Red River College

  • Course Name :: Concepts in Community Health Community Health Nursing NURS 3012
  • Time :: Fall 2008
  • Instructor :: Alison Fyfe-Carlson RN, BN, MA-Ed.
  • Email ::

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Unit Objectives

Poverty Notes Guest Speaker: Jennifer Schmidt Determinants of Health: 1. Income & Social Status: EI $250/month for transportation; <$200/month for rent; Sex trade workers make $10-20/sex act; have to resort to crime (stealing or “boosting”) Sage House provides food, free laundry, counselling, nurse (provide primary health care, STI screening, tx for burns and wounds etc..) 2. Social Support Network: Social supports help with problem solving and coping, provided feeling of self-control. “Street families” develop as people often use drugs in groups, often look out for each other (eg. Clean needle exchange). But can also have unhealthy relationships, threatened by change and can stand in the way of getting sobor. Harm Reduction strategies; engaging in activities that could cause harm→ how do we reduce the harm? (eg. Dressing supplies & potassium supplements). Often dealing with grief as well as many friends lost to disease, suicide, accidents, and violence. Many programs such as angel wings at Sage house, Families first program (post-partum visits, screening), assistance with anger management, coping, and expectations of them. 3. Education & Literacy: very little access to higher education→ TERF program (Transitional, Education & Resources for Females) ran by New Directions; assists females and transgender individuals to leave street life, offer counselling, child care, financial compenstation to help them transition out of sex trade into mainstream employment. 4. Employment/Working Conditions: have low paying jobs→ help them to build skills to seek better employment. 5. Social Environment: Provide list of supports in the area to clients→ put them in touch with social supports→(eg. Weekly solvent user support group meetings {mount Carmel & Sage house}) 6. Physical Environment: Housing→ fear of assault (transgender at↑ risk for assault as they are often put with the men; → sleep on thin gym mats at main street project, often run out of mats for people. → they also have less access to healthcare, groceries and housing. 7. Personal Health Practices & Coping Skills: Addictions→co-dependant, unhealthy relationships: ↓ ability to cope; ↑ spread of blood-born pathogens (HIV, hep C) 8. Healthy Child Development: Partners with Manitoba Housing for Healthy Baby Program→ help with financing and education, nutrition & health information.→ Well child clinics (immunizations, screening)→ pre-school wellness clinic. 9. Biology & Genetic Endowment: ages 0-5 years old, counsil pregnant woman who drink ETOH/substance abuse, they can have an inability to understand consequences→ FASD programs. 10. Health Services: Hospitals→ not able to access in the same way (Health promotion through “street news”. 11. Gender: 12. Culture: Live under dominant culture (European)→ face lifelong racism→ affects of Residential school system (last closed 1972) → didn’t learn parenting & partnering skills→ abuse → their culture was devalued Aboriginal head start→ culturally relevant day care→ involves parents in care→ social supports→ school readiness Native pre-natal program.  

Poverty-notes from Text Ch. 27 Pg 377 Poverty; Lack of food, clothing, and shelter plus other necessities “required to maintain long-term physical well being.” • Root of poor health • ↑ incidence of disease • Shortened life expectancy • Extreme isolation • Social exclusion Social Exclusion: various types of structures and practices (legal, economic, social) that through the processes and results support inequality, barriers, and stigma. • Aboriginal peoples • Immigrant & refugees • Racialized groups • People with disabilities • Single parents • Children & youth in disadvantaged circumstances • Lesbians/gays/bisexuals/transgender people The United Nations International Covenant on Economic, Social, and Culteral Rights states that every person has the right to an adequate standard of living, including the right to be free from hunger, to have a job, be paid fair wages, and to get an eduction. (pg. 377) Poverty facts; • Single-parent mothers have highest poverty rate • 1 in 10 people using food banks reported their primary source of income as paid employment • Seniors living in poverty received about 90% of their income from government programs • ↑ in after-tax incomes since 1980 (richest 20% of families = 14.4% and by poorest 20% = 4.3%) In 1996 the fed government eliminated the Canada Assistance Plan & drastically ↓ the EI program. The combo of ↓ government spending and ↑ tax cuts has led to an ↑ income gap between rich & poor. Homelessness: includes • Those living outdoors/emergency hostels/Violence Against Women shelters • People who are precariously housed (families doubled up, sharing crowded living space, & those living in inadequate housing. • Those in core housing need (>30% of their income in rent) • • Homelessness epidemic in 1990’s d/t cancellation of the federal gov’t national housing program in 1993. • Now an emergency in almost every Canadian community (urban & rural) Low Income Cut-Off (LICO) • Stats Canada determines what percentage of gross income is spent on food, clothing, and shelter by an average Canadian family in a given year. • Premise = Average Canadian family spends 50% of income on food clothing & shelter. • The average percentage is marked up by 20%. If spend more than 70% on food, clothing and shelter would have little disposable income for other (eg. Bus pass, etc..). • Shifting into middle class families d/t tax shift into lower income workers, GST & PST consumption impact, wages ↑ below inflation rate. Who Provides the Care? • First Nations & Inuit Health Branch (FNIHB) • Increasing local transfer of control & First Nations Health Authorities have been established to assist with transfer of control • Depending on the reserve and the medical condition there can be varying levels of input from the general health care system.

Major health concerns among Aboriginal clients; • High morbidity & mortality from injury & trauma • High rates of chronic illness, especially diabetes, renal disease, heart disease • High suicide rates • ↑ TB, F.A.S, HIV/AIDS • Problems with housing & vehicle safety • High rates of alcoholism & substance abuse

Class 1:

Introduction; Concepts of Health, community, financing, policy & politics


Describe the concept of community & healthy community.


Identify the historical forces which contributed to the development of community health nursing (CHN) in Canada.


Discuss the theoretical and practical distinctions between the practices of visiting nurses and public health nurses.


Examine delivery models and funding mechanisms as they pertain to community health care.


Explain health from 3 different views: medical, systems and lay.

- medical: absence of disease - Systems: WHO u r mental, physical, & social, determinants of lifestyle choice - Lay: When we feel healthy = vitality, harmony, connected, fulfilled, optimistic


Examine how these 3 views on health influence the practice of CHN.

Class 2:

Ethical and Legal Considerations Practice Setting, Roles & Functions


Describe settings in which community health nurses practice.


Identify current issues and trends in CHN.


Describe the central values of Canadian nursing and how they relate to CHN.


Identify the main ethical and legal issues in community health nursing.


Describe the concept of primary health care (PHC).


Define PHC and describe its 5 principles and its 8 main elements.


Understand the concepts of PHC


Discuss the diversity of roles and functions of community health nurses as outlined in the Canadian Community Health Nursing Standard of Practice

Class 3:

In-Class Assignment General Principles of Epidemiology


Define epidemiology.

  • Epidemiology is defined as the study of the distribution and determinants of health related states or events in specified populations, and the application of this study to control of health problems.


Interpret and use basic epidemiologic, demography and statistical measures related to community health.


Identify the main sources of epidemiologic data

In-Class Assignment #1 - Sept. 26/08

To date, we have had 3 lectures, 2 films and covered the following chapters in your textbook‐Stamler and Yiu‐ 2nd ed. ‐ 1, 2, 5, 6, 8, & 11. For your in‐class assignment you will need a pen (no pencils please) and you may have a water bottle. As with exams you are only permitted these 2 items at your desk. Jackets, backpacks etc. can be left at the back of the room or in your locker. The in‐class assignment will consist of you picking 4‐6 essay questions (# to be given on the day of, not before) from a list, and you will be given 1 hour of time to do this. The assignment will be from 9‐10 a.m. on Friday morning in EM‐ 15 a –the usual classroom. If you wish to use point form in your essay answers you can. You will not be marked on writing style –unless it is terrible to read and unclear. Most people answer these questions in about ½ ‐3/4 of a page of the writing booklet you will be provided with which has legal‐sized paper. Following the assignment there will be a short break, and then there will be a lecture until 12 noon. The following list of questions are very similar to the types of questions that you will get to choose from (some even may be exactly the same!!). You will find them useful as a study guide.


Describe the 2 types of Community Health Nursing that evolved in Canada in the early 20th century and discuss which segments of the population were the focuses of early Community Health Nursing programs.

  • District or visiting nursing:

Evolved in the 1800's - Charitable organizations("maternal feminist") employ visiting nurses to provide care for poor & destitute families usually in rural communities. VON - Lady Aberdeen started school + training.

  • Public Health Nursing:

PHN - are assign to specific jobs (TB control, school health, prevent sick children from becoming sicker). - Established by civic government for health education, preventable programs to control decease, infant & child morbidity & mortality. Move to generalist practice, Blurred role boundaries.


Describe the 5 key principles that are the legal cornerstones of Medicare.

  • Public Health Administration - The plan must be administered and operated on a non-profit basis by a public authority responsible to the provincial/territorial government and subject to audit of its account and financial trasaction.
  • Comprehensiveness - The plan must cover all medically necessary hospital and physician services and when the province or territory permits, services rendered by other health care providers.
  • Universality - Every permanent resident of a province or territory is entitled to receive the insured health care services provided by the plan on uniform terms and conditions.
  • Portability - Coverage for insured services must be maintained when an insured person moves within or travel outside Canada.
  • Accessibility - Insured residents must have reasonable access to medically necessary hospital and physician services, regardless of their income, age,health status, gender or geographical location. Additional charges for insured services are not permitted.


Contrast the terms Primary Care and Primary Health Care and give an example of how each relates to Community Health Nursing Practice.

  • Primary Care

- The point of first contact with the health care system, generally referring to preventive, curative, and rehabilitative care provided to individuals

- Medically focused

Eg. Community nurses providing education on how to prevent head injuries by wearing a helmet.

  • Primary health care

- Essential health care based on practical, scientifically sound, and acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination

- Broad

Eg. Community development - CHN is involved in the planned evolution of all aspects of the community's well-being.


Describe the 3 key views of health that were discussed in class and why Community health Nurses need to be aware of these views and sensitive to each.

  • A) Medical Model of health

- Definition of health according to this model is the absence of disease.

- What our current system is largely based on

- Health professionals who adopt this view of health are technical experts and by association, guardians of a “social order” that build capacities to predict and control health.

  • B) Systems view of health

- A competing discourse to the medical model

- A shift in understanding health initial by the world Health Organization (WHO)

- Definition: state of complete physical, mental and social well-being, not merely the absence of disease and infirmity.

- Began in the mid 1970s, with the release of a new report “ A new perspective on the health of Canadians” this report reintroduced lifestyle and environment as a key determinant of health and stated that health is tied to overall conditions of living (Lalonde)

- The argument with this report is that health is not achievable solely as a result of medical care, but rather from the interplay of determinants from four health-field elements: human biology, lifestyle, the environment, and the health care systems

- The vision of health care was advanced from illness care to health care and advanced health promotion as a science due to the Lalonde report.

  • C) Lay Definitions of Health: Giving voice to our Clients p.85

- Orients nurses to views of those in their care

- Perspectives are diverse

Community Health Nurses need to be aware and sensitive to these views because they need to know of which view of health that dominates in their practice environment and to begin practice from the client’s perspective on health, working collaboratively within this view in the interest of the client.


Explain what is meant by the term Population Health and describe the 3 streams of pomoting Population Health and give an example of each.

  • Population health aims to maintain and improve the health status of

(1) the entire population (i.e., community-focused),

(2) a specific target population (i.e., systems-focused),

(3) the individuals (i.e., individual-focused) within the community.

It strives to reduce inequities in health status between population groups by addressing what determines their health. Population Health Promotion - it is an approach blending the principles of health promotion with the populations and the factors that influence the health of populations. This incorporates 3 streams:

1. Downstream - an individual focused orientation to tx and care (surgery, rehab). Health at a primary care level.

2. Midstream - support at the community and organization level for creating envt's conducive to living healthfully (e.g. screening, prenatal classes)

3. Upstream - promote way to reduce/prevent. Putting healthy public policies in place - universal health care. (e.g. law for children wearing helmets, smoking ban).


Compare and contrast the following: demography and epidemiology; incidence and prevalence; morbidity and mortality, and association and causation. List and explain 3 criteria that are needed in order to prove causation.

  • Demography: is the statistical study of all populations.
  • Epidemiology: is defined as “the study of the distribution and determinants of health-related states or events in specified populations, and application of this study to control of health problems” have further identified sub-disciplines of epidemiology.


  • Prevalence: A picture of a specific disease process in a population at one given point in time.
  • Incidence: The identification of new cases of a disease in a population over time.


  • Morbidity: A disease or health challenge.
  • Mortality: Death.


  • Association: Occurs when there is reasonable evidence that a connection exists between a stressor or environmental factor and a disease or health challenge.
  • Causation: (Or causality) is when a relationship or association has been confirmed. Causality occurs when once can state that there is a definite, statistical, cause-and-effect relationship between a particular stimulus and the occurrence of a specific disease or health challenge, or that the occurrence could not happen by chance alone.

3 criteria needed to prove causation:

  • Consistency: everyone who eats food contaminated with a certain bacteria gets sick. If other food at a different time and place is contaminated with the same bacteria, the illness occurs.
  • Strength: persons who are most exposed to the contaminated food (i.e. ate the most) are the most ill.
  • Specificity: The cause is linked to a specific problem: Mycobacterium tuberculosis does not cause chickenpox.


Summarize the Lalonde report and the Epp report and give an example of why they are important on an international level.

Lalonde ( p 24,81,95,324) Epp (p 24, 81-82, 97) <<new text pages

  • Lalonde Report 1974 - report produced in Canada entitled A new perspective on the health of Canadians. It is considered the first report acknowledged by a major industrialized nation to state that health is determined by more than just biological factors.

Identified 4 key components (determinants of health) that needed addressing were:

1) human biology eg (developing a new vaccine)

2) environment eg (clean water)

3) lifestyle eg (smoking, increase exercise)

4) health care organization eg (screening for breast cancer)

Simpler-Rather than pour more money into services for the sick it looked at prevention. Shifting the emphasis from illness care to health care.

  • Importance to International Level – “The Lalonde report was revolutionary in its time, leading a global reconceptualization of health promotion” (p 24) Canada was signatory in the world health organazitions declaration of Alma ata- a report that urged govt to take action to “protect and promote the health”

  • Epp Report 1986 – Built on the Lalonde report by identifying specific challenges to achieving health for all Canadians.

- reducing inequities

- increasing prevention

- enhancing coping

Stating these could be addressed by; - health promotion mechanisms of self care, mutual aid, & healthy environments by such strategies as: public participation, strengthening community health services and coordinating public policy.

Simpler - prevent ,promote ,unify - big on community/public involvement


Describe the 5 key strategies for Health Promotion from the Ottawa charter and give an example of how a Community Health Nurse could employ each.

  • 1.- Strengthen community action :: Health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. Nurses can approach communities are involved in partnership with health practitioners and government authorities in promotion of health. Eg. a morning walking club.

  • 2.- Build healthy public policy :: It puts health on the agenda of policymakers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health. Eg. Nurses can become knowledgeable about global health problems and issues, and connect with other nurses in other countries to promote health throughout the world.

  • 3.- Create supportive environments :: The inextricable links between people and their environment constitutes the basis for a socio-ecological approach to health. The nurse can start a support group among the community and help support the needs of people. Eg. alcoholics anonymous.

  • 4.- Developing personal skills :: Health promotion supports personal and social development through providing information, education for health and enhancing lifeskills. The nurse can educate people in decision making so they can have more control over their own health and environments. Eg. time management, planning, problem solving.

  • 5.- Re-orientating health services :: The responsibility for health promotion in health services is shared among individuals, community groups, health professionals, health service institutions and governments. Eg. Nurse can provide support and education for new mothers.


Discuss what factors led to the development of the Socio‐Environmental approach to health care and what key health determinant, target group, and strategies would be employed using this framework. Discuss also what factors would indicate that this approach is being successful.

  • The Factors that led to the development of Socio - Environmental approach to health came from the social justice movement, the failure of high profile initiatives to create health improvements & epidemiological evidence.
  • The key health determinants are psychosocial and socio-environmental risk factors.
  • The Target group are high risk conditions and environments.
  • The strategies employed in this framework are the Ottawa charter strategies & empowerment with education and solidarity managed by the community.
  • The factors that would indicate that this approach is being successful are improved personal & social health; more equitable distribution of resources; environmental sustainability.


Describe what is meant by the following terms: Community Engagement; Community Governance; Community Development and Capacity Building.

  • Community Engagement: is a process involving citizens at various levels of participation based on interpersonal communication and trust and a common understanding and purpose.
  • Community Governance: is a method of community engagement that ensures effective involvement and empowerment of local community representatives in the planning, direction setting and monitoring of health organizations to meet the health needs and priorities of the populations within local neighborhood communities.
  • Community Development: is the process of involving a community in the identification and reinforcement of those aspects of everyday life, culture and political activity which are conducive to health.
  • Capacity Building: is a process that strengthens the ability of an individual, organization, community, or health system to develop and implement health promotion initiatives and sustain positive health outcomes over time.

In-Class Assignment #2 - Friday, Oct.24th/08

This in-class assignment will cover topics from Classes 4, 5, and 7 – including the related readings from your text, and content from the two guest speakers. The assignment will consist of 4-6 essay questions chosen from a list which may be answered in paragraph or point form. Pen only, no pencils. You will have one hour to do this – in Rm EM15A. The only personal item allowed at your desk is your water bottle.

The assignment will take place AFTER our guest speaker who will be here from 9-10am.

The following questions will help you study and prepare… and some may be included in the assignment.


Identify and describe 5 of the 10 defining attributes of social justice.

  • Ethical practise-Ethic review boards & CNA code of ethics for RN (2002) define ethical practise for nurses.

Advocacy-Active pursuit of support for the rights of a person, including self or a course by means such as policy or system change.

Partnership-sharing of rights, roles, & responsibilites among institutions & individuals in the private, public, government, education, community or the non-governmental organization sectors.

Poverty Reduction-projects programs of an economic political or social nature that reduce poverty, increase the overall standard of living or increase the participation of the poor in socail and political life.

Just institutions-engage in fair instituitional practise as well as the just treatment of all individuals in institutions and institution systems.


Discuss 4 reasons why Feminist Bioethics makes a good framework for community health nursing.






Identify and describe CNA’s five principles of primary health care.

1) Accessibility

· 5 types of health care are universally available to all clients regardless of location

· Communities define and manage health care services

· Clients receive appropriate care from appropriate health care professionals within an appropriate time frame

2) Public participation

· Clients are encouraged to participate in making their own decisions about their health

· Identifying their communities needs

· Considering alternate approaches to those needs

· Health care is flexible and responsive

· Participation ensures effective and strategic planning for and evaluation of community health care services

3) Health promotion

· Health education, nutrition, sanitization, maternal and child health care, immunization, prevention and control of endemic disease

· Goal is to reduce demands for curative and rehabilitative care

· Build understanding of determinants of health, and thereby develop skills and maintain health and well-being

· Schools promote health and self esteem

4) Appropriate technology

· Modes of care are appropriately adapted to the communities social, economic and cultural development

· Improves knowledge and of on-going capacity building to design and deliver health care services

· Alternatives to high cost, high tech services

· Recognizes importance of developing and testing models of health care and relating the results to health care

5) Intersectoral cooperation

· Links health and well being to economic and social policy

· Cooperation is needed to establish goals, public policy and planning and evaluation of health services

· Ensures providers from different disciplines collaborate an function together

· Health care professionals will participate in government policy formulation and evaluation as well as design and delivery of services in congruent fashion


Of the eight elements of primary health care, describe 4 elements and give an example for each of how a PHN might be involved in their implementation.

1) Education concerning prevailing health problems and the methods of prevention and controlling them · Dash diet for hypertension

2) Promotion of food supply and proper nutrition · Referring to dietician

3) An adequate supply of safe water and basic sanitation · Teaching low SES about proper disposal of garbage

4) Maternal and child health care, including family planning · Babies first home visits

5) Immunization against the major infectious diseases · Measles

6) Prevention and control of locally endemic diseases · Education on hand washing

7) Appropriate treatment of common diseases and injuries · Teaching diabetics about proper foot care

8) Provision of essential drugs · Teaching about drug interactions or with herbal medications


Chris Ainley, our guest speaker from the Winnipeg Remand Centre, described many challenges within correctional nursing. Give 3 examples and discuss.

1. Phia is the biggest challenge, with respect to people asking you about certain cases, and guards asking you about the medications a prisoner is taking.

2. Recriutment is difficult-very hard to get nurses to work in a confined setting, and to work with prisoners.

3. Less training for nurses-nurses have to do many different aspects of the job and no training is provided as well the equipment is not up to date.


Discuss why community health nurses should be concerned about family violence, and give two examples of health effects of abuse seen in 3 different vulnerable populations.


No one Answer me :_(


Identify and discuss 5 ways a community health nurse can work to eliminate family violence.

1.Know indicators of emotional abuse & neglect for children, adults, elders-as well as physical abuse present or suspected. 2.Understand importance of asking about abuse 3.Learn how to ask about abuse. 4.Understand individuals risk factors SES 5.Make referrals to support services in their community to assist abused women, children, seniors, and men.


From the class on “Expanding Community Health Nursing Practice”, five types of community health practice were discussed, including guest speaker, Jennifer Joslin’s role at HSC. Choose 3 and briefly describe what they involve.

Forensic Nursing- provide care to victim of crime

                -collect evidence
                -provide health care services within prison system

Work both autonomously & collaborately with police collecting physical evidence.

Faith Community Nursing-is a RN hired/recognized by a faith community to carry out an intentional health promotion ministry.

Disaster Nursing- is a nurse who has a systematic and flexible utilization of knowledge & skills sepcific to disaster related nursing & the promotion of a wide range of activities to minimize the health hazards & life threatening damage caused by disasters in collaboration with other fields.


In the event of a mass casualty incident, what 4 core competencies should a nurse display? Identify 2 phases of the Jennings Disaster nursing Management Model where these competencies might be seen and give one example for each phase.

4 Competencies

1. Critical Thinking – Using approved ethical framework to support decision-making 2. Assessment – Assessing the safety of self, team members and victims before responding to an incident. 3. Technical Skills – Demonstrate safe administration of immunizations, including smallpox vaccine. 4. Communication – Describe local chain of command and mgmt system for emergency response during mass casualty incidences.

2 Phases of Jennings Disaster Mgmt Model

1. Phase II (Disaster Occurs) – A nurse in this phase would practice all 4 competencies (communicating with the local services, assessing the safety of everyone in the situation, including self, quick critical thinking that must be ethically supported, and using technical skills help disaster victims in a holistic way.

2. Phase III (Post – Disaster) – In this phase the nurse continues to assess and practice ethical decision making through tertiary prevention strategies, also, the nurse would continue to assess the safety of everyone involved in the incident and continue communication with the local services and multidisciplinary teams.


Of the many current issues and trends in community health nursing, summarize 3 discussed in your text.

1. An aging society- baby boomers will make geriatric care and health promotion for seniors more of a critical issue

2. Multiculturalism- immigration patterns are changing. Sensitivity to cultural care is a must. Communication challenges are arising.

3. Technological Advances- email, internet, telephone, hand held devices and the electronic world has made comuication in community nursing easier. Northern nursing can now have faster contact with doctors and to electronically send tests and gets results faster.

Special Thanks goes to all who contribute to this and made the life of many of your fellow students a little easier :)


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