Seminar on trends, issue, challanges in community health nursing and care delivery system

seminar on issue, trends, challange in community health nurisng

1. CURRENT STATUS, TRENDS AND CHALLENGES OF COMMUNITY HEALTHNURSING

INTRODUCTION

Forces affecting health care in the future will also affect the role of the nurse. One can only speculate about what that
future will be. Some broad changes can almost certainly be predicted. Nurses will seek to learn from the past and to
avoid known pitfalls, even as they seek successful strategies to meet the complex needs of today's vulnerable
populations.
As plans for the future are made, as the public health challenges that remain unmet are acknowledged, it is the vision
of what nursing can accomplish that sustains these nurses.

CURRENT STATUS OF COMMUNITY HEALTH NURSING
In India

Even after 74 years of independence, we do not have a health care system that can efficiently look after the
health status of our people. India has a large share of poor, illiterate, and malnourished of the world. Majority of our
people do not have basic health care facilities. There is always the dichotomy between the affluent opting for five stars
treatment at institutions having world class infrastructure, while the poor go to over -crowded public care facilities
where no adequate care is provided forcing them to leave everything to fate. Health care is expensive and beyond their
reach.

A deep analysis of the lifestyle of people would help in assessing some aspects of the prevailing public health
situation in India. With the ever increasing life expectancy, the epidemiological transition points towards greater
incidence of non-communicable or life style diseases. India is an exception to other countries in that nearly 4/5 th of
its health care expenditure is out of pocket.

Communicable and non communicable diseases have still to be brought under effective control as well as
eradicated. Blindness, leprosy and tuberculosis continue to have a high incidence. HIV/ AIDS pandemic make the
situation worse.

Communicable and non communicable diseases have still to be brought under effective control as well as
eradicated. Blindness, leprosy and tuberculosis continue to have a high incidence. HIV/ AIDS pandemic make the
situation worse.
High incidence of diarrhoeal disease as well as other preventive and infectious disease, especially among
infants and children, lack of clean and safe drinking water, poor hygiene and sanitation, poverty and ignorance are
among the major contributory causes of the high incidence of disease and mortality. Only 31% of the rural population
has access to potable water and only 0.5% of people enjoy basic sanitation.

In uttrakhand
Trends in Health Status in Uttrakhand
The demography and vital statistics provide the base information on the health status of any region or community. Life
Expectancy at Birth (LEB), Infant Mortality Rate (IMR), Crude Birth Rate (CBR) and Crude Death Rate (CDR) are
the important indicators that reflect the health status and human development. The comparison of these health
indicators for Tamil Nadu and All India average reveal the advantageous position of the state.
Life Expectancy at
birth (2011-15)
Infant mortality (per
1000 live birth )
Birth rate (per 1000) Death rate (Per 1000)
Male

Female

Male Female Total
Uttrakhand 69.1 74.5 34 33 38 23 33
All India 67.3 69.1 62 65 28.3 17.3 8.1

2. Goals of uttrakhand State Health Mission by 2012 for improving Health Status

National level Uttrakhand
To reduce infants Mortality rate to 30/1000 live birth 48/1000 live birth (not achieved)
To reduce Maternal Mortality ratio to 100/ 1000 440/1000 mortality ratio (not achived)
Total fertility rate reduced to 2.1 2.6
Malaria mortality reduction rate 50% upto 2010,
additional 10% by 2012
70% by 2012
Filaria Micro reduction rate70 % by 2010, 80% by 2012
and elimination 2015

Dengue Mortality reduction rate 50% by 2010 and
sustained at that level until 2012
70% by 2012
Cataract operation increasing to 46 lakhs per year until
2012
40 thousands per year until 2016 -17
Leprosy prevalence rate reduce from 1.8/ 10000 in 2005
to less than 1/10000 there after
0.22/10,000in 2014
Tuberculosis DOTS services; Maintain 85% cure rate
through entire mission period
68.5 cure rate
Upgrading community health center to Indian public
health standard


CURRENT TRENDS IN COMMUNITY NURSING
Forces affecting health care in the future will also affect the role of the nurse. One can only speculate about
what that future will be. Some broad changes can almost certainly be predicted. These include: emphasis on cost
containment resulting from market-driven economic policy; advancements in technology: knowledge explosion;
expanded use of alternative and complementary therapies; and demographic shift.

TRENDS IN COMMUNITY HEALTH NURSING
Changing demographics, changing disease patterns, an increase in chronic illnesses resulting in
underestimated health-care expenditure, a reform in the health financing system, and a renewed focus on health
promotion open up new opportunities for providing community-based care in community settings. Health care in the
context of the community represents an alternative mode of health-care delivery. Emphasis is placed on promoting
health and access to care by addressing the health-care needs of people where they live and work. Moreover, local
community needs, resources and preferences of the people drive community health services. In any country, the health
services/family health/disease prevention and health promotion provided to the community are delivered through the
available community health service system.
Recent developments have taken place in community health care. Various types of providers have been used
to increase access to care and healing services to meet the needs of the people. Since the health-care demands of the
community and people are diverse, non-professional care and services may be needed to complement professional
care and fulfil demands. Some of their practices mimic professional services. A number of actions help in meeting the
health-care demands of patients. Thus, capacity building for non-professional caregivers and service providers is
crucial. Health-care professionals including nurses play major roles in guiding the functions of such non-professional
providers. For this reason, non-professional care providers must be in the community health-care team. Therefore,
professional roles and functions, which can be differentiated from non-professional ones, must be highlighted and
strengthened during the education programme.

The future of nursing care
Nurses must be prepared to used critical thinking skills to solve problems and make independent clinical
judgments regarding care based on the most recent evidence. They must be knowledgeable about making age-
appropriate referrals to other disciplines and community agencies. Because more acute care will be provided in the
home and clinics, nurses must be more technically advanced in their skills, able to practice autonomously, and adept at
detailed documentation to ensure payment for services. As a larger number and percentage of the population are living
with chronic conditions and managing symptoms at home, there will be a need for competent, skilled nursing
practitioners who are comfortable practicing independently in the area of disease management.

3. In home care nursing, this 1st evidenced by nurse doing venipunctures (a laboratory technician's role) and
teaching and monitoring administration of oxygen (a respiratory therapists role). To prepare for the home care role,
nurses must be competent case managers and health educators.

In the last decade, our profession has made major process in several areas of public policy. The issue of
delegating duties to no licensed personnel has been addressed and continues to need clarification. Today, advanced
practice nurses (APNs) can bill directly through Medicare and in most states can prescribe medication. In some states
hospitals are mandated to maintain a safe level of staffing registered nurses based on the research on
staffing ratio and hospitals mortality.

Educational preparation and advanced practice nursing
Specialty areas of nurse practitioners have expanded to numerous subspecialties in the last 3 decades. These
include adult, gerontologic, neonatal, occupational, pediatric, psychiatric, school or college student, and women's
health. Nurse practitioners work in both rural and urban areas, from rural North Dakota to New York City. They
practice in diverse settings such as community health centers, hospitals, college student health clinics, physician
offices, nursing homes and hospices, home health care agencies, and nursing schools.

Educated Consumer
The educated consumer despite some information gaps, today's patient is a well-informed consumer who
expects to participate in decisions affecting personal and family health care. With advances in information technology
and quality measurement, previously unavailable information is now public information, and consumers are asked to
play a more active role in health care decision making and management. The increased power of the consumer in the
patient provider relationship creates a heightened demand for more sophisticated health education techniques and
greater levels of participation by patients in clinical decisions. Nurses must be prepared to understand this.

Technology and information
Computer technology has freed the nurse from some paper work, allowing more time for client care and
teaching about self-care. The expanding implementation of computer- based client records allows the preservation of a
client's history from birth to death.

Information age
 Consumer today are more computer savvy regarding healthcare
 More info on internet
 Consumer could possibly be more health care worker
 Joints commission 2014 all medical records have to be emergency.

Alternative and complementary therapies
To follow the holistic perspective, nurses must be knowledgeable about alternative therapies. With such
knowledge, they can monitor care and treatment and provide information about benefits and potential harm for clients.

In the future, nurses will increasingly be called on to provide knowledge about and use of alternative
therapies. Therefore, it is imperative that nurses continue to build their knowledge and skill base about alternative
therapies. As the population becomes more diverse ethnically, it is anticipated that more methods of promoting health
and treating illness will be necessary.
Research provides evidence that some alternative therapies enhance health and promote recovery from illness
for both the client and family caregivers (Research in Community-Based Nursing Care). While some caregivers still
support only Western methods of health care and continue to ignore or repudiate the value of more traditional or
alternative methods, the use of these practices has persisted and grown because people find them useful.

Shifting demographics
The nursing shortage is the latest demographic trend that will impact community-based care in the future. One
national survey of RNs indicated that 82% of nurses reported a shortage in their hospital or community. These nurse
did not have positive expectations of the impact of the shortage on work conditions, believing that some tasks

4. currently assigned to nurses will shift to other staff. They anticipate the shortage will result in nurses leaving nursing
for non-nursing jobs, thus intensifying the shortage. These changes could result in lower quality of care provided.
Because community-based nursing practice will be central to the care of a population of aging and chronically
ill people, nurses will be confronted will many challenges. In the future, regardless of the nurse's own ethnic
background, the nurse must be proficient at transcultural nursing to be an effective caregiver. Nurses will play a major
role in promoting self-care and addressing health promotion and disease prevention issues for elderly clients.
Collaboration is even more important when working with diverse populations. Collaboration across
disciplines is always challenging, but it is particularly so if the interdisciplinary team members are from several
cultural backgrounds.

Preventive care
Focusing on prevention will be particularly challenging as the percentage of the population ages and is living
with chronic conditions. Growing trends in alternative health therapies allow more culturally sensitive options in
preventive care. There are different ways that nurses can operationalize the concepts of health promotion and disease
prevention in community-based nursing. Nurses can position themselves as the first link between clients
and the hospitals, thus developing long-term relationships. This involves developing systems and models of care that
require periodically contacting clients with chronic problems.

Continuity of care and collaborative care
The hospital of the future may be known as a health care organization or an integrated health care system.
These systems already exist in many parts of the country. More community-based care programs will come from these
integrated systems. Another them used is seamless care, in which all levels of care are available in an integrated form.
Continuity allows quality care to be preserved in a changing health care delivery system.

Evidence based practice
 Goal is to achieve cost effective, high quality patient care vased on scientific research inquiry.
 Nurses needs to understands research process involved
 Nursing care should not be based on opinions, past practice, but on the result of scientific research
 Clinical journal
 Practice guidelines
 Nursing research

Current trends in nursing employment
As a result of cost-containment measures and medical practice modifications, nursing employment has
changed over the past several years. The Public Health Service's Division of Nursing has chronicled this change in
practice settings through periodic survey of Registered Nurses.

The 2004 National Sample Survey of Registered Nurses (RNs) discovered the following:
 Rate for RNs who is working outside of hospitals 43.8% (up from 33.5% in 1992 and an increase of 2.9%
since 2000).
 Although the number of RNs working in hospitals increases, the proportion of nurses working in hospitals
declined significantly.
 The number of nurses employed in public health and community health settings increased by 128.8%.

Community based employment opportunities for registered nurses
1. Ambulatory care
2. Adult day care centres
3. Day care centres for ill children
4. Mental health clinics
5. Family planning clinics
6. Cardiac rehabilitation programs
7. Geriatric clinics Migrant health clinics

5. 8. AIDS clinics
9. Diabetes management and education services
10. Pulmonary clinics (asthma, chronic obstructive pulmonary disease, cystic fibrosis)
11. Genetic screening and counselling services
12. Bloodmobiles
13. Freestanding diagnostic centers
14. Diagnostic imaging centers
15. Mobile mammography centers

Health department services
1. Maternal/child clinics
2. Family planning clinics
3. Communicable disease control programs
4. HIV/AIDS (testing, counselling, and treatment)
5. Tuberculosis (testing, treatment, and surveillance)
6. Sexually transmitted diseases (testing, counselling, and treatment)
7. Immunization clinics
8. Mobile clinics serving disenfranchised populations
9. Substance abuse programs
10. Jails and prisons
11. Indian health service (American Indians and Alaska natives)

Home health care services
1. Skilled nursing care
2. Intravenous therapy
3. High-risk pregnancy/neonate care
4. Maternal/child newborn care
5. Private duty (hourly care)
6. Respite care
7. Hospice care
8. Long-term care
9. Skilled nursing facilities
10. Hospital-based facilities
11. Freestanding/nursing home-based facilities
12. Hospice facilities
13. Nursing homes
14. Skilled nursing care
15. Assisted living

Other community health settings
1. School health programs
2. Occupational health programs
3. Parish nursing programs.
4. Summer camp programs
5. Childbirth education programs

6. ISSUE IN COMMUNITY HEALTH NURSING

Current Issues in Nursing
Issues mean a subject which people are talking and arguing about evaluating past and present. The nursing profession can
be very rewarding but it is equally challenging. In some cases, there is a lack of universal legislation to address these issues at the
organizational, state, or national level.

Migration of Nurses
Migration of health worker is one of the biggest issues that is faced by country today. Since most of the nurses graduated
from different institutions have started leaving the country in search of better jobs abroad and further study as the demand of
nurses in developed countries is increasing Study conducted by ILO (2016) shows reason for migrating of health worker for better
salary is 91.2% followed by ( 85.3%) better living condition.

Under financing
Indian nurses have made their reputation in the international markets but it is found that they are low paid in their own
countries inspite of heavy workload and longer hour of duties in most of the non-government health institutions. Moreover, the
private nursing homes who are charging huge amounts with the patient's are giving low salaries and less facility to nurses.

Unequal distribution
It is vital for healthcare system to have a sufficient numbers of suitably trained health professionals including nurses at
all levels of health services to deliver effective health care, study findings suggest that there is severe mal distribution of the
nursing workforce in rural and urban healthcare centre s in India. Although there is an oversupply of newly qualified nurses in
hospitals in Delhi, the staffing situation outside the valley is undesirable.

Employment problem:
The nurses who have a high demand in global markets are facing problems in getting a job placement in their own
country. Despite the huge number of hospitals many nurses are still lacking the job placement. The reason behind this could be
massive production of nursing colleges due to which nursing products are in increasing state thus only few getting opportunities.
Hospitals are running with inadequate number of nursing staffs in spite of huge patients’ flow and at the same time not
maintaining nurse patients’ ratio.

Recruitment issues:
There are different recruitment issues in the health sector of the country. Insufficient competencies in providing services,
narrow skill mix of the workforce, and uneven distribution of trained human resources, improper HR management and political
influence are the key issues. Similarly commonly observed problem areas in HR management in the public sector in Nepal are
recruitment, legislation, discipline, development, training, rewards, and promotions

Genetics
 Many major development in the field of genetics research
 Stem cell
 Human genome project
 Cloning
 Legal and ethical issues
Globalization of health
 Health care has become a global issue
 People are mobile disease can travel
 Nurses needs to have an understanding of the issue pertaining to global health.
Legal issue in nursing
 Nurses Practice act
 Standard of professional practice
 Advanced directives
 Licensure
 Good Samaritan laws

7.  Public health laws
 Physician- assisted suicide
 American with disabilities act

Civil and common Law issue in Nursing Practice
 Intentional Tort
 Unintentional Tort
 Negligence
 Malpractice
 Consent
 Informed consent
 Malpractice insurance


CHALLENGES OF COMMUNITY HEALTH NURSING
Autonomy:
Rural community health nurse have the opportunity to use autonomy in daily practice. Nurses must rapidly
assume independent and interdependent decision-making roles because of the small workforce and large workload.
Rural community health nurses learn to prioritize tasks quickly and work efficiently with others to "get the job done".
Referrals to other rural providers are facilitated because providers frequently know one another. The rural community
health nurse has an advantage over urban nurses in that the rural health care system is smaller and easier to influence
and change.

Safe staffing is an important for both professional and personal concern. Inappropriate staffing levels can
not only threaten patient health and safety, and lead to greater complexity of care, but also impact on nurses’
health and safety by increasing nurse pressure, fatigue, injury rate, and ability to provide safe care.

Always a Nurse":
Anonymity is not easy for the rural community health nurse, who is always "on duty'". A trip to the grocery
store on a Saturday morning may include interactions with rural clients and their families about their pressing health
concerns. Rural community health nurses may have confidentiality and personal/professional boundary issues that
need to be addressed.
However, rural community health nurses are often respected, known, and trusted by the populations they serve.

Funding for Education:
Some of the educational loans available to you at the under-graduate and graduate levels may be reduced or
forgiven if you practice in a rural community after graduation. You should inquire through your nursing program
about the possibility. It is also possible to contact a specific rural community as to whether they can offer some
monetary support in return for a pledge to return to the host community to work for several years.


Isolation:
Rural community health nurses may experience the challenge of physical isolation from personal and
professional opportunities associated with urban area. Travel to cities for basic and continuing education can be a
barrier. Rural nurses may also feel isolated in their clinical practices because of the scarcity professional colleagues.
Many rural community health nurses overcome these barriers and learn to appreciate the benefits of clinical practice in
a rural setting by discussing their concerns with peers and seeking ways to combat isolation.

Dollars and "Sense":
The rural community health nurse often receives a salary that is lower than that of urban nurses in comparable
positions. However, there are benefits to rural nursing. Housing costs are usually less than in larger cities, and long

8. commutes to and from work on congested highways are avoided. Rural communities are great places to live and raise
a family. The slower pace of life, open spaces, clean air, and friendly atmosphere may make more "sense".

Many Possibilities:
The smaller system of health care in a rural community can be an advantage to the community health nurse. It
may be easier to "understand the system" and initiate planned change. For example, if a rural nurse wants to continue
his or her education, college of nursing could be contacted to offer the needed classes. There are many possibilities to
enhance rural nursing practice, including continuing education by satellite or Internet, partnerships with larger medical
centers and invitations to clinical experts to provide on-site workshops. Grants can be written to facilitate these
endeavors. Challenges in the area of demographic and mortality Profile in our country: Large population base and
tapering top in the age pyramid is a typical sign of under developed country. 32% of the population between 0-14
years in the base of the pyramid reflects the need for Health care services in abundance as morbidity and mortality
among them are high in our country.

Ageing Population
In the rapidly growing world were 8 % of the current population are elderly healthy ageing has become a vital
need in the country.
The country will face a heavy double burden of infectious and non-communicable diseases with existing lack
in significant resources including comprehensive ageing policies to cope.

Fertility related challenges:
Fertility rate of 2.8 per women (2007) is comparatively high than that of the developed countries.
The combination of high fertility rate along with a 34 % of non-literate population and a Adolescent fertility
rate of 45 per 1000 women when compared to 4 and 7 in the developed countries are all considered the major leads for
population explosion. The challenge reflected here is high birth rate and declining death rate [9.4% to 7.5 % (2004)] in
our country which is a vicious cycle not very easy to break.
Hence population explosion is the greatest challenge for the health care sector to match the resources with
need.

Climate change and communicable diseases: the challenge ahead
The global warming induced by climate change has added a new dimension to the burgeoning problem of
communicable diseases in particularly in South-East Asia Region.
The countries of this Region must be prepared to respond to this challenge.

The changes in weather will have direct and indirect health consequences such as greater morbidity and
mortality resulting from heat stroke, skin and eye diseases An increase in vector borne, water borne and respiratory
diseases besides eye and skin diseases are expected to rise.

Diarrhoea is the second most common cause of death among children under the age of five in the developing
world.India is major contributor to the global disease burden.

We don't have to look back too long to see what happened during the Plague outbreak in Surat (Gujarat) in
India in 1994 where strong monsoon following an immense heat wave, led to intense animal and human interface.
 The onset of Chicken guinea in India is the result of climate changes.
 Droughts can lead to malnutrition and starvation.
 This can affect the growth and development of children.

Reduced crop yields are bound to put farmers and their families into difficult circumstances and cause
psychological stress as they may not be able to pay their debts during extended and repeated droughts.

Changes in the frequency of extreme weather events as heat waves, cold spells, hurricanes, floods, cyclones
and storms can cause loss of life, injuries and lifelong disabilities

9. BIBLIOGRAPHY
1.Kamalam S. Essentials in community health nursing practice. 2n edition. New Delhi. Jaypee brothers medical
publishers; 2012: 340-1.
2. Park K. Preventive and social medicine. 24"edition. Jabalpur. Banarasidas bhanot; 2017:493-4.
3.Veerbhadrappa GM. The short textbook of community health nursing. New Delhi. The health sciences publisher;
2016: 50-52.
4.Govt. of India. National Population Policy 2000. Government of India Ministry of Health & Family welfare.
5. Lal Sundar, Adarsh, Pankaj. Textbook of community medicine. Preventive & social medicine. 3d edition. New
Delhi. CBS publisher;2011: 165-9.
6.Kishore J. National health Programs of India. National Policies and legislation related to health. I1h edition. New
Delhi; 637-45.
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