Primary Health Care: Module 5

One of the challenges faced by those implementing PHC, who share the responsibility of reorientating the health care system and providing preservice education in various health care disciplines, is that it is impossible to start with a blank slate. The system has a pre-existent state. Students come with preconceived images and ideals. A second challenge perhaps, is that there is always resistance to change. As you cover the material in this module you are invited to reflect on the extent to which this is true of the health system and of yourself. Ultimately, the responsibility for implementing PHC rests with each one of us, it has both a corporate and a personal dimension.

In this module we shall continue our emphases on both the community and practice as we extend our exploration of primary health care. We will note the wide variety of intervention possibilities, many of which will likely seem quite familiar to you, since you will have encountered them as a community member or health service consumer. The material presents an orthodox view of nursing practice but should not be construed as describing any bounds or providing constraints to PHC. Indeed, you will certainly have an opportunity to explore much wider intervention possibilities in your own practice within this subject.

We shall briefly discuss five major elements of PHC nursing practice. There is nothing special or unique about this classification of the 'elements'. It is simply one convenient and reasonably common way to set out the description.

The terms 'encouragement' and 'enhancement' are most apt because they do not imply that the nurse alone takes on responsibility for the outcomes. They are suggestive of the most important partnership between nurse and client (of any level) introduced in module four. It is also important to note that the concern is with healthful 'living'. This implies that our practice must be able to reach the cognitive (thinking), affective (feeling/valuing) and psychomotor (behaving/action) domains of the client. Unless all three domains are involved it is unlikely that positive change will be lasting, if achieved at all.

This encouragement and enhancement can be addressed in terms of the '3 P s' as follows.

2.1.2 Protection measures which aim to raise community standards for health.

2.1.3 Promotion programs which aim to develop more positive health practices.

In a sense this may be thought of as the remedial aspect of practice. It may appear as though it embodies a sense of failure, but the reality is that one cannot move into any community without finding some morbidity. It is appropriate therefore that we engage in various interventions aimed at remediating this situation as much as possible. The interventions are at the secondary intervention level and may be:

a) direct and individualised
eg. home care for a client recovering from a work injury

b) programmatic and targeted at identified conditions
eg. chemical dependency counselling service

When the morbidity within a community is entrenched or unavoidable it is appropriate to engage in tertiary intervention. Whilst not ignoring the home or work based individual rehabilitation role, the focus is mainly on families, groups and communities. Examples would include:

By now you will have grasped the importance of evaluation and hopefully are not surprised to find it mentioned again. Evaluation may be performed at two levels. These are:

This is an essential activity. It is aimed at solving problems and improving methods as well as determining the impact on health of social and physical environmental conditions and changes.

At this stage it may be helpful to make a few observations about the nature of community oriented PHC nursing practice. These can readily be derived by a thoughtful approach to the material covered so far but it is generally best to make these points explicitly. We are aided by the Australian Council of Community Nursing Services (ACCNS) who articulated the essence of the following (ACCNS 1989).

The focus of practice is on the needs of populations (or subpopulations or communities if you prefer) as well as on those of groups, families and individuals. This wider client perspective makes it essential to apply principles from epidemiology, sociology and demography as well as the usual physical, biological and clinical sciences.

It is important to remember that each community is unique. This places demands upon practitioners to be creative, adaptable and responsive to a variety of norms, cultures and value systems.

Practice settings themselves are diverse and service networks are quite complex. Practitioners must therefore have a variety of proven interpersonal skills to enable effective interaction at multiple levels.

As primary health care workers, nurses are involved in continuous monitoring and episodic responses. The activity is continuous but the focus changes regularly.

It is also important to recognise that access to peer support is often limited. Practitioners must be self-directed, able to exercise a high level of autonomous professional judgement and, very importantly, know where, when and how their own personal support needs may be met. It is vital that the practitioner is preserved and not 'burnt out' in the process of providing care for clients.

Adjusting one's outlook from individuals and institutional settings to accommodate PHC practice in community settings is not simple. It requires what could be likened to a paradigmatic change and many people have reported an experience something like the gestalt shift. It may be worthwhile demonstrating this. Precondition yourself by thinking of an old woman. Try to get a close-up image in your mind of an old woman and then click here.

Hopefully you will experience the necessary shift in perception to fully appreciate community oriented practice and will capture the vision of primary health care! It must be acknowledged that one thing that can make this harder than necessary is subscribing for one reason or another to one or more misunderstandings of the nature of community practice. Spradley and Allender (1996, 190-191) refer to three classic misunderstandings, so common that we might refer to them as the main "mythunderstandings" of community practice (if you'll pardon the pun). They are:

Just as it is possible due to previous learning (or cueing) to tend to interpret what you think you see in a particular and sometimes rigid way, such as when you could see only the old woman or perhaps only the young woman, it is possible to change, such as I hope you did in the gestalt demonstration. No doubt you will encounter people who subscribe to one or more of the above myths. Perhaps you will be able to paint a picture of the reality of community oriented practice for them and help them to see it.

Several key roles can be identified in the material presented to date. You should have no difficulty in recognising them as:

1. State five (5) features of the nature of community oriented PHC nursing practice
outlined by the ACCNS in 3.0 above:

2. Match the following intervention approaches with the listed interventions by entering
the appropriate letter:

A) Prevention

B) Protection

C) Promotion

Interventions	Your Response	The Answer
Lobbying for dual carriageway highway construction.
Education on pregnancy risks associated with alcohol and tobacco.
Scoliosis screening of junior high school students.
Programs to encourage use of home smoke alarms.
Education on child safety in the home.
Establishing 'proof of age' systems for alcohol and tobacco outlets.
BSL screening in shopping centres.
Encouraging compliance with approved building codes.

To view the answers click here:

If you encountered difficulty with this question, return to the applicable section in the module by clicking here.

3) Identify which of the following classic forms of misunderstanding is illustrated below:

The way to reduce hospital costs is to have patients spend less time in hospital, after all, we can have nurses and other health professionals treat them in their homes. Surely that's what community nursing is all about.

Objectives