Community nursing: roles, practice, and patient outcomes

Community Nursing

Generally, in any Hospital or Health Care Center, the patient would be looked after and taken care of by the Primary Care team, comprised of General Practitioners, Health Visitors, Practice Nurses, Physiotherapists, Podiatrists, Dieticians, and a team of Nurses, of which District Nurses or Community Nurses play a major part. Community Nurses or District Nurses usually work in a partnership with Acute Trusts, Hospices, as well as with Social Services, in order to provide a complete package of Health Care for those patients who would want to or prefer to stay at home and avail of these services. The so-called 'Joint Futures Agenda' is responsible for promoting a sort of collaborative working within the health care sector and thereby dramatically improve the service so that there may be a more holistic type of care given to the patients of today. Community Nurses provide highly skilled health care for those patients who would stay at home and be cared for, and they also offer firm and good advice on a wide range of issues, and also critical support wherever and whenever needed. (Community Nursing: Glasgow Palliative Care Information Network)

Some of the chronic illnesses that the Community Nurses are trained to handle are: heart disease and failure, multiple sclerosis, mental illness, or dementia, chronic obstructive pulmonary disease, post hospital care after any type of surgery, care of the elderly, and palliative care. When a patient feels that he needs to be looked after by a District or a Community Nurses, then he must get in touch with the District Nurse Team, who is headed by a senior District Nurse, who would send a District Nurse to visit the patient and assess the type of care that he actually needs. After the initial assessment, the patient would be given a care plan, along with the contact numbers and other details that the patient or his family members may need. When a patient needs the services of the Community Nurse, all he has to do is to contact his own GP or call his local Clinic or the Local Health Center. (Community Nursing: Glasgow Palliative Care Information Network)

It is a fact that over the past thirty years or so, palliative care services or the home care of patients through the system of Community Nurses has been developing all over the world. Today, not only is the patient more aware of health care issues, but he also knows the type of care that he can avail of, and he is also knowledgeable about the various types of health care services that are available to a patient suffering from any type of disease, and the concept of Community Nursing is a choice that he may be able to make after a thorough research and investigation into it. Community expectations of the patient, especially in relation to palliative care has been growing steadily, over the past thirty years, and as the evolution of he issue of palliative care has been taking place, so has the evolution of the very definition of palliative care by the World Health Organization. These changes have been proving to be a challenge to the planners and the funders of the providers of palliative care, and it is noticed that many services have not been able to attract the proper and the adequate amount of nursing and the various other related services like medical and health resources in order to provide the proper amount of inter-disciplinary palliative health care for any patient. (A planning guide: developing a consensus document for palliative care service provision)

This has led to the development of a 'Planning Guide' or what is otherwise a virtual national consensus that outlines the minimum needs for the provision of services to a patient needing it, and this would be independent of the various fund holders and the various models of service delivery. The Plan or the Guide that was released by the PCA or the 'Palliative Care, Australia' has created a blueprint of the various services that a patient would need and it can be used as a 'service planner' for the next few decades by any team of health care professionals who desire to provide such services to the needy patient. The aim of the Guide is to make sure that a network of health care professionals who are all well versed and experienced in providing acute care and other services to the needy are available to the patients when they actually need them. In this context, palliative care does not merely mean the treatment of those patients who are suffering form cancer, but it also includes the sufferers of various other diseases who may need interdisciplinary and acute care from the physicians and Community Nurses attending to them. (A planning guide: developing a consensus document for palliative care service provision)

Nursing, and especially Community Nursing, is one of the fastest growing fields of opportunities for the Nurses who give health care of any type for the patient. In fact, the Bureau of Labor Statistics, 2001, states that nursing as a profession, is one of the fastest growing in the United States of America. The number of positions that are available to nurses are growing everyday, and the growth has in fact remained steady over the past few decades, and it has been predicted that at the end of the year 2008, there would be about 2.5 million nursing positions available in the United States of America alone, while at the same time, more than half of the registered nurses of today would retire in the next fifteen years. If the situation were ideal, then the number of nurses entering the profession would be the same as the number of nurses who are leaving the position, but it is not the case today. The number of registrations of nurses has been steadily declining over the past few years, and what is even more alarming is the fact that today, there is a vital need for more and more nurses in the profession. This is because of the fact that in addition to the traditional nurses, there is an additional requirement of nurses in several new positions, like for example, in the field of home care, long-term health care, as well as palliative care, and ambulatory care. (Window of Opportunity for Home Care Nurses: Tele-health Technologies)

The situation today is that, since there is a paucity of the number of nurses, and then technology would have to intervene and make up for the lack of numbers of nurses. When the fact that American society is elderly or ageing, and the number of elderly, who have grown in the number of the population almost twice as rapidly as the younger population, who need long-term health care or palliative care, and so on has also increased simultaneously, most of the nurses of today would be required to perform and meet efficiently the health care needs of the ageing or the elderly population of America. It is also a fact that technology would help these nurses meet and perform their duties with relative ease. Patient care decisions, the various decision support systems, the management protocols that are assisted in their maintenance by the computerized technology that is available today are all part of the facilities that are provided by the improvement in technology for Nurses. (Window of Opportunity for Home Care Nurses: Tele-health Technologies)

The population in the United States of America has been growing by leaps and bounds over the past few decades, and the health problems that are associated with such increases of population have been a cause for great concern for the Health Care Authorities of the country. For example, there are more than 22,000 per square mile in NYC alone, and strict measures must be taken immediately and urgently in order to counteract the effects of such huge numbers of people on the environment and on the health of the people living in such over crowded areas. The several types of health problems that generally arise from a density of population are asthma, PCBs, and lead poisoning. Illegal dumping forms a major problem and this causes quite a few respiratory problems and infections. For example, in Staten Island, America, there was quite a great fuss about the Fresh Kills Landfills, across the harbor. However, in Staten Island itself, there is no dearth of dumpers of trash and rubbish all over the place. Council Member James Oddo states that people do dump trash on the sidewalk; people do drop a cigarette butt wherever and whenever they want to, completely without thinking about the long-term consequences of such actions.

The population on Staten Island, according to the U.S. Census, has grown from a mere 380,000 residents in the year 1990, to a 445,000 in the year 2000, thus demonstrating a stupendous 17 percentage of growth rate of population, a figure that was not seen in any other borough in the city, or in any other county in any other state. Though Staten Island is larger than most of the other states of America the response and the measures taken to combat the trash and dumping problem in the state are that of a smaller town in nature. The Staten Island Advance, the sole newspaper that is printed in the state, conducts, every summer, a camp wherein 'trashbusters', a voluntary group of concerned citizens are engaged in picking up or gathering trash and dumping it in its proper place. At the same time, the citizens of Staten Island do exhibit a Puritanical streak; whereby politicians and small property holders are actually shamed into being responsible for keeping the area clean, under a publication entitled 'Staten Island Source' that is distributed free of cost to ferry workers. The photographs and pictures of some of the dirtiest sidewalks and properties on the Staten Island are published within its pages, and the idea is to make the owners so very ashamed that they would take immediate action to clear the trash. (Littering on Staten Island)

However, it rarely, if ever, works in such a simple manner. The Borough President, James Molinaro, joined in this campaign, and enlisted a 'Dirty Dozen' of the places that had to be cleaned for the sake of the health and welfare of the citizens of the place. A street sweeper was purchased, some inmates from the 'Arthur Kill Correctional Facility' were engaged, and the dirtiest sites were cleaned up successfully. However, the Borough President also stated that it would be almost impossible to maintain the same steady pace of clean up operations throughout the year, and therefore, a 'business improvement district', which is a year round cleaning and remedy plan, was suggested for the residents of the Staten Island, but the fact was that Staten Island was too slow to catch on, and still remains as 'dirty' as ever, with no full time plan to maintain a clean city. The Executive Director of the West Brighton Local development Corporation, Susan Meeker, hopes to take up the project and make it work for the residents of the area, so that any health problems that may result as a consequence of the illegal dumping of the trash and rubbish on the sidewalks and other areas may be effectively prevented.

As far as Fresh Kills is concerned, the 3000 acres of area of land used to serve as the dumping ground of all the New York City's wastes until it happened to be phased over in the year 2000. 2000 new trees were planted over the trash yard, and within a year 1000 new saplings had grown. After the debacle of the terrorist attacks on the World Trade Center in 2001, the Fresh Kills was used as a dumping ground, and fresh trash was accumulated. Huge sums of money are now needed if the land were to be reclaimed and re-established, as a cultivable area and not just left to be a dump yard. Were a wooded environment to be created out of the salty and marshy area that is the land of Fresh Kills, it could be very well made into a virtual oasis for a large variety of birds and animals and varieties of insects. (Urban Restoration Ecology: the Fresh Kills Experiment)

The traffic on Staten Island has many weaknesses and not much strength. The faults or weaknesses are: Staten Island do not have the facility of subway links to the various other parts of New York City from that area, and in addition, there is no real rail service outside of SIRT, and there is also no transit to New Jersey. The road system in Staten Island is most of the time quite circuitous, and inexplicably over taxed and strained in some other areas and this is most inadequate to meet the future requirements of the area in terms of growing traffic and the growing population. The roads and all the bridges are permanently congested, and, quite naturally, the average commuting time, whether the passenger is commuting by car or bus or taxi or any other means at all, is one of the longest in the entire nation, and in the entire region, and of course, in the City. Staten Island has been given no importance in the latest ferry system that serves to connect the entire city of New York and its harbor, and this means that there is no ferry service to the Island too. However, the transport system of Staten Island does show some strengths, though very few. These are: an extensive and efficient bus transit system, a '24-7' ferry system that goes in and out of Manhattan, and a rail system that serves one part of the Island, and a system of bridge links, three in all, connecting Staten Island to New Jersey and to Brooklyn. (Present Problems and Future Solutions for Staten Island's Transportation System)

For the people who live along the different garbage city truck corridors, where garbage trucks travel all through the night and the early morning, adding to the congestion and the traffic snarls along the routes that the garbage trucks now take to dump the garbage, after the order was issued to close the Fresh Kill down and fill it with cultivable land, the floors and the windows and the doors of their homes vibrate through the night because of the traveling of the trucks in the night. The smell of garbage fills the area and chokes the breath of many a resident, and there is severe air pollution all along the route, not only because of the smell of the garbage, but also because of the truck exhaust. The figures show that air pollution has gone up to 16% because of this latest phenomenon of traveling garbage trucks. In fact, the New York State Attorney's Office is suing the city for not considering the implications of transporting the garbage form Staten Island to other areas properly before implementing the plan of transporting garbage from one place to another through trucks. A concerned citizen in SoHo stated that the closure of garbage dumps in Fresh Kills may be an environmental disaster, and the cast iron buildings in SoHo that are built close together cause an effect of reverberation, and this is acutely disturbing to the already disturbed residents of the area, and if immediate action were not taken to stop the noisy trucks from traveling through the streets at all times, the n the residents would definitely be faced with severe health problems, he said. Asthma attacks and severe respiratory problems will soon be the norm rather than the exception, and where will it end, asked other citizens. (Efforts to Close a Landfill Are Taking Unforseen Tolls)

The residents of the areas near Fresh Kill landfills and of Staten Island are at present suffering from several severe respiratory problems. The 'Agency for Toxic Substances and Disease Registry' or the ATSDR, uses a certain conservative approach in order to determine whether the levels of environmental contamination generally do include an indication of the past and the present and the future health hazard of the citizens of a particular area in question. The ATSDR method uses an established methodology for the determination of whether or not the person who has been exposed to the contamination in the area of Fresh Kills is at risk to his health, and the methods in which such exposure may take place. When evaluating a particular site, what the ATSDR does is to, at the outset, determine if the said exposure to chemicals and pollutants is at all possible from the said site or area. If the ATSDR is able to identify potential pathways and/or completed exposure pathways, then it will go on to the next step, which is to determine whether there is any type of chemical present in the body that may prove to be harmful to the human body. This is done by the process of screening the concentrations of the contaminants that were detected in the analyses against the 'Health-Based Comparison Values', or what is also known as the CV's. Extremely conservative assumptions are made through this method, and they have large safety limits built into them to be mindful of the health of the human body. (Petitioned Public Health Assessment)

Therefore, it is obvious that concentrations at or below that of the CVs may be considered safe, but at the same time, these levels of concentration need not necessarily mean that a concentration that may exceed a CV may be responsible for producing adverse health effects in the community that is being analyzed. In Staten Island, the residents felt that the air quality in their neighborhood was neither safe nor was it fresh and clean, because of the rubbish dumping grounds at Fresh Kills just adjacent to it. ATSDR happened to review, intensively, the reports and all the data that had anything to do with the chemicals that were being released by the garbage at Fresh Kills lands, and the various chemicals that were found in the very air that the residents of the areas were being forced to breathe. The reports showed that Fresh Kills was indeed releasing toxic chemical substances, about 100 organic chemicals, into the air, and in addition, some operators at the landfills found that they were being exposed to the dust in that area that was prone to contain certain groups of toxic metals, and these would release organic chemicals, metals and certain other pollutants into the air for a great many years into the future too.

However, since the dumping at these grounds has now ceased, the chemicals would be a lesser amount, and now that the technique of emission control technology is available, when they are installed, they would be able to control emissions to a large extent. How do the chemicals actually enter the air? They enter through a process of evaporation, mainly through the solid wastes that are brought in form other areas, and the chemicals that are released into the air from these solid wastes are extremely harmful to the health. In addition, metals can also enter the air through the particulate matter that is released into the air in the form of dust, and when a study was conducted in 1995 as to assess how much of the air was being polluted by these metals, it was discovered that the highest emission rates of toxins was found at the Fresh Kill landfill area. The winds that blow in the area also carry these harmful chemicals and pollutants to its neighboring areas, and the result is that the people there too are exposed to these chemicals. (Petitioned Public Health Assessment)