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MODULE 6
Roles and Settings
&
Client Advocacy and Consumer Empowerment
By: Dr Peter Tylee
On successful completion of this module you will be able to:
In this module we begin with a brief review of the development of the concept of community health nursing. We noted in an earlier module that it was 1975 when what we now call community health nursing began to take shape in Australia. Here, as in other countries, the nature of the nursing role in the community has evolved in response to various factors, including PHC. Next we note the variety of nursing practice settings, which will demonstrate some of these factors. With this background we briefly discuss the relationship between community health nursing and primary health care.
The advocate role of the nurse is very important and one useful way to enhance consumer empowerment. We examine what is meant by advocacy and note some of the risks associated with its use as an intervention strategy. We conclude with an introduction to the consumer health movement, which should be seen as a powerful ally in primary health care practice.
2.0 Community Health Nursing Role Development
The role development of the community health nurse traces the very definition of this field of practice and highlights some of the tensions between various interpretations and implementations. Indeed there has been considerable debate concerning the definition and focus of community health nursing.
Amongst contemporary authors with whom you are probably already familiar we can see most of the development. Logan and Dawkins (1986) drew heavily on work published in 1976 by Archer. They suggest that community health nurses work in a variety of positions reflecting a focus on one of individual, family or community. Although brief, this is a useful starting point.
Stanhope and Lancaster (1992) acknowledge the debate concerning the definition and focus of this area of nursing practice and clarify their position as follows. They suggest that community health nurses:
| a) work outside of institutions within a specified geographic community or with a certain population group where they: |
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| b) focus on the community as the client, where the health of the total community is the designated caresphere, in which they: |
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The position adopted by Spradley and Allender (1996) has already been introduced. You will recall that three common misunderstandings about the nature of community health nursing practice were specifically rejected, related to location of practice, skills employed and client focus. It is perhaps worth observing that clearly many people have subscribed to these "myths". The existence of these views, being held by so many, has both contributed to the confusion about the nature of community health nursing practice and given rise to the debate which sought to provide clarification and direction.
Spradley and Allender (1996) address the myths, providing a correction for each. They also suggest a range of roles, which we have already seen, as listed below.
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They maintain that these roles are developed in many settings, including the following.
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It seems clear that we may safely conclude the role of the community health nurse is complex. It spans many subroles in the overall role set, relates to several different client levels ranging from individuals to whole populations and is practiced in a wide variety of settings where a wide range of skills are employed. Naturally, being nursing, it spans cultures and developmental ranges, is process orientated, targets interventions ranging from primary to tertiary levels, and is fundamentally ethical and caring.
This is a far cry from the impoverished view as espoused in the so called "myths". The main problem faced by many people however, is trying to understand just how in practice one can deal with individuals yet "maintain a community focus". Consider the following illustration which makes this easier to visualise.
| A generalist community nurse who worked in a large rural town in
western NSW was refered to a family reported to be in distress. The police had been
contacted by the parents to report that their 15 year old daughter was missing. This was
completely out of character for the girl, who was described as a fairly quiet, responsible
teenager, who fitted comfortably into this conservative, church-going family comprising
two parents and three children, a boy aged 10 and two girls aged 13 and 15 years. The
police had been concerned at the high state of distress and suggested the family contact
their local doctor, who in turn had contacted the community nurse. The nurse visited the
client family, made a brief assessment, provided supportive counselling and arranged to
return the next day. At this acute stage the nurse could only respond with supportive
interventions while waiting to see what direction would become appropriate as the
situation unfolded. As it happened, the outcome was an unusually happy one in these circumstances, as the daughter had gone to the home of a relative in a nearby town and was returned home the following day. On visiting the family later that day the nurse found them very relieved and somewhat embarrased at "causing so much fuss". The nurse asked to speak to the girl and learned that the girl had left home because she believed she had become pregnant and felt too ashamed to tell her parents. This presented another client situation and the nurse spent some time with the girl assessing the situation to enable an appropriate intervention. The nurse now had both a client family and an individual client who happened to be a member of that family. Though their needs were related, they required and were entitled to specific attention which could sensitively address both common and individual needs. The nurse noted that the family had arranged for the girl to see their local doctor and made a follow-up appointment with the girl for one week later. At this meeting, in the course of discussion, the girl happened to remark that she was not alone in being ignorant about "sex and getting pregnant" as none of her "friends or the other girls at school know anything either". These statements might simply have been interpreted as a somewhat ego-defensive thing to say, an expression of a desire to seek comfort from the thought that she was not alone. This would be a quite reasonable and probably correct conclusion for anyone who had an individual orientation. This is precisely where we can see the operation of maintaining a community focus, even when dealing with individuals. Instead of simply viewing this statement as understandably defensive, indicating a measure of personal discomfort, and revealing a personal knowledge deficit, all of which might be correct, it was taken as an indicator of a community of common interest with a presenting need. That is, this girl was considered as possibly representative of a larger group of similar members who might be similarly at risk. Accordingly, the nurse made enquiries at the two local high schools and discovered that neither had programs to address sex education and that their personal development curriculum was also lacking in relevant areas. With some skilful negotiation the nurse was able to persuade the schools' principals to allow a targeted intervention provided by the nurse in the short term and for curriculum revision for the intermediate and longer terms. |
This community orientation, even when working with an individual client, enabled an intervention aimed at prevention of the problem encountered. A community was identified based on a casual remark. Without a community focus it is most unlikely that this would have occurred. It is worth noting that at no time did this community orientation impair the nurse's ability to function effectively with clients at the family or individual levels.
3.0 Community Health Nursing Practice Settings
We have already acknowledged that the very nature of community health nursing involves practice in a diverse range of settings, some of which were listed above. The following is a list of major practice areas in Australia as identified by Rice (1985).
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This is somewhat more extensive than the list provided by Spradley and Allender (1996) but it is similar. In view of the roles discussed above however, it seems fitting to critique this list. One might ask: are all nurses who work in these settings actually community nurses? That is, do they actually maintain a community focus? Or do they, as one "myth" suggests, merely work outside of institutions, in the community?
By virtue of the nature of the associated settings, remote area nursing and generalist community nursing both provide a very broad scope for practice. It is not difficult to understand that practitioners in these settings are able to identify a whole geographic community and various communities of common interest within it, any and all of which may become client communities. Nurses in occupational health services may practice on one or many sites while generally operating within the narrower confines of an industrial concern. They may be understood to practice with a specific community of employees (or possibly employees and their families) and may also identify communities of common interest, such as sedentry employees or outdoor workers for example. A similar view might be taken of those who work in some other settings, such as mental health and even family planning, although this latter example stretches the model.
Experience in the field may lead one to question domiciliary, district and some community nurse settings as being areas where a community focus is maintained. As strange as it may seem, some nurses work under the title of community nurse, but may not meet the criteria outlined above. Very often, practice in these settings is exclusively individual centred. There may on occasion be interaction with family members but still no recourse to special family practice skills. One may then question whether practice in these settings is really community nursing, or simply nursing in the community. It should be easy to see why there has been confusion and debate concerning just what community nursing practice actually is.
4.0 Community Health Nursing and PHC
Activity 6.4.1
| Make a
note to read the following document on Closed Reserve. Goeppinger, J. 1984, Primary health care: An answer to the dilemmas of community nursing?, Public Health Nursing, September, 1, 3, 129-140. |
Goeppinger (1984) addresses some penetrating questions about community health nursing, including what are appropriate or legitimate:
The conclusion is that PHC does indeed offer answers to these difining questions. To quote Goeppinger (1984 137):
In summary, primary health care appears to offer solutions to all
four issues faced by community-oriented nurses.
These answers suggest that community nursing encompasses a variety of goals, reflects a philosophical orientation to the collective and a practice orientation to the many levels - individuals, groups, and communities - comprising the collective, and recognizes the community as the usual locus of care. [Layout and emphasis mine.] |
It is interesting to observe the references to "community oriented practice" and "perceived community needs". There is no doubt that the perception referred to here is that of the professional nurse. This raises the issue of the distinction between community oriented practice and community based practice. As the Christian Medical Commission (1988) made clear, there is a world of difference. Community oriented is largely a reflection of the professional model while community based is closer to the community development model.
One may have little doubt that community based practice is ultimately more powerful in effecting change which is empowering of communities and their members, but there appears to be no research on this issue. Goeppinger (1984 138) raises the matter of empowerment in the following discussion of unresolved issues:
| The remaining issues relate primarily to implementation. One, many
individuals do not choose to participate actively in health care matters. This remains
true even though nurses have long noted the benefits of patient participation, self-care
has enjoyed a renewed interest, and advocates of primary health care have adopted
participation and even partnership as basic tenets. Parker, Walsh, and Coon (1976, p. 428)
for example, found that 92 percent of the public health social workers and nurses ranked
"patient as partner" of high value, while only 33 percent of consumers did so.
Additionally, 83 percent of the public health workers ranked "assists individuals and
families in assuming responsibility for their own well-being" high; only 39 percent
of consumers did so. These findings may be astonishing; they should not be. Is it not possible, as Illich (1976) and others have noted, that health professionals have stripped patients and consumers of their capabilities to be responsible for themselves? If so, can we redress the balance? |
Can we indeed? Do give this matter some serious thought. Perhaps now would be a good time to consider client advocacy and consumer empowerment.
5.1 What is Advocacy/Client Advocacy?
Activity 6.5.1
| Enter your own answer to this question:
what is advocacy? |
It can also be suggested that it is:
5.2 Why Consider Advocacy?
There are three main reasons why it is appropriate to consider advocacy. They are:
5.3 The Main Goals of Advocacy
There are two main goals of advocacy, namely:
It is important to understand that these goals are tightly bound to one another. The phrase health care system is used in the first goal in its broadest possible sense and does not refer to merely the public system or the hospital system, or the medical system. Without an understanding of and commitment to the second goal, clients would be at risk of developing dependency, on either the system or the advocate. Dependency is never desirable and advocates need to keep the goal of client independence firmly in mind.
5.4 Characteristics of Advocates
These have been summarised by Donahue (1978) as follows.
5.5 Advocates Beware
There are several risks associated with the advocate role. Considering them from the outset may help to avoid causing problems for the client, the system and the advocate. Four major issues are briefly considered here.
5.5.1 Avoid paternalism, ie "knowing what's best" for the client (at any level, individual to community). Be especially careful if the client shows any tendency towards dependency.
5.5.2 Avoid being a "rescuer". Some members of the caring professions who lack adequate self-knowledge and/or practice skills have a tendency to want to "fix things". When they identify what either they or a client sees as a problem, they believe they can "sort things out". Frequently this is also quite paternalistic. It may be that the intervention targeted at the problem does indeed solve it. The trouble is that rescuing doesn't empower the client, who often remains passive. This means that should the problem recur, or a very similar one perhaps, the client will tend to respond in one of two ways. The first possibility is that the client will simply seek another "fix" from the professional, thereby developing a dependency relationship, instead of taking a more active role in solving the problem themselves (they have already learned little from the first episode and have failed to prevent or avoid the recurrence). The second possibility, frequently observed, is that the client will blame their new problem on the rescuer (who often reacts incompetently as an "injured innocent"). One may hear statements such as: "I thought you said this was all fixed now!", "Is this what you call fixed?" or, perhaps with more anger than sarcasm and showing great insight, "Bloody lot of good you were!".
5.5.3 It is also important to consider the effect on the system of an informed, assertive client. One needs to be cautious to avoid setting up either the client or oneself (as the advocate) to be viewed as a troublemaker.
5.5.4 One should also consider one's legal and ethical responsibilities. It is not acceptable to address a perceived wrong with another wrong. Nor can one break the law in the name of doing good (unless you are Robin Hood perhaps, but don't quote me Robin). It can be tempting to do these things and one does encounter them from time to time. Informing someone that they have a right to a second opinion or even recommending that they seek one is quite acceptable. Telling that person that the doctor or service in question has a poor track record with their type of problem however, is not acceptable. Such behaviour may result in adverse consequences for the advocate and may diminish the effectiveness of the advocacy, even though the opposite may have been intended.
5.6 Common Barriers to Advocacy
Advocacy can fail for many reasons. The following four barriers to effective advocacy can be significant obstacles, but it is hoped that awareness of them will be an effective means of avoiding them.
| 1. Role ambiguity. | This is typically seen in the situation where there is uncertainty as to who has "responsibility for the client", ie there is some confusion of jurisdiction. In the end, no one takes up the advocacy role, possibly believing that someone else will or perhaps should. |
| 2. Territorialism. | This is similar to the above but here everyone want to help. One may find this situation within community teams or between community based and hospital based professionals. |
| 3. Adversary relationships. | These are unhelpful. They may develop between any of the stakeholders, such as the client, the advocate, the health care system and individual professionals or their associations. |
| 4. Conflicts of interest. | These are powerful barriers and are sometimes virtually unconscious. They typically arise for nurses because they are not independent practitioners but are employees of an agency. There can be a tendency to defend the agency rather than to advocate for the client. |
6.1 Who or What is a Health Consumer?
Quite simply:
6.2 The Consumer Health Movement
The consumer health movement may be encountered in various forms. The following observations can generally be made.
6.3 Consumer Empowerment then...
In conclusion, consider the next activity.
Activity 6.6.1
| As you make various visits to health agencies in the community, for this subject or for any reason, look for brochures which describe various health consumer groups. You might also find one describing the Consumer Health Council, a national peak body with considerable lobbying power. Read carefully all that you find and remember what is offered for future reference in your career. |
To complete this module, write a response to the following.
| Goeppinger (1984) stated a
concern that PHC may itself become so istitutionalised that it would simply become the
next force that dominates society, much as the medical model has and does. Think carefully
about the principles of PHC and the material covered in this module and outline the
features of an approach which would make such an outcome less likely. Note: If your browser doesn't scroll the text in the form below, please press enter at the edge of each input line. (I don't want your work to be lost.) |
Use this link if you want to send e-mail to the Subject Coordinator. (removed)
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