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A Textbook of
Community Nursing
A Textbook of Community Nursing is a comprehensive and evidence-based introduction covering the full range
of professional topics, including professional approaches to care, public health, eHealth, therapeutic relationships
and the role of community nursing in mental health. The new edition has been updated throughout, including
new guidelines and policies. It also provides a stronger focus on evidence-based practice.
This user-friendly and accessible textbook includes the following:
• Current theory, policy and guidelines for practice. All chapters are underpinned by a strong evidence base.
• Learning objectives are provided for each chapter, plus exercises and activities to test current understanding,
promote reflective practice and encourage further reading.
• Case studies and examples from practice which draw on all branches of community nursing are provided to
illustrate practical application of theory.

This is an essential text for all pre-registration nursing students, students in specialist community nursing
courses and qualified nurses entering community practice for the first time.

Sue Chilton, Senior Lecturer/Academic Course Leader in the School of Health and Social Care, University of
Gloucestershire, Gloucester, UK

Heather Bain, Academic Strategic Lead: Academic Programmes, School of Nursing and Midwifery, Robert
Gordon University, Aberdeen
A Textbook of
Community Nursing
Edited by
SUE CHILTON and HEATHER BAIN
First published 2018
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN

and by Routledge
711 Third Avenue, New York, NY 10017

Routledge is an imprint of the Taylor & Francis Group, an informa business

© 2018 Taylor & Francis

The right of the editor to be identified as the author of the editorial material, and of the authors for their individual chapters, has been asserted
in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means,
now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission
in writing from the publishers.

Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation
without intent to infringe.

British Library Cataloguing-in-Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging‑in‑Publication Data

Names: Chilton, Sue, editor. | Bain, Heather, editor.

Title: A textbook of community nursing / edited by Sue Chilton and Heather Bain.
Description: 2. | Abingdon, Oxon ; New York, NY : Routledge, 2018. | Includes
bibliographical references and index.
Identifiers: LCCN 2017015104| ISBN 9781138068247 (hbk) | ISBN 9781498725378
(pbk) | ISBN 9781315157207 (ebk)
Subjects: | MESH: Community Health Nursing
Classification: LCC RT98 | NLM WY 106 | DDC 610.73/43--dc23
LC record available at https://lccn.loc.gov/2017015104

ISBN: 978-1-138-06824-7 (hbk)

ISBN: 978-1-4987-2537-8 (pbk)
ISBN: 978-1-315-15720-7 (ebk)

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CONTENTS
Contributors vii
Foreword ix
Introduction xi
Acknowledgement xv

1 Nursing in a community environment 1

Sue Chilton
2 Public health and the promotion of well-being 25
Fiona Baguley
3 Professional approaches to care 45
Jo Skinner
4 Managing risk 68
Jayne Murphy and Debra Smith
5 Therapeutic relationships 89
Jacqueline Corbett, Patricia Wilson and Sue Miller
6 Care across the lifespan 110
Helen McVeigh
7 Community nursing assessment 132
Helen Gough
8 The role of the community nurse in mental health 147
Julie Bliss and Fiona Couper
9 Carers: The keystone of communities and families 163
Sally Sprung and Fiona Baguley
10 Spirituality: A neglected aspect of care 182
Ann Clarridge
11 Collaborative working: Benefits and barriers 200
Sally Sprung and Sue Harness
12 Approaches to acute care in the community 219
Nicola Brownie
13 Emerging issues in long-term conditions 245
Lois Seddon
14 Providing quality care at the end of life 267
Gina King
15 Organisation and management of care 289
Jill Y. Gould
vi Contents

16 Leading quality, person-centred care in the community 318

Caroline A.W. Dickson
17 eHealth 342
Heather Bain
18 Development of community nursing in the
context of changing times 361
Anne Smith and Debbie Brown
Index 384
CONTRIBUTORS
Fiona Baguley MSc PgCert HELT
School of Nursing and Midwifery
Robert Gordon University
Aberdeen, Scotland
Heather Bain EdD PgCert HELT BA DipDN RGN
School of Nursing and Midwifery
Robert Gordon University
Aberdeen, Scotland
Julie Bliss MSc PGCE BSc RGN DN FHEA QN
Florence Nightingale Faculty of Nursing and Midwifery
King’s College London
London, England
Debbie Brown PgDip BSc (Hons) SRN
Department of Primary Care/ANP Burnt Ash Surgery
NHS Lewisham Clinical Commissioning Group
London, England
Nicola Brownie MSc PGCert HELT
School of Nursing and Midwifery
Robert Gordon University
Aberdeen, Scotland
Sue Chilton MSc PGCHE BNurs RN DN HV DNT
School of Health and Social Care
University of Gloucestershire
Gloucester, United Kingdom
Ann Clarridge MSc BSc (Hons) Dip Th PCCEA RN DN
Holy Trinity Church
Northwood, Diocese of Londonformerly Principal Lecturer
London South Bank University
London, United Kingdom
Jacqueline Corbett MSc BSc (Hons)
University of South Wales
Glyntaff, United Kingdom
Fiona Couper MA BA (Hons) SRN RMN Dip Nurse Education Lecturer
Florence Nightingale Faculty of Nursing and Midwifery
King’s College London
London, England
Caroline A.W. Dickson PhD MSc PG Cert Prof Ed BA RN Dip DN RNT
SPQ Community Nursing in the Home/District Nursing, Division of Nursing
Occupational Therapy and Arts Therapies, School of Health Sciences
Queen Margaret University
Edinburgh, Scotland
Helen Gough MEd PgC BSc DN RGN FHEA
School of Health and Life Sciences
Glasgow Caledonian University
Glasgow, Scotland
Jill Y Gould MSc BSc (Hons) RGN DN CPT QN SF HEA
University of Derby
Derby, United Kingdom
Sue Harness PGCE BSc (Hons) SFHEA DN QN RGN
Programme Lead Community Specialist Practice
University of Cumbria
Carlisle, England
viii Contributors

Gina King RN DN BSc (Palliative Care) PGCHE Dip Reflexology

Quality Improvement Lead for End of Life Care
South West Strategic Clinical Network
Bristol, United Kingdom
Helen McVeigh MA BSc (Hons) RNT RGN
Leicester School of Nursing and Midwifery
De Montfort University
Leicester, England
Sue Miller RGN RSCN DN Cert Ed BSc (Hons) MSc
Jayne Murphy MA BSc (Hons) DipHE, RN (Adult) SFHEA QN
University of Wolverhampton
Wolverhampton, West Midlands, England
Lois Seddon, RN MSc PGCE RNT DN SCPHN (HV) QN
Nursing Specialist Practice Programmes
University of Suffolk
Ipswich, England
Jo Skinner
London Metropolitan University
London, England
Anne Smith MSc BSc (Hons) (Dist Nurs) PGCHE QN RN
University of Reading
Berkshire, England
Debra Smith MA BSc (Hons) DN RN
University of Wolverhampton
West Midlands, England
Sally Sprung MA BSc (Hons) DN RNT RGN FHEA QN
School of Nursing and Allied Health
Liverpool John Moores University
Liverpool, England
Patricia Wilson PhD MSc BED (Hons) RN NDN
Primary Care Unit Centre for Health Service Studies
University of Kent
Canterbury, Kent, England
FOREWORD
All four countries of the United Kingdom recognize that nurses are leading and
supporting the implementation of the shared policy imperative for more care to be
delivered in or closer to the home.
This comprehensive book confirms the critical and evolving role of the nurse in
the community in supporting individuals, families and carers at every stage of their
lives.
The themes of each chapter illustrate both the rapidly changing policy context
of care in the community and the political, economic, scientific and technical
developments that have influenced and supported the growth of the nurse’s role.
There could not be a better time to work in the community, as this book illustrates
so clearly; autonomous roles, leadership of teams and the potential to care for
acutely ill patients in their own homes are just some examples which demonstrate
the range of advanced level, specialized skills now required.
There is also a clear recognition that with this responsibility there is a need
for the underpinning high level of nursing knowledge which includes asset- and
strength-based approaches to care, a demonstration of cultural competence and a
considerable level of understanding concerning the social determinants of health.
In the world of healthcare today, there is an expectation that people will take
a greater part in decisions about their health and in managing their healthcare.
Consideration of what it is to be a professional in this current context is therefore
important – but also serves as a reminder of the privilege of working with individuals
and communities and the trusting, often long-term therapeutic relationships that
are developed and maintained.
For those who are new to nursing in the community there is a coverage of
holistic assessments, a nursing practice that involves a person-centred, partnership
approach and includes addressing the spiritual needs of patients. The central role
of carers and the nurses’ role in supporting adult and young carers are given a
high profile. This is significant as carers frequently provide the majority of care for
patients, and yet their role so often goes unrecognized.
Collaborative working has always been important to nurses working in the
community. There is now an imperative to working with colleagues in the voluntary,
social and healthcare systems in a more integrated way. New service models provide
many opportunities for this and nurses are experts at building relationships with
others to the benefit of the patient, family and carers.
With people living increasingly longer lives – which is a cause for celebration
– there is a consequent increase in those living with long-term conditions. It is
excellent to see a focus on the principles of long-term condition management within
the current policy context and the pivotal role of the nurse in the community setting.
A focus on the nurse’s central role and the skills required to provide high-quality
care in the home at the end of life is given the attention it rightly deserves. There is
 x Foreword

an often forgotten army of nurses who provide a critical service in the co-ordination
and delivery of care for patients at the end of their lives, every day. This happens in
every village, town and city around the United Kingdom and yet is rarely given the
attention it deserves in the media.
The ways in which nursing is embracing technology to enhance patient care are
illustrated in their leadership of new ways of working and a nuanced understanding
of patients’ responses to such opportunities.
Reading this cleverly woven set of chapters provides a reminder of the unique
combination of autonomous and team working that is the joy of serving a
community as a highly skilled, creative and resourceful nurse. It provides essential
reading to those who are new to a rewarding nursing career in the community and
a welcome invigoration for those nurses who have been privileged to serve their
communities for many years.

Dr Crystal Oldman
Chief Executive
The Queen’s Nursing Institute
INTRODUCTION

Sue Chilton and Heather Bain

This book has been designed to support staff who may be new to working in a
community setting and is an essential guide to practice. We envisage that it will
be useful for pre-registration students on community placement, community staff
nurses and nurses moving from an acute work environment to take up a community
post. The aim of the book is to develop and support nurses to work safely and
effectively in a range of community locations.
Community nurses work in a great diversity of roles and a variety of settings –
including schools, the workplace, health clinics and the home (Naidoo and Wills,
2016). They empower individuals, families and communities to have control over their
health and to improve their wellbeing. They also work across the lifespan, and with a
range of social groups that include those who are vulnerable, experience inequalities
and are socially excluded. Not only do community nurses work autonomously
in leading, managing and providing acute and long-term health and social care,
anticipatory care and palliative care, but they also have a public health remit. They
have a pivotal role in health protection, ill-health prevention and health improvement.
Community practice is dynamic, forever changing and in a constant state of flux.
Baguley et al. (2010) have conceptualized community nursing in Figure I.1, which
illustrates that, in the promotion of optimum health and wellbeing, community

Promotion of optimum health and well-being

y Res
bilit ilie
n era nce
Vul
Bir
ent

Individual
th
essm
Ass

Community Family
Int
e

ath
rve

De
nti
on

Lea my
der
ship ono
Aut

FIGURE I.1 Promotion of optimum health and well-being. (Reproduced from Baguley
et al., Concept of Community Nursing, Aberdeen: Robert Gordon University, 2010.)
xii Introduction

practitioners work in a range of locations – with individuals, families and

communities. The overlapping spheres demonstrate the intricacies and relationships
between individuals, families and communities.
Community nursing is complex but essentially falls within the following four
continuums, which are all addressed within this book:
• Birth to death: They work with all ages across the lifespan.
• Vulnerability and resilience: Individuals, families and communities fluctuate in
and out of vulnerability and resilience throughout their life.
• Assessment and intervention: Community practitioners work within a cycle
of assessment of needs and interventions to address the needs and support
individuals, families and communities.
• Leadership and autonomy: Community practitioners work in varying degrees
of autonomy and leadership in advancing practice, evidencing practice and
providing the best practice.

A range of topics relating to professional issues in community nursing is

addressed within the book. The text reflects recent and current government health
and social care policy reforms and the effect of these on the roles and responsibilities
of community nurses. It is acknowledged that the devolution of political power
to the four countries within the United Kingdom has influenced health policies.
There is now a much greater degree of freedom in relation to the health policies
they produce. All recognize the shifting balance of care from the acute sector to the
community, with an increasing focus on the management of long-term conditions
to reduce hospital admissions. There are, however, various political stances
providing differing opinions on how to develop their own health services that take
the demographics of each of the four countries into consideration (Timmins, 2013).
Community nursing is seen in the context of not only political but also social and
environmental influences. The authors take an inclusive approach, working from a
health and social care perspective to meet the needs of service users. Interpersonal
and practical skills, as well as the knowledge base required by community nurses, are
critically analyzed and linked to relevant theory. The use of activities, examples and
case studies/scenarios relating to the range of community nursing disciplines are
included throughout the book to stimulate the reader’s creative thinking. Themes
running through the text are evidence-based practice, reflection, vulnerability and
current government policy drivers across the four UK countries. Each chapter has
been written by a contributor(s) with in-depth knowledge and experience of the
specific subject area, resulting in a range of writing styles.
Topics covered within this text inform key aspects of the community nurse’s role.
A brief summary of each chapter is detailed below:

Chapter 1 – Nursing in a community environment – Explores definitions

of ‘community’ and acknowledges its complex nature. A range of factors
influencing the delivery of community healthcare services and the expertise
required of community nurses is discussed.
 Introduction xiii
Chapter 2 – Public health and the promotion of well-being – Analyses the role
of public health in community nursing and ways of determining health needs.
Opportunities for positively influencing care delivery are explored.

Chapter 3 – Professional approaches to care – Discusses the concept of

‘professionalism’, comparing and contrasting the traditional, hierarchical
and individualistic model of professional practice with a more inclusive
partnership model.

Chapter 4 – Managing risk – Explores health and safety considerations in

relation to community nursing with particular emphasis upon vulnerable
groups – people with mental health issues, older people and children.

Chapter 5 – Therapeutic relationships – Discusses the challenges and issues

involved in establishing therapeutic relationships between service users and
community nurses.

Chapter 6 – Care across the lifespan – Considers how an understanding of

the lifespan can enhance the quality of care provision by exploring different
theories of growth and development.

Chapter 7 – Community nursing assessment – Explores the notion of

‘assessment’ and the concept of need. Assessment frameworks and decision-
making processes are discussed.

Chapter 8 – The role of the community nurse in mental health – Explores

the relationship between physical and mental health. The roles of the
community nurse in mental health assessment and associated interventions
are examined.

Chapter 9 – Carers: The keystone of communities and families – Discusses the

role of carers identifying some of the inherent challenges and rewards. Carer
assessment tools and carer support networks are considered.

Chapter 10 – Spirituality: A neglected aspect of care – Highlights the

importance of developing self-awareness and using appropriate tools to
assess and address a person’s spiritual needs.

Chapter 11 – Collaborative working: benefits and barriers – Examines the

importance of collaborative working including some of the opportunities
and constraints.

Chapter 12 – Approaches to acute care in the community – Defines acute care

in the community setting and identifies the knowledge and skills required
by community nurses to manage it.

Chapter 13 – Emerging issues in long-term conditions – Describes

contributing factors and the potential impact of a long-term condition on
individuals, families and communities.
xiv Introduction

Chapter 14 – Providing quality care at the end of life – Highlights the importance of a holistic and timely
assessment in order to effectively manage the end-of-life care needs.

Chapter 15 – Organisation and management of care – Critically analyzes work organisation and care
delivery in the community setting with particular reference to prioritization, delegation and skill mix.

Chapter 16 – Leading quality, person-centred care in the community – Explores the role of leadership and
clinical governance at practice level within community nursing.

Chapter 17 – eHealth – Defines the terminology used in telehealth and telecare and appraises its potential
use in community nursing practice.

Chapter 18 – Development of community nursing in the context of changing times – Identifies contemporary
political influences and discusses new ways of working and responding as community nurses.

Within each chapter, further reading and resources are suggested. We hope you find this book informative
and inspirational in developing your professional practice.

REFERENCES
Baguley F, Bain H and Cowie J (2010) Concept of Community Nursing. Aberdeen: Robert Gordon University.
Naidoo J and Wills J (2016) Health Promotion, 4th edn. Edinburgh: Elsevier.
Timmins N (2013) The Four UK Health Systems. London: King’s Fund.
ACKNOWLEDGEMENT
The editors would like to thank colleagues from the Association of District
Nurse Educators (ADNE), many of whom have contributed to the book. The ADNE
(www.adne.co.uk) is committed to raising the profile of district nursing and its
purpose is the educational preparation and support of district nurses and other
health professionals working in primary and community care across the United
Kingdom. At various stages along the way, members of this professional group have
offered guidance and support.
CHAPTER

1 Nursing in a community
environment
Sue Chilton

LEARNING OUTCOMES
• Compare and contrast definitions of ‘community’, exploring the contexts
in which the term is used and, specifically, how it is interpreted within
community nursing.
• Explore the environmental, social, economic, professional and political
factors influencing the delivery of community healthcare services and
critically appraise ways in which local services aim to be responsive to the
specific needs of their population.
• Develop insight into the complex nature of the environment of community
healthcare.
• Identify the skills and qualities required of nurses working in community
settings.

INTRODUCTION
This chapter considers the complex environment within which community nurses
practice and offers some definitions of ‘community’ and ways in which the term is
used. It explores the wide range of factors impacting upon the services community
nurses provide for patients and discusses ways of tailoring care to respond to
local needs. Key skills and qualities currently required by community nurses are
identified and discussed.

DEFINITIONS OF ‘COMMUNITY’
Changes in terms of the location and nature of community nursing care provision
have occurred over the years in response to a variety of influencing factors. More
recently, we have seen a distinct shift of services from the hospital setting to primary
care and community locations (Turnbull, 2017; McGarry, 2003). Current health and
social care policy directives indicate that still more services will be provided within
the community context in the future (Scottish Government, 2013; Welsh Assembly
Government, 2013; Scottish Government, 2010; DHSSPSSNI, 2011; NHS England,
2014). In order to provide the required administrative and managerial infrastructure
to accommodate these changes, several major organisational reconfigurations have
2 Nursing in a community environment

taken place across the United Kingdom in recent years. In England, for example,
general practitioner (GP) fundholding was replaced by primary care groups, which
then developed into primary care trusts (DH, 1997). Further changes quickly
followed with the largest structural reorganisation of the National Health Service
(NHS) since its inception in 1948, involving the development of GP consortia (DH,
2010a), which have wide-ranging responsibilities for commissioning services and
manage the vast majority of the NHS budget. Over the last few months, there has
been the development of ‘Sustainability and Transformation Plans’ (STPs) which
involve partners working together in ‘place-based systems of care’ to transform
health and social care delivery within local populations. These plans are focused
on improving quality and developing new ways of working; improving health and
well-being; and improving the efficiency of services in hospitals and the community
(Alderwick et al., 2016). Political analysts have recognised the potential value of
STPs in supporting new care models and promoting collaboration between
key stakeholders but also advise caution and the need for close monitoring and
evaluation in testing whether service changes and related financial plans are viable
(King’s Fund, 2017).
Although, from an academic perspective, the notion of ‘community’ has been
discussed widely across a range of disciplines, including sociology and anthropology
(Cohen, 1985), clarity with regard to a definitive definition eludes us.

ACTIVITY 1.1 Reflection point

Compile a list of words that helps to define ‘community’ for you. Identify
any recurring themes that emerge when considering different types of
communities or different contexts within which the term is used.

Laverack (2009) offers four key characteristics of a ‘community’ which help to

summarise many of the definitions found in the literature. These are as follows:
• Spatial dimension – referring to a place or location
• Interests, issues or identities that heterogeneous groups of people share
• Social interactions that are often powerful in nature and tie people into
relationships or strong bonds with each other
• Shared needs and concerns that can be addressed by collective and collaborative
actions

Although the essence of ‘community’ is difficult to capture within a definition, the

word itself largely conveys a positive impression conjuring up feelings of harmony
and co-operation. It is unsurprising to find that it is a word used frequently by
politicians within government documents to create just that effect.
The uncertainty with regard to the true meaning of the word ‘community’ also
applies within community nursing (Hickey and Hardyman, 2000). It is pivotal
(Carr, 2001) that the context within which care takes place, including physical
and social aspects among many others, is considered alongside the geographical
 Definitions of ‘Community’ 3
location of care. By attempting to include the wide array of elements involved, the
true complexity of nursing within the community begins to emerge. Although
some of the challenges, such as interacting with patients and families in their own
homes, are acknowledged within the literature (Luker et al., 2000; Quaile, 2016a),
the meaning of ‘community’ within community nursing is often assumed and
taken for granted (St John, 1998).
St John (1998: 63) interviewed community nurses who explained the nature of the
communities they worked within in terms of ‘geography; provision of resources; a
network and target groups’. Some nurses described their communities as a ‘client’
or an entity, particularly where members of the community were connected. If
a population was not connected, nurses defined community as the next largest
connected element such as a group or family.
It would appear, therefore, that definitions of community often include the
dimensions of people, geography or space and shared elements, relationships or
interests and incorporate some form of interaction. Many of these common themes
are captured in the following definition of ‘community’ as

... 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.
(WHO, 1974)

Awareness of the networks that exist within a community helps in identifying

opportunities or strategies to engage ‘hidden’ members of the population. ‘Social
capital’ is a term used to explain networks and shared norms that form an essential
component of effective community development (Wills, 2009). It is proposed that
poor health is linked to low social capital and social exclusion where poverty or
discrimination exist (Wilkinson, 2005). According to the National Occupational
Standards in Community Development Work, the main aim of community
development work is

collectively to bring about social change and justice by working

with communities to identify their needs, opportunities, rights and
responsibilities; plan, organise and take action and evaluate the effectiveness
and impact of the action all in ways which challenge oppressions and tackle
inequalities.
(Lifelong Learning UK, 2009)

Community development work is inclusive, empowering and collaborative in

nature and is underpinned by the principles of equality and anti-discrimination,
social justice, collective action, community empowerment and working and
learning together.
A study by McGarry (2003) identifies the central position of the home and
relationships that take place within it in defining the community nurse’s role. Four
key themes emerging from her research are ‘being a guest’ within the home, the
4 Nursing in a community environment

maintenance of personal-professional boundaries, notions of holistic care and

professional definitions of community. The findings highlight the tensions for nurses
in embracing their personal perceptions of community nursing while trying to work
effectively within the constraints of organisational and professional boundaries.
Kelly and Symonds (2003), in their exploration of the social construction of
community nursing, discuss three key perspectives of the community nurse as
carer, the community nurse as an agent of social control and community nursing
as a unified discipline. The authors discuss the proposition that community nurses
are still reliant on others to present the public image of community nursing that
is portrayed. They argue, interestingly, that community nurses may not possess
enough autonomy to define their own constructs and articulate these to others.
Community Links is a charitable organisation which, through its national work,
shares lessons with government and community groups across the country to
achieve social change. The charity’s chief executive, Blake, believes the concept of
community has become more complex and that a top-down or narrow definition
may not be useful and can, in certain instances, have negative consequences.
According to Blake (2013), community is a ‘fluid, chaotic thing’ and defining the
concept is not essential and adds that ‘It’s the doing something together that is
important’. People can belong to many different communities whether based on
geography, ethnicity, religion, interest or other social factors such as disability or
refugee status and this notion of multiple communities can strengthen and add
value to communities. In addition, communities are not static and can change
over time, presenting challenges to service providers who may need to adapt their
interventions depending on the expressed needs of a community at any one time
(Niven, 2013).
Niven (2013) interviewed five community leaders from different charitable and
voluntary organisations and found that, although community identity is difficult to
conceptualise, these leaders sensed that a strong desire from the public to be part of
a community is returning.

FACTORS INFLUENCING THE DELIVERY OF

COMMUNITY HEALTHCARE SERVICES
Community nurses face many challenges within their evolving roles. The transition
from working in an institutional setting to working in the community can be
somewhat daunting at first (Sines et al., 2013a). As a student on community placement
or a newly employed staff nurse, it soon becomes apparent that there is a wide range
of factors influencing the planning and delivery of community healthcare services.
Within the home/community context, those issues that impact upon an individual’s
health are more apparent. People are encountered in their natural habitats rather
than being isolated within the hospital setting. Assessment is so much more complex
in the community, as the nurse must consider the interconnections between the
various elements of a person’s lifestyle. Chapter 7 explores the concept of assessment
in more detail. In addition, community nurses are often working independently,
 Factors Influencing the Delivery of Community Healthcare Services 5
making complex clinical decisions without the immediate support of the wider
multidisciplinary team or access to a range of equipment and resources as would be
the case in a hospital or other institutional healthcare environment. It is recognised,
for example, that district nurses are frequently challenged with managing very
complex care situations which require advanced clinical skills, sophisticated decision
making and expert care planning (Quaile, 2016a). Ford (2016) also acknowledges
the need for specialist district nurse practitioners to have expert knowledge and
advanced clinical skills as well as highly developed interpersonal skills and a clear
understanding of a whole systems approach.
Defining health is complex as it involves multiple factors. According to Blaxter
(1990), health can be defined from four different perspectives: an absence of disease,
fitness, ability to function and general well-being. The concept of health has many
dimensions such as physical, mental, emotional, social, spiritual and societal. All
aspects of health are interdependent in a holistic approach. It is prudent to view
individuals within their wider context, when considering issues relating to their
health and well-being to ensure that relevant social determinants are taken into
account (Figure 1.1).

BAL ECOSYSTEM
GLO
AL ENVIRONMENT
TUR
NA
IRONMENT
LT ENV
BUI
ACTIVITIES
AL ECONOMY
g LOC
in
MUNITY
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ility

v
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Bio
pin s

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s

Air
itat
stab

ac

TY
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g,

dive
ing
on

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l
hab

g, P

eets
ati

tal

sili

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ity
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rsity
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cre

PEOPLE
api
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e
iv
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cial

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n
act

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t markets
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rk
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n
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etworks

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hereditary factors
oth
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o liti es oth er n
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on lo s ho
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01

The determinants of
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an
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in our neighbourhoods
nd
ona
rt
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Figure 1.1 The health map. (From Barton H and Grant M., Journal of the Royal
Society for the Promotion of Health, 126, 152–253, 2006.) The determinants of health
and well-being in our neighbourhoods.
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