1. Gerber, Lois MPH, BSN, RN

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COMMUNITY HEALTH NURSES (CHNs) offer care to individuals, families, and groups, usually outside of the hospital, in a creative way. These nurses need strong clinical skills and a comprehensive knowledge base along with abilities in critical thinking, advocacy, and analysis. Self-reliance, flexibility, and adaptability are essential for this autonomous role.1,2


This article will help you evaluate whether this challenging and rewarding career is the path you should follow.


The right career for you?

The community health nursing relationship style, a partnership of care, is less authoritarian and more egalitarian than the relationship of a nurse and a hospitalized patient. In the home setting, clients have more control over their behaviors in relation to the plan of care; they choose whether or not to follow special diets, exercise regimens, or medication schedules. Nurses can help clients internalize the importance of healthy behaviors by teaching and adapting the care plan to the individual client. Care is more holistic. In community health nursing, interventions can target individuals, families, or the larger community. An example of a community-based service is BP screening at a mall.


As their clients' guests, CHNs must adapt to working in many living styles and situations. A nonjudgmental approach plus effective communication and organizational skills are essential.1-3


Incorporating clients' belief systems, personal issues, and lifestyles into the nursing process is an important function of community health nursing. Care focuses on managing diseases or wellness issues such as nutrition, exercise, aging, family developmental tasks, spirituality, sexuality, and stress. CHNs explore clients' needs related to their cultural beliefs, environmental and socioeconomic factors, and lifestyle.2


Both existing health problems and potential ones are addressed by CHNs. Teaching health promotion and disease prevention is an important function. Referrals to community agencies, such as the Multiple Sclerosis Society, American Cancer Society, Area Agency on Aging, the Department of Social Services, and the Women, Infants, and Children's food program, are common.3


A broad range of settings and types of clients are served by CHNs:


* Home healthcare is a popular community-based nursing service offered in the client's home or assisted living residence. These homebound clients may be recovering from surgery or have a newly diagnosed disease or an exacerbation of a chronic condition. Some home healthcare clients may be extremely debilitated by age or illness; some may be dying. Care is individualized for the client, and teaching caregivers who are family members and friends is an important part of the care plan.Home healthcare nurses coordinate the healthcare team, which may include physicians, physical and occupational therapists, and social workers. They also supervise the work of home health-care aides. Other duties may include drawing blood, changing dressings and urinary catheters, and filling medication boxes and insulin syringes.Full-time nurses make an average of six visits per day.4 Documentation may be done on paper or on a laptop computer. In some areas, telemedicine interactive audiovisual equipment monitors home healthcare clients from a distance. Funding sources for most home healthcare services are Medicare, Medicaid, and private insurance.2,3


* Case management, either private or through insurance companies, is another community-based nursing role. Case management can be a long-term relationship, sometimes lasting several years. In this problem-solving and monitoring role, the nurse handles client assessment, care planning, service coordination, and referrals.3


* Wellness care involves CHNs serving healthy clients in a potpourri of community-based group settings. The focus is on performing health screenings, making referrals, and teaching healthy living practices. Schools, camps, work sites, churches, prisons, homeless shelters, shopping malls, organized health fairs, and college campuses are sites where CHNs meet clients in their own environment. By working in public settings, CHNs can reach marginalized members of society in a cost-effective way.1-3


* Public health nurses working in traditional public health departments also focus on wellness issues as well as communicable disease control. They provide child and adult immunizations, manage family planning and well-baby clinics, and screen for diseases and conditions such as hypertension, developmental delays, and visual impairments. Accident prevention and parenting techniques also come under the umbrella of wellness teaching.3,5Control of communicable diseases, particularly tuberculosis, HIV/AIDS, and hepatitis, is a priority. In addition to working on-site, nurses often make home visits to new mothers at risk for maternal-child health problems, the mentally and physically disabled, and frail older adults.2,3Public health nurses address problems related to large-scale food poisonings, natural disasters, and worldwide pandemics. Since 2002, they've had responsibility for initiating emergency plans providing mass prophylaxis to manage biochemical threats. Health department services are subsidized by federal and state taxes and grants from private or nonprofit sources.1,3


* Community-oriented nursing is a broader service concept in which the client is the larger community rather than an individual or family. The goal is to provide disease prevention and health promotion services to groups of people. Community-oriented nursing addresses the connection between the population's health status and the physical, social-cultural, and biologic environment.3



CHNs work with community leaders to address citizens' health problems and environmental hazards, with a focus on vulnerable groups. Advanced practice CHNs function at local, national, or international levels to establish community health policies and develop and administer public health programs.3


One aim of community-oriented care is to improve the health of a group of people with a specific disease, such as diabetes. Another focus is disease prevention and health promotion for people with disease risk factors, such as adults who are obese and at risk for diabetes. Or they may try to improve or protect the health of essentially healthy people at risk for disease, such as sexually active teens who aren't practicing safe sex.2


Stepping up to the nursing process

All CHNs follow the same five-step nursing process to serve their clients.


Assessment requires strong interviewing and listening skills. This step goes beyond collecting basic physical and psychological data to include information about cultural, environmental, and everyday life skills. Clients, whether individuals, families, or communities, must trust the nurse before sharing sensitive information. Establishing rapport is essential to the process.


In nursing diagnoses development, the CHN addresses environmental and socioeconomic problems. An example of a family community health nursing diagnosis is alteration in family health management. An example of this is a family eating a diet high in saturated fats and leading a sedentary lifestyle. One community health nursing diagnosis is community knowledge deficit of the need for infant immunizations.


Plans of care generally are broader in scope and more complex than those for hospitalized patients. The more people involved, the more expansive the plan and the stronger the partnership between the nurse and client.


Interventions must be flexible and adapted to the client's lifestyle and the community's social and political environment. Health teaching, wellness counseling, and referral to community agencies may be incorporated into the care plan.


Evaluation, especially for CHNs working with large populations, may be more difficult than if working with one client because client progress is slower and has more variables. Outcomes may not be apparent for months or years. Evaluation is easier for nurses working with clients in one-on-one settings where changes are more evident.3


Moving into the field

Although CHNs usually need a BSN degree and a year's basic experience to work in most community-based settings, some agencies have eased their standards. A master's degree in either nursing or public health is required for many community-oriented jobs involving larger population groups.1,3


Computer competence is helpful for this career choice. For most community health nursing positions, a dependable car is essential.


Working as a CHN has drawbacks, such as having fewer opportunities to consult with colleagues about challenges than in other settings such as a hospital. The median annual salary of CHNs is below the median hospital nurse's salary.1,2,6


The rewards of being a CHN far outweigh any disadvantages. Having one-to-one client interaction fosters an authentic and personal nurse/client relationship. Those CHNs working with community groups can affect the health of many and have input about how scarce resources are used.3


On the practical side, CHNs have a more flexible work schedule than hospital-based nurses and more independence. CHNs rarely work on weekends and holidays.


Community health nursing is challenging, rewarding, and filled with professional and personal satisfaction. It could be the right career for you.




1. Meadows P. Community health nursing. Am J Nurs. 2009;109(Suppl 1):19. [Context Link]


2. Lundy KS, Janes S, Hartman S. Opening the door to health care in the community. In Lundy KS, Janes S, eds. Community Health Nursing: Caring for the Public's Health. 2nd ed. Sudbury, MA: Jones and Bartlett; 2009. [Context Link]


3. Stanhope M, Lancaster J. Public Health Nursing: Population-Centered Health Care in the Community. 7th ed. St. Louis, MO: Mosby; 2008. [Context Link]


4. National Association for Home Care and Hospice. Home care and hospice facts and statistics. [Context Link]


5. El Dorado County Health Department: Public health-community nursing. 2008. [Context Link]


6. Bureau of Labor Statistics. Occupational Outlook Handbook, 2010. [Context Link]