Question

How is ethics part of the core functions of community health nursing?

How does the Nursing Code of Ethics influence the practice of the community health nurse?

What are the responsibilities or legal duties of community/public health nurses?

What are some tools (strategies) that help community health nurses practice ethically?

Answer 1

******** How is ethics part of the core functions of community health nursing?

The four core functions of community health nursing practice are:

(1) community social capital, including community culture, and
identification of resources as key actors in the community health-
care system
(2) assessment of community health conditions, health risks and
problems to identify the health-care demands of the people
(3) design and implementation of comprehensive community health
interventions, care, services and programmes, and
(4) health policies/agreements developed at the local community
level to drive policies/agreements at the state and national levels
for collaborative endeavours and actions.

(1) Community social capital and resource identification
The methods used for identification of community social capital and resources include human mapping, resource mapping, rapid ethnographic community assessment, etc. Human mapping relies on qualitative research methods such as in-depth interviews, observations and deep listening. This process, employed for community social capital and resource identification, leads to other functions and usually ends at the design and implementation of comprehensive community health interventions, services, care and programmes that are mostly focused on capacity building of the key actors, whether or not policies are developed and formulated.

(2) Assessment of community health conditions, health risks and
problems:
The health-care demands of the people are identified by critically
analyzing information related to health conditions, risks and problems
of people in the community. To do this, at least four major factors
that contribute to health are used: (1) health problems and risks,

(2) lifestyle in terms of health behaviour and care,

(3) environment, such as health threats, and

(4) available and accessible health services
and care.

The regular collection, analysis and sharing of information employs

methods that reveal current community health conditions, risks and
problems in the cultural context. Examples of such methods are:
community health nursing assessment process, participatory rural
appraisal (PRA), participatory action research (PAR), epidemiological
study, qualitative research, ethnographic study, etc.

(3) Comprehensive community health interventions, care, services,
and programme design and implementation
This function targets the design and implementation of interventions,
care, services and programmes that respond to the health-care
demands of the people in the community in a culturally sensitive
manner. This function ensures that necessary health care and
services are available and accessible to all, especially underserved
and vulnerable groups. It should
– be participatory in nature, especially with stakeholders who
are involved in the provision of interventions, care, services
and programmes;
– represent the interactive learning through action process of
stakeholders in designing and implementing the interventions,
care, services and programmes;
– require two essential sets of knowledge

: (1) the health-care
demands evidently supported by four contributory factors; and

(2) solutions which may be practice guidelines, care models,
practice modalities, services reform, effective programmes
and interventions, etc. from the literature, best practice
experiences, and research and development projects;
– critically select interventions, care, services and programmes
through consensus building of stakeholders to fit well with their
roles and missions for community health care;
– be oriented towards the health outcomes of the entire
community rather than service oriented.
Examples of ways of designing and implementing community
health interventions, care, services and programmes are care and
service model development, regular design and implementation of
intervention, care, services and programmes, health-care initiatives,
etc.
(4) Development of health policies/agreements
This function relies on critical analysis of the information and
evidence gathered during the community health assessment.
Development of local health policies or agreements requires at least
three essentials.

These are: (1) shared understanding of the nature of
apparent health-care demands of the people,

(2) identifying social capital and resources for possible solutions to meet the demands in health care, and

(3) knowledge about the roles and functions of
each stakeholder to fulfill the missions and scope of work.
Methods to carry out this function mostly use platforms to encourage
conversation and communication among stakeholders. These
include forums, conferences, seminars, and the like. Indicators of
success are workable agreements or policies on community health
care, especially at the local level.
The following are key to the development of workable agreements
and policies.(1) Sufficient information, especially on health-care
demands, possible solutions, and required supports/mechanisms
to implement solutions; (2) a cycle of interactive learning through
actions to help verify the potential agreements/policies; (3) accepted
platforms of communication among members of the working team;
and (4) opportunities for stakeholders to present information and
evidence relevant to the development of particular agreements or
policies.

*********How does the Nursing Code of Ethics influence the practice of the community health nurse?

Beneficence:
A fundamental principle of beneficence in traditional health care settings is to “maximize benefit and minimize harm to patients”  This implies that it is the health care professional who is best able to identify potential harm and benefit. However, from a caring and ethical point of view, nurses understand the difference between acts of paternalistic
beneficence and the essential knowledge that patients are part of any decision. In nursing ethics beneficence is a moral obligation seen as worthy and noble. And, nurses need to go further and
understand that acts of beneficence may not always be in the patient’s best interest Throughout clinical decision-making situations, novice and expert nurses have an obligation to remain mindful of the patient’s right to autonomy, even if the nurse considers their
nursing care as beneficial to patient outcomes .However,
when nurses are required to make decisions that by necessity negate patient choices, these decisions should be considered as beneficence . Nurses must not only treat persons autonomously and refrain from causing harm, but they should also be aware of the overall
welfare of individuals and communities. Public health programs related to childhood immunizations and vaccinations demonstrate
beneficence on a community level. These programs weigh the harm and benefit of immunizations and vaccinations and recognize that harm may be done to few but the majority of the people will benefit . With an individual and community framework, the obligation of nursing grounded in ethics and caring realizes the effect of current situations to guide inform future acts of beneficence.

Autonomy:
Traditionally, autonomy in Western culture is a moral principle and the foundation of many social and political systems. Autonomy recognizes the right of individuals, and to a lesser extent, communities to choose without undue external pressure. Autonomy also recognizes the
responsibility of the autonomous individual to not harm another
Nursing ethics and morals compel nursing to treat patients in ways that will contribute to their welfare as autonomous individuals. The complexity arises when the concept of being truly autonomous is an unrealistic ideal. Individuals and communities are in relationships and therefore are influenced by people and events. In healthcare settings, decisions need to be made in relationship to the patient and their families and, at times, their communities. Autonomy, does not require participation. The right to autonomy provides the choice of participation. With this value, patients become partners or directors of care. Paley defined autonomy as self-determination for those involved in the situation. An authentic respect for the innate differences between other persons and groups and
can be demonstrated by active listening, recognizing differences, and judicious caring A caring nursing practice works to protect a community’s right of autonomy. Conscious participation by nursing with policy makers on ethical questions related to health care decisions expands the scope of a caring nursing practice and benefits communities as well as individuals. Community discourse addressing issues directly related to patient autonomy, access to healthcare as well as resource allocation is within the scope of this practice.

Advocacy:
When the community health nurse encounters ethical issues, often the choice is from an impartial or justice viewpoint. Building on Piaget’s and Vygotsky’s cognitive approaches to moral development, Lawrence Kohlberg developed a hierarchical model of morality based on
justice. Kohlberg’s justice model consists of three main stages: pre-conventional, conventional and post-conventional. As the moral agent progresses through this model and reaches the post-conventional stage, moral reasoning is based on abstract reasoning using universal ethical
principles . Nursing supports individuals to indisputably act on their right of self-determination. Through advocacy, nursing participates in the experience with the individual. It can be said that nurses’ ethical duty to patients is to ensure their informed involvement in their care decisions. And, nurses should be sensitive to any actions that may threaten the balance of power experienced in healthcare situations (Trailer, 2004). Assuming the role of community advocate, nursing can work to ensure a decision making process that reflects individual and community values. Often policy makers miss valuable insights when the populations affected are not represented (Jonsen, 1998).

Social Justice ::
Social justice is a concept that is often described as the foundational underpinning of community development, community health and community health policy development. The following is a definition developed by the Toowoomba Social Justice Commission:Social justice is defined as "... promoting a just society by challenging injustice
and valuing diversity." It exists when "all people share a common humanity and therefore have a right to equitable treatment, support for their human rights, and a fair allocation of community resources." In conditions of social justice, people are "not be discriminated against, nor their welfare and well-being constrained orprejudiced on the basis of gender, sexuality, religion, political affiliations, age, race, belief, disability, location, social class, socioeconomic circumstances, or other characteristic of background or group membership"

*****What are the responsibilities or legal duties of community/public health nurses?

• Assessing health trends to identify health risk factors specific to communities
• Assigning priorities for health-related interventions in order to provide the greatest benefit
• Advocacy with local, state and federal authorities in improving the access to health services in underserved communities
• Design and implement health education campaigns and activities for disease prevention
• Provide information on local health programs and services that are available to improve access to care
• Providing direct health care services to at-risk populations. **********What are some tools (strategies) that help community health nurses practice ethically?   

1. Public health should address principally the fundamental causes of disease and requirements for
health, aiming to prevent adverse health outcomes.
2. Public health should achieve community health in a way that respects the rights of individuals in
the community.
3. Public health policies, programs, and priorities should be developed and evaluated through
processes that ensure an opportunity for input from community members.
4. Public health should advocate and work for the empowerment of disenfranchised community mem-
bers, aiming to ensure that the basic resources and conditions necessary for health are accessible to all.
5. Public health should seek the information needed to implement effective policies and programs
that protect and promote health.
6. Public health institutions should provide communities with the information they have that is
needed for decisions on policies or programs and should obtain the community’s consent for
their implementation.
7. Public health institutions should act in a timely manner on the information they have within the
resources and the mandate given to them by the public.
8. Public health programs and policies should incorporate a variety of approaches that anticipate
and respect diverse values, beliefs, and cultures in the community.
9. Public health programs and policies should be implemented in a manner that most enhances the
physical and social environment.
10. Public health institutions should protect the confidentiality of information that can bring harm
to an individual or community if made public. Exceptions must be justified on the basis of the
high likelihood of significant harm to the individual or others.
11. Public health institutions should ensure the professional competence of their employees.
12. Public health institutions and their employees should engage in collaborations and affiliations in
ways that build the public’s trust and the institution’s effectiveness.