health or community health nursing.
The early home care stage
The district nursing stage
The public health nursing stage
The community health nursing stage
Early Home Care Stage (Before Mid 1800s)
For many centuries female family members and friends attended the sick at home. The focus of this care was to reduce suffering and promote healing (Kalish and Kalish, 1986). The early roots of home care nursing began with religious and charitable groups. In England the Elizabethan poor law written in 1600, provided medical and nursing care to the poor and disabled. In Paris, St. Vincent DePaul started the sisters of charity in 1617, an organization composed of laywomen dedicated to serving the poor and the needy. In its emphasis on preparing nurses and supervising care as well as determine causes and solutions for clients' problems their work laid a foundation for modern community health nursing (Bullough and Bullough, 1978). The set back of these services were:
Social approval following the reformation caused a decline in the number of religious orders with subsequent curtailing of nursing care for the sick and poor.
High maternal mortality rates prompted efforts to better prepare midwives and medical students.
Industrial revolution created additional problems; among them were epidemics, high infant mortality, occupational diseases, injuries and increasing mental illness both in Europe and America.
This stage was in the midst of these deplorable conditions and response to them that Florence Nightingale (1820 - 1910) began her work. Much of the foundation for modern community health nursing practice was laid through Florence Nightingale's remarkable accomplishments. Nightingale’s concern for population at risk as well as her vision and successful efforts at health reform provided a model for community health nursing today.
District Nursing (Mid 1800s to 1900)
The next stage in the development of community health nursing was the formal organization of visiting nursing (Phoebe, 58AD) or district nursing. Although district nurses primarily care for the sick, they also thought cleanliness and wholesome living to their patients, even in that early period. Nightingale referred to them as “health nurse”. This early emphasis on prevention and health nursing became one of the distinguishing features of district nursing and later of public health nursing as a specialty. The work of district nurses focused almost exclusively on the care of individuals. District nurses recorded temperatures and pulse rates and gave simple treatments to the sick poor under the immediate direction of a physician. They also instructed family members in personal hygiene, diet and healthful living habits and the care of the sick. Problems of district nursing:
Increased number of immigrants
Increased crowded city slums
Inadequate sanitation practices
Unsafe and unhealthy working conditions
Nevertheless, nursing educational programs at that time did not truly prepare district nurses to cope with their patients, multiple health, and social problems.
Public Health Nursing Training (1900-1970)
By the turn of the century, district nursing had broadened its focus to include the health and welfare of the general public, not just the poor. This new emphasis was part of a broader consciousness about public health. Specialized programs such as infant welfare that brought health care and health teaching to the public and gave nurses an opportunity for more independent work, and helped to improve nursing education (Bullough and Bullough 1978, p. 143). Lillian D. Wald’s (1867-1940) contributions to public health nursing were enormous. Her driving commitment was to serve needy populations. Wald’s emphasis on illness prevention and health promotion through health teaching and nursing intervention as well as her use of epidemiological methodology established these actions as hallmarks of public health nursing practice .The public health nursing stage was characterized by service to the public with the family targeted as a primary unit of care.
Community Health Nursing (1970 to present)
The emergence of the term community health nursing heralded a new era while public health nurses continued their work in public health by the late 1960s and early 1970s. Many other nurses, not necessarily practicing public health, were based in the community. Their practice settings included
community based clinics, doctor’s office, work sites, schools, etc, to provide a label that encompassed all nurses in the community.
The confusion was laid in distinguishing between public health nursing and community health nursing. The terms were being used interchangeably and yet, had different meanings for many in the field in 1984 the division of nursing convened a consensus conference on the essentials of Public Health Nursing practice and education in Washington DC (1985). This group concluded that community health nursing was the broader term referring to all nurses practicing in the community regardless of their educational preparation.
Public health nursing, viewed as a part of community health nursing, was described as generalist practice for nurses prepared with basic public health content at the baccalaureate level and a specialized practice for nurses prepared in the public health at the masters level or beyond. The debate over these areas of confusion continued through the 1980’s with some issues unresolved even today. Public health nursing continues to mean the synthesis of nursing and public health sciences applied to promoting and protecting the health of populations. Community health nursing is used synonymously with public health nursing and refers to specialized population focused nursing practice which applies public health sciences as well as nursing services.
A possible distinction between the two terms might be to view community health nursing as a beginning level of specialization and public health nursing as advanced level. Whichever term is used to describe this specialty, the fundamental issues and defining criteria remain as: Are the populations and communities the target of practice? Are the nurses prepared in public health and engaging in public health practice?
The specialty of Community Health Nursing
The two characteristics of any specialized nursing practice are:
Specialized knowledge and skills, and
Focus on a particular set of people receiving the service.
These two characteristics are also true for community health nursing. As a specialty, community health nursing adds public health knowledge and skills that address the needs and problems of communities and focuses are on communities and vulnerable population. Community health nursing then, as a specialty, combines nursing and public health sciences to formulate a practice that is community based and population focused (Williams, 1992). It is a synthesis of the body of knowledge from the public health sciences and professional nursing theories to improve the health of communities and vulnerable populations (American Public Health Association, 1992). Community health nursing is grounded in both public health and nursing sciences, which makes its philosophical orientation and the nature of its practice unique.
Four general stages mark the development of public health or community health nursing.
The early home care stage
The district nursing stage
The public health nursing stage
The community health nursing stage
Early Home Care Stage (Before Mid 1800s)
For many centuries female family members and friends attended the sick at home. The focus of this care was to reduce suffering and promote healing (Kalish and Kalish, 1986). The early roots of home care nursing began with religious and charitable groups. In England the Elizabethan poor law written in 1600, provided medical and nursing care to the poor and disabled. In Paris, St. Vincent DePaul started the sisters of charity in 1617, an organization composed of laywomen dedicated to serving the poor and the needy. In its emphasis on preparing nurses and supervising care as well as determine causes and solutions for clients' problems their work laid a foundation for modern community health nursing (Bullough and Bullough, 1978). The set back of these services were:
Social approval following the reformation caused a decline in the number of religious orders with subsequent curtailing of nursing care for the sick and poor.
High maternal mortality rates prompted efforts to better prepare midwives and medical students.
Industrial revolution created additional problems; among them were epidemics, high infant mortality, occupational diseases, injuries and increasing mental illness both in Europe and America.
This stage was in the midst of these deplorable conditions and response to them that Florence Nightingale (1820 - 1910) began her work. Much of the foundation for modern community health nursing practice was laid through Florence Nightingale's remarkable accomplishments. Nightingale’s concern for population at risk as well as her vision and successful efforts at health reform provided a model for community health nursing today.
District Nursing (Mid 1800s to 1900)
The next stage in the development of community health nursing was the formal organization of visiting nursing (Phoebe, 58AD) or district nursing. Although district nurses primarily care for the sick, they also thought cleanliness and wholesome living to their patients, even in that early period. Nightingale referred to them as “health nurse”. This early emphasis on prevention and health nursing became one of the distinguishing features of district nursing and later of public health nursing as a specialty. The work of district nurses focused almost exclusively on the care of individuals. District nurses recorded temperatures and pulse rates and gave simple treatments to the sick poor under the immediate direction of a physician. They also instructed family members in personal hygiene, diet and healthful living habits and the care of the sick. Problems of district nursing:
Increased number of immigrants
Increased crowded city slums
Inadequate sanitation practices
Unsafe and unhealthy working conditions
Nevertheless, nursing educational programs at that time did not truly prepare district nurses to cope with their patients, multiple health, and social problems.
Public Health Nursing Training (1900-1970)
By the turn of the century, district nursing had broadened its focus to include the health and welfare of the general public, not just the poor. This new emphasis was part of a broader consciousness about public health. Specialized programs such as infant welfare that brought health care and health teaching to the public and gave nurses an opportunity for more independent work, and helped to improve nursing education (Bullough and Bullough 1978, p. 143). Lillian D. Wald’s (1867-1940) contributions to public health nursing were enormous. Her driving commitment was to serve needy populations. Wald’s emphasis on illness prevention and health promotion through health teaching and nursing intervention as well as her use of epidemiological methodology established these actions as hallmarks of public health nursing practice .The public health nursing stage was characterized by service to the public with the family targeted as a primary unit of care.
Community Health Nursing (1970 to present)
The emergence of the term community health nursing heralded a new era while public health nurses continued their work in public health by the late 1960s and early 1970s. Many other nurses, not necessarily practicing public health, were based in the community. Their practice settings included
community based clinics, doctor’s office, work sites, schools, etc, to provide a label that encompassed all nurses in the community.
The confusion was laid in distinguishing between public health nursing and community health nursing. The terms were being used interchangeably and yet, had different meanings for many in the field in 1984 the division of nursing convened a consensus conference on the essentials of Public Health Nursing practice and education in Washington DC (1985). This group concluded that community health nursing was the broader term referring to all nurses practicing in the community regardless of their educational preparation.
Public health nursing, viewed as a part of community health nursing, was described as generalist practice for nurses prepared with basic public health content at the baccalaureate level and a specialized practice for nurses prepared in the public health at the masters level or beyond. The debate over these areas of confusion continued through the 1980’s with some issues unresolved even today. Public health nursing continues to mean the synthesis of nursing and public health sciences applied to promoting and protecting the health of populations. Community health nursing is used synonymously with public health nursing and refers to specialized population focused nursing practice which applies public health sciences as well as nursing services.
A possible distinction between the two terms might be to view community health nursing as a beginning level of specialization and public health nursing as advanced level. Whichever term is used to describe this specialty, the fundamental issues and defining criteria remain as: Are the populations and communities the target of practice? Are the nurses prepared in public health and engaging in public health practice?
The specialty of Community Health Nursing
The two characteristics of any specialized nursing practice are:
Specialized knowledge and skills, and
Focus on a particular set of people receiving the service.
These two characteristics are also true for community health nursing. As a specialty, community health nursing adds public health knowledge and skills that address the needs and problems of communities and focuses are on communities and vulnerable population. Community health nursing then, as a specialty, combines nursing and public health sciences to formulate a practice that is community based and population focused (Williams, 1992). It is a synthesis of the body of knowledge from the public health sciences and professional nursing theories to improve the health of communities and vulnerable populations (American Public Health Association, 1992). Community health nursing is grounded in both public health and nursing sciences, which makes its philosophical orientation and the nature of its practice unique.
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