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1 Introduction to the use of
Canadian Community Health Nursing Standards of Practice (CCHN Standards) Workshop 1 Introduction to the use of CCHN Standards- 2011 Adapted by Liz Diem The original workshop presentation is part of the 2007 CCHN Standards Toolkit- Workshop 1 Prepared for Community Health Nurses Association of Canada and Public Health Agency of Canada Elizabeth (Liz) Diem & Alwyn Moyer 1

2 Thinking about your practice (or experience)
Write your response to the following: The community nursing experience that I have experienced or observed….. [Think about something that you might use to explain what you do in the community to someone you know] Your experience will be used in the group work after Standard 3. Students are encouraged to recount an experience in the community that was observed (or desired) if they have not yet had much time in the community.

3 Sources for 2003 CCHN Standards*
• Community Health Nurses Association of Canada (CHNAC) website: • Diem & Moyer (2005) Community health nursing projects: Making a difference. Appendix D • Stamler & Yiu (2012) Community health nursing: A Canadian perspective. Appendix A * Next slide indicates changed numbers and order for 2011 version 3

4 2011 Comparison to 2003/8 versions
Similar in 2003/8 Standard 1a Standard 1b Standard 1C Standard 3 Standard 2 Standard 4 Standard 5 2011 revision Standard 1: Health Promotion Standard 2: Prevention and Health Protection Standard 3: Health Maintenance, Restoration and Palliation Standard 4: Professional Relationships Standard 5: Capacity Building Standard 6: Access and Equity Standard 7: Professional Responsibility and Accountability

5 Workshop Objectives 1. Develop knowledge of CCHN Standards with examples from Home, Public, and Community Health Nursing Practice 2. Identify how the CCHN Standards can support practice and organizations and contribute to the health of the community 3. Identify the use of CCHN Standards in your community experience or practice 5

6 Timing for Presentation & Group Work
Introduction to Standards Standard 1, 2, 3 with examples Group work Standards 4, 5, 6, 7 with examples Report summary from each group 6

7 Development of the CCHN Standards
Developed by a geographically representative committee of CHNs under the auspices of CHNAC now called CHNC (Community Health Nurses of Canada) Input received from over 1000 CHNs across Canada Process took over 3 years – formally released October 2003 Revision in 2008 Revision in 2011 -national practice standards for CHN had never been developed – only one province – Ontario had developed its own standards (1985 – now out of print) -the Canadian Public Health Association’s 1990 booklet entitled Community Health – Public Health Nursing in Canada – still remains in print, but does not explicitly identify practice standards -in 1999 the Community Health Nursing Initiatives Group of Ontario (CHNIG) began to revise their standards (out of print in1985) -at the same time, CHNAC began to explore with the Canadian Nurses Association the possibility of having Community Health Nursing designated as a specialty. One of the first steps in being acknowledged as a specialty, was to have standards with indicators specific to the specialty -CHNAC began to work with CHNIG to develop national standards. This was a lengthy process (over 2 years) which involved a working group (the CCHN Standards Committee – see next slide), extensive consultation with CHNs from across Canada (via feedback on the document, a survey, and drafts being posted on the CHNAC website for feedback). It also involved the hard work of many consultants e.g. Joyce Fox, Judy Lalonde, Jane Underwood -funding was generously provided by a number of groups (2 slides forward) 7

8 Summary of 2011 Changes Changes in order of standards: 2003 Standard 1 with 3 sub-standards becomes 3 separate standards # 1-3 resulting in 7 Standards in 2011 rather than 5 in 2003; changed order of 2003 Standards 2 & 3. Increased emphasis on: social and environmental determinants of health; social justice Language: Title of standards changed to nouns; removed redundancy in indicator statements Additions: Integration of new CHN Professional Practice Model New appendices on CHN practice and application of the standards Inclusion of history of CHN practice Moyer’s Model on relationship between standards and competencies   For more details see- Canadian Community Health Nursing Professional Practice Model and Standards of Practice (2011): A summary of changes 8

9 Why are CCHN Standards important?
Define scope & depth of CHN (community health nurse) practice Establish criteria and expectations for acceptable practice and safe ethical care Provide criteria for measuring performance Support the ongoing development of CHN Promote CHN as a specialty and provide a foundation for certification as a clinical specialty with Canadian Nurses Association Inspire excellence in & commitment to CHN practice Set a benchmark for new community health nurses Open discussion questions: What could the Standards do for you? What could the Standards do for your organization and community? It is hoped that you will be able to use the standards to describe the work that you do to others. 9

10 Provincial/ Territorial Standards for Nursing Practice and Specialty Standards
The triangle with the regulatory nursing standards at the bottom emphasizes how all other nursing standards build on that foundation. Of course in Ontario that means the Quality Assurance Program of the College of Nurses of Ontario. Most provincial/ territorial standards include a learning or quality assurance component that can incorporate the CCHN Standards. At the end of this workshop and in preparation for the next one, you will be asked to consider how you can combine the CCHN Standards with your annual requirement for provincial/territorial nursing standards. Adapted from: College of Registered Nurses of Nova Scotia (2003), Standards for nursing practice (effective Jan. 1, 2004) (3) 10

11 Types of Nursing Standards
• Provincial/territorial Standards of Practice apply to all nurses working in a defined jurisdiction Defined and regulated by a provincial/territorial nursing association Legal requirement to practice Begin when hired into any nursing position • Specialty Standards of Practice (e.g. CCHN Standards) Defined by a national nursing organization associated with the Canadian Nurses Association Provide standards specific to the practice of community nurses Provide standards specific to a particular area of practice which may or may not be part of organizational policy Require a defined period of practice in the specialty area (e.g. 2 years) Nurses and employers may ask how the CCHN Standards compare to required provincial or territorial standards. The primary difference is that specialty standards such as the CCHN Standards are voluntary. 11

12 The use of the CCHN Standards will vary according to the phase of career of the CHN. It is the responsibility of educational institutions to provide nursing students with opportunities to learn about the CCHN Standards. Organizations employing nurses would expect to provide opportunities for nurses in their first two years in community health to apply the CCHN Standards. Experienced nurses would need opportunities to expand their application in different areas or in more depth, possibly with the expectation of attaining certification. 12

13 COMMUNITY HEALTH NURSING Includes: Nurses promoting health of individuals, groups & communities and an environment that supports health Public Health (PHN) • focus on health promotion, illness prevention & population health • link individual & family health experiences into the population health framework and links population health to families and individuals • practice in diverse settings e.g. community health centers, schools, streets, nursing stations • educational preparation: baccalaureate degree required Home Health (HHN) • focus on prevention, health restoration, maintenance & palliation • focus on clients & families • practice in homes, schools or workplace and integrates health promotion, teaching & counseling with provision of care • educational preparation: baccalaureate degree preferred Note that community health nursing is not limited to nurses working in Public Health or Home Health. It includes other nurses who promote health of individuals, groups & communities and an environment that supports health. What other nurses might be included in this description? However, since public health and home health are the two largest groups in community health, most of the examples include them. 13

14 Unique Characteristics of Community Health Nursing
CHNs promote, protect & preserve the health of individuals, families, groups, communities & populations… …wherever people live, work, learn, worship & play…. …in a continuous versus episodic process Work at a high level of autonomy View health as a resource & focus on capacities Box 1: this is different from other types of nursing e.g. hospital nursing. Whereas in a facility setting like a hospital, the main focus is mostly on individuals and families, the CHN has a broad scope of practice that includes working with individuals & families, but also with groups and the broader community. Behind all endeavors is the overarching health of the entire population Box 2: this again is unique to CHNsg – in a hospital setting, the clients come to the facility. In the community, the nurse brings the care to the individual, group community. CHNs provide service in diverse places such as people’s homes, schools, churches, community centres, on the street. This often poses challenges (Murray, 1998; Simoni & McKinney, 1998): practice in the client’s personal environment (versus a facility environment). distractions in other settings. unpredictable situations (which are often the norm). ‘unique’ home situations encountered. some family members may differ in their level of acceptance of the nurse in their territory having to learn to use and trust what other professionals, the client and the community have already contributed and can contribute. Box 3: this again is unique to CHNsg – much of the work that CHNs do is long-term and is usually not immediately apparent. The impact of the work is evident over the long-term. Box 4 (Health is resource) – the focus on health and health promotion is critical to the work of CHNs. CHNs focus on individual/family/group/community strengths as a starting point. This is much different approach than focusing on illness or case finding. Box 5 (autonomy) – CHNs work individually and as part of a team. They are very autonomous in the work that they do which can pose challenges e.g. lack of access to immediate professional support systems, few supplies, low technology, and difficulty in connecting with other professional caregivers. CHNs are skilled at relationship building and thus, some of these challenges can be mitigated. Box 6 (environment) – CHNs have expertise in understanding the effects of the determinants of health – research is continually showing us that the determinants have much more impact on health than some of the ‘traditional’ aspects of health. Examples of the determinants include education level, poverty. The determinants will be discussed in more detail later. Box 7 (partnerships) – much of the impact of CHNs’ work is due to the successful partnerships that are developed within communities. Partnerships, primary health care, caring & empowerment will be discussed in more detail later. Box 8 (specialized) – CHNs draw from a broad base of specialties including nursing, social science & public health science. Box 9 (marshal resources) – CHNs are masters at seeking out resources and facilitating what need to be done to support health. Combine specialized nursing, social and public health science with experiential knowledge Marshal resources to support health by coordinating care & plan Nsg services, programs & policies Build partnerships based on primary health care principles, caring & empowerment Have a unique understanding of the influence of the environmental context of health 14

15 Components of Professional Practice Model
Individuals, families, groups, communities, populations, systems Code of Ethics Community Health Nurse Community Health Nursing Standards Delivery Structure and Process Determinants of Health Discipline specific competencies: Public Health, Home Health Government support Management practices Professional relationships and partnerships Professional Regulatory Standards Theoretical Foundation Values and principles More details of each component can be found on pages 3-6 15

16 • Intervention (action) • Evaluation
The Community Health Nursing Process Apparent in the order of indicators in each Standard • Assessment • Planning • Intervention (action) • Evaluation 16

17 CCHN Standards of Practice
Health Promotion Prevention and Health Protection Health Maintenance, Restoration and Palliation Professional Relationships Capacity Building Access and Equity Professional Responsibility and Accountability 17

18 Standards 1, 2 and 3 describe what we do in practice; Standards 4, 5, 6 & 7 describe how we practice and what we expect to achieve 18

19 Parts of each Standard: Description & Indicators
Description of Standard is provided in initial paragraph Indicators: begin with the heading “The community health nurse...” and define the specific activities that CHNs are expected to perform to achieve the Standard. The indicators begin with assessment type activities, move to planning, action and end with evaluation activities. 19

20 Standard 1- Health Promotion
Overview Involves the population as a whole in the context of their everyday life rather than focusing only on at-risk people Is the process of addressing health inequities and enabling people to increase control over & to improve their health. Brings together people who recognize that basic resources & conditions for health (eg. social and environmental determinants of health) are critical. Works best when all levels- individuals, groups, community, society (government, media) and multiple approaches are used 20

21 EXAMPLES from practice - Health Promotion
• PHNs work with a community to advocate for a smoke-free town or municipality • PHNs promote physical activity and healthy eating through programs such as the In-Motion, Supermarket Safari and the Schools Awards Program. • HHNs encourage families dealing with a chronic illness to participate in regular physical and social activities Note: you may wish to ask the audience for other examples of health promotion that they have been involved in The first example is public policy. The second example could involve the reorientation of health services. The third example is a strategy to develop personal skills – access to information 21

22 Standard 2- Prevention & Health Protection
Overview • The CHN applies a repertoire of activities to minimize the occurrence of diseases or injuries and their consequences. • Health protection strategies often become mandated programs & laws. -disease prevention refers to activities that protect individuals/groups/communities for potential or actual health threats & their harmful consequences -health protection strategies includes surveillance – in the community the nurse is often the first to know that there is a health issue and is in a good position to collect additional information for ongoing monitoring/surveillance which can lead to developing appropriate actions (Underwood, 2003). 22

23 EXAMPLES from practice Prevention & Health Protection
• PHN track immunization schedules for each child so that when a child is overdue for vaccine they can be contacted. (CHNAC) • A CHN observes high rates of smoking within a particular client group. The concern is raised with the practice team and a plan is developed to find ways to address the issue. • PHN work with a parent’s organization and the police to promote proper installation of car seats through the media and conduct several clinics to provide one-on-one assessment and teaching. 23

24 Standard 3- Health Maintenance, Restoration & Palliation
Overview • Includes the full spectrum of acute, chronic and palliative nursing care (HHNs), health teaching & counseling for health maintenance or dealing with acute, chronic or terminal illness (HHNs and PHNs). • Links people to community resources & facilitates/coordinates care needs & supports. -this is promoting health through maintenance, restoration & palliation – restoring the individual/family/community to an optimum level of functioning 24

25 Examples from practice- Health Maintenance, Restoration & Palliation
• HHNs care for disabled students in the classroom: Communication is required with the child’s guardian, teacher and/classroom assistant (CHNIG HHN Position Paper, 2000) • CHNs provides ongoing nursing care to families with seniors who are experiencing difficulties. The care may be provided directly or through unregulated workers. This may include telephone follow-up, home visits or community referrals. A HHN provides long term nursing care in the classroom setting, which includes tube feeding, meds & chest percussion/postural drainage. Communication is required with the child’s guardian, teacher and/classroom assistant to provide health teaching and information re child’s status and response to treatment. (CHNIG HHN Position Paper, 2000) A CHN provides ongoing nursing care to families with seniors who are experiencing difficulties. The care may be provided directly or through supervision of unregulated workers. This may include telephone follow-up, home visits or referrals to other community based services. 25

26 Group work Introductions: Your name, where you live, where you work, focus of your practice (change for student groups) Each person in turn (no discussion) describes their experience Recorder takes down main points of each experience Discuss and determine which of the first three Standards is most relevant for each experience. Decide which example from your group could be used in the reporting session at the end. Possible format for group work: Form audience into groups of 4 to 10 (depending on space and furniture) Provide about minutes for them to complete 1 to 3 (may include break) 26

27 Standard 4. Professional Relationships
Overview: • Built on the principles of connecting & caring • Relationships may be with clients and/or with organizations/stakeholders • Relationships built on mutual respect and on an understanding of the power inherent to the CHN position. • Unique to CHN is building a network of relationships & partnerships – occurs within a complex environment for both PHNs and HHNs. This standard will be reviewed in more depth. It has some commonality with the BPG of Therapeutic relationships The final point identifies the uniqueness of this standard -CHN work in/with a variety of environments, organizations and people – this is often changing and evolving which may present conflicting & unpredictable circumstances. For example a Public Health Nurse may work with town councils, food banks, transition homes, community advocacy groups. A HHN may work with apartment superintendents, landlords, pharmacists, faith leaders of all religions 27

28 Examples from practice Professional Relationships
• A HHN working in palliative care listens to the concerns of stressed and exhausted caregivers and supports them in making decisions about respite and hospice care. • A group of PHN working with families experiencing child care difficulties identify that post natal visits based on issues or tasks moves them around too much to be able to develop a continuing relationship with families. They bring their concern to the attention of management. 28

29 Standard 5. Capacity Building
Overview • Capacity building describes an increase in ability of individuals/communities to define, assess, analyze & act on health concerns. • Active involvement by those affected is critical. • CHN works collaboratively with those affected by the health concern and those who control resources. • CHNs assess the stage of readiness for change & priorities for action. • CHNs build on existing strengths. This standard defines the PHC principle of citizen participation and has some commonality with the BPG of Client Centered Care. In comparison to institutional practice with individuals, CHNs build capacity at the group, organization and community levels. -participation is basic to community capacity – peoples’ participation with others promotes health through several pathways: increased social networks & support, improved self/social esteem & decreased isolation -CHN are in a unique position to work with those affected by the health concern, but they also are adept at building relationships and acting as a liaison with those who control the resources -behavioural or structural change may be difficult for individuals/communities – an important component of CHN practice is to assess readiness for change. -CHN build on existing strengths – this may include seeking organizational elements which represent the ways in which people come together in order to socialize and address their concerns. These organizational structures may include small groups such as committees, church and youth groups 29

30 Examples from practice Capacity Building
• A HHN encourages a mother and teens to work out a schedule for ROM exercises for the grandmother. The family is happy that they were able to work out the problem together. • A PHN encourages a school to mobilize a school health committee that includes students, parents, teachers, administration, and community partners. Committee members identify the school community’s strengths and needs, and prioritize, plan, implement, evaluate and celebrate action for a healthier school. The school community’s capacity to take its own action for health is enhanced via a sustainable structure (the committee). The PHN is a partner in the process. 30

31 Standard 6. Access & Equity
Overview: • CHNs identify & facilitate universal & equitable access to services and resources. • CHNs engage in advocacy on many levels including services appropriate for cultural groups in the community. • CHNs collaborate with other services and sectors to promote effective working relationships that contribute to comprehensive client care & achievement of optimal outcomes. This standard is particularly unique to CHNs. CHNs bring health care to people where they live work play learn and worship. This includes on the streets, in their homes and in community meeting places. CHN also have the responsibility to advocate for change in policies for underserved populations. -this standard ties in with one of the principles of primary health care – universal access to health services -CHN are involved in advocacy at many levels e.g. influencing policies for a positive impact on health, client/community advocacy to ensure adequate services -CHN engage in advocacy by analyzing the full range of possibilities for action, acting on affected determinants of health & influencing other sectors to ensure their policies & programs have a positive impact on health 31

32 Examples from practice Access & Equity
A PHN identifies that one ethnic group does not use health care services (including prenatal classes) outside their area. The PHN works with a champion from this group to organize local prenatal classes delivered by a PHN and translated by a woman from the community. (CHNAC). A HHN and Case Manager advocate for families caring for medically fragile children by: • Seeking respite care for an exhausted families • Contacting the local MPP • Planning for a resolution through Provincial/Territorial nursing association

33 Standard 7. Professional Responsibility & Accountability
Overview: • CHNs work with a high degree of autonomy – accountable for their competence & quality of their practice • CHNs work in a complex environment with accountability to a variety of authorities • CHNs encounter unique ethical dilemmas -professional responsibility & accountability is a basic standard for all nurses in Canada. The complex environment in which CHN work and the high degree of autonomy they have makes this standard more challenging. CHN are responsible not only for nursing care of individuals, but also for the health of communities and populations. CHN work with many organizations, governmental levels and businesses. Unique ethical dilemmas are encountered. These include whether responsibility for an issue lies with the individual/community/population or with the nurse or the nurse’s employer. For example, if a family chooses not to immunize a child, this may have implications for the population at large since herd immunity may be compromised. 33

34 Examples from practice- Professional Responsibility and Accountability
• A HHN is asked by an ALS client to be present when his wife removes his Bi-PAP machine, which will result in his death. The nurse explores the client’s reasons for this decision and discusses the ethics around responding to this request with the health care team as well as the nursing practice advisor at their College of Nurses. • A PHN is assigned to work in a needle exchange program based on harm reduction. He has difficulty accepting the tenets of harm reduction and uses reflective practice personally and with his supervisor to understand and change his assumptions. • Both teamwork and communication are reduced after the hiring of a new manager. You have been with the program for awhile and can see that people are not receiving the same level of services and newly hired staff are not being supported. You decide to meet with the new manager to discuss the situation. Depending on the response from the manager, you will either go to a higher level or offer to collaborate to improve the work and service environment. 34

35 Group work questions 1. Identify why CHN Standards would be useful in a community health nursing organization and nursing education Identify how the selected example from the first group work session fits with one or more of the Standards: 4, 5, 6 & 7. Summarize findings to full group: Description of example and the use of the example as an illustration for the different Standards: 1, 2, 3, and 4, 5, 6, 7. Reasons why Standards might be useful in practice and education Ask for short report ( 5 min) from each group or examples for each question and each Standard from different groups 35

36 Follow-up activity • Work individually or with others to determine how the CCHN Standards could be combined with the annual nursing registration requirements in your province or territory. • You will be asked to share your findings at the next workshop The next workshop (workshop 2) involves developing teamwork based on the standards 36

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