Introduction
Community practice is a field that is not only diverse but fraught with challenges and responsibilities that full-time nurses working in health care institutions do not have to deal with (John & Keleher 2006, p. 3). The health care industry aims to provide care needed by the clients and to cater to their health needs. In this regard, nursing practice is aimed at buttressing the care and health interventions being provided by the doctors and health care professionals. The nursing profession is dedicated to the promotion of the health and well-being of the patient. Nurses who work in the community often work in association with health care agencies and are often required to function as independent health care providers. It follows that these nurses often face situations where they have to work and make decisions on their own. Moreover, they have the added responsibility of promoting the overall health of the patient, and to provide care beyond the obvious health care need. Working in the community also necessitates that the nurse learns to work in a variety of environments and be prepared to deal with an assortment of attitudes ranging from both sheer reluctance to accept the care and readiness to intersperse positive health attitudes into daily routines. Furthermore, the nurse should be flexible enough to adjust and tailor her care according to the political, social and environmental attitude that he or she has to face in different households (John & Keleher 2006, p. 4).
In the recent years, there has been a shift in the dependability of patients on tertiary care (John & Keleher 2006, p. 4). Not only is it expensive at times for governments to provide hospital care to patients who need less intensive care but keeping such patients in the hospital takes up space, beds and nursing care that could be given to patients who are in more dire need of them. Since community nursing practice is directly affected by political and organizational decision-making and is responsive to any local changes and prevailing social issues, nurses are taught to encourage the decreased dependability on tertiary care and to increase community care (John & Keleher 2006, p. 4). When working as a nurse in the community during my placement, I got to experience both the opportunities and challenges that were characteristic of community nursing. During my years as a nursing student, the responsibilities of the nurses and the extended role of the nurse to encourage positive health attitudes while working in the community was impregnated deeply into my mind, and hence automatically became an important constituent of my practice. Sarah Wilson was one such patient who came under my care during my time as the community nurse and it was during her care that I used the tools of community nursing to cater to her health needs and promote her wellness.
Patient Profile
Sarah Wilson was a patient of diabetes for the past three years. Aged 55, she was diagnosed with uncontrolled diabetes when she was 52 and was on medications for controlling it ever since. However, she did not pay much attention to her drugs and did not restrict sugar intake in her diet. As a result, her diabetes worsened over the years. Recently, she went to the doctor for her check-up and seeing her condition, he started her on insulin injections. I was given the responsibility for injecting insulin into the patient and to teach her how to do it on her own. Moreover, I was asked to advice her on the importance of controlling her diet and sugar intake, as the medicines are going to have a more effective result if the patient controls her diet. Keeping these instructions in mind, I set off for Sarah’s home. At her home, I took note of several things. The first thing that struck me was her weight. Sarah appeared to be about 5 feet but her she was very obese. On further inquiry, she told me that her weight was currently 73 kg; her weight used to be less than 60 kg six years ago but she had gained weight over the past few years. In a casual chat with her, I gathered that Sarah was not very active and lived a sedentary lifestyle. I noticed that other house members like Sarah’s son and his wife were also obese. I asked Sarah about her diet and she said that she often had pizza and fast food, sometimes three to four times in a week because her five year old grandson liked it and insisted on having such foods for dinner frequently. According to her, eating large amounts of food was a sign of good health, and back from where she came from, a plump person was considered to be in good health. Her parents were plump individuals as well and used to live on a farm. Sarah had spent most of her childhood at the farm and had not pursued higher education as well. During my first visit, I made a mental assessment of all these factors and performed the required protocol for the injection of insulin, explaining it to Sarah how she could do it on her own.
Fats: where does it go wrong?
Nutrition has a very significant part to play in the normal functioning of the human body (Khosla 2006, p.8). It acts as a shield from both extrinsic and intrinsic agents that are deleterious to the body; it achieves this partly by strengthening and cementing the immune system of the body. Therefore any deficiency of the required nutrients in the body results in a deterioration of the body functions, with the liver being exposed to the brunt of the nutritional deficiency (Khosla 2006, p.8). The diet consists of carbohydrates, proteins, fats, vitamins, minerals, fibre and water mainly. The most common fats in the diet and hence in the person’s body are glycerides, which are made up of fatty acids and glycerol (Sussman & Bates-Jensen 2007, p.66). Saturated fat is obtained from a variety of sources such as fatty cuts of meat, full fat milk, cheese, butter, cream, most commercially baked products such as biscuits and pastries, most deep-fried fast foods, coconut and palm oil (State Government of Victoria 2008). Being the third major macronutrient of the body, it is the “most concentrated energy source” (Remedium 2010). It has several functions in the body from being part of cell surface membranes to providing a protective cushioning to the body’s organs and ferrying of fat soluble vitamins for their absorption and transport (Remedium 2010). Good fats are beneficial for the healthy functioning of the body. However when the intake of fats exceed the nutritional requirements, fat starts to get stored. Fats are stored in the subcutaneous tissue, which is regarded as the natural storehouse for energy (Ibrahim 2009). Of all the constituents of diet that can be linked to some disease, fats are the ones that cause the most trouble (Boyle & Long 2008, p.106).
Community nurses are trained to identify the health abuses that may be going on in the community and might present themselves as serious health problems in the future. Therefore community nursing requires a holistic approach that integrates many clinical, communication, research, teaching and people skills to inculcate positive health attitudes in individuals, groups of peoples such as family units and even entire communities (John & Keleher 2006, p. 4). I was appreciating the gravity of the health problem that was budding at Sarah’s house. The deposition of fat in the abdomen is a vital cardiovascular risk factor (Bandekar, Naghavi & Kakadiaris 2006). Not only was Sarah obese but her diabetes condition raised the risk factor for coronary heart disease several times (Kopelman, Caterson & Dietz 2009, p.60). Furthermore, the consumption of high amounts of fatty foods in her diet as well as that of the rest of the family members living with her was not a very healthy sign. Her parents were also obese and the fact that she and her son were obese could predispose her grandchildren to obesity. Moreover, Diabetes type 2 has been closely associated with obesity and its incidence in children and adolescents has increased considerably with the increased prevalence of obesity in the youth (Rolfes, Pinna & Whitney 2008, p. 554). It has also been documented that obesity and cancer have a relationship (Buchwald, Cowan & Pories 2007, p.48). Diabetes itself has a lot of bad effects on the body including an increased chance for problems in blood circulation, lack of vision and renal problems (Freedman 2008, p.23). An imbalance in the nutrition leads to obesity, obesity culminates in bad health and bad health produces increased costs to individuals and the community (Mazzocchi, Traill & Shogren 2009, p.94).
Role of Public health
Craig and Lindsay (2000, p.6) are of the view that there is no well-defined role of nurses working for the promotion of public health. This is primarily because of the lack of a comprehensive definition of public health that encompasses its various aspects. One of the definitions of public health that is still considered valid today was put forward by Charles-Edward A. Winslow in 1920. He defined public health as “the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts” (Schneider 2010, p.5). In the UK, public health has been regarded as the aspect of health promotion which deals with the prevention of ill-health and encouragement of well-being and health of the community (Craig & Lindsay 2000, p.6). Public health and health promotion is given a lot of emphasis in the UK. A white paper is expected to be passed by the end of November 2010 that regards public health as a “competence-based profession”; the white paper proposes a greater emphasis on making the public health more inter-professional, with people from both medical and non-medical areas, working together for the promotion of health (Middleton 2010).
For many people, health promotion and public health are synonymous terms (Green & Tones 2010, p.50). As a consequence, governments and health care agencies have made health promotion a major objective of the achievement and maintenance of public health. For instance, the WHO launched the Health for All campaign in 1977, which, by the year 2000, aimed to improve the health of the individuals to a level that would result in a productive and social life (Craig & Lindsay 2000, p.6). In the UK, public health networks have also developed. These networks are groups of public health professionals working in concert with each other within a defined geographic area for the delivery of the public health function (Hunter, Marks & Smith 2010, p.85). With regard to nursing, health promotion is done through the principles of “equity, collaboration and participation with others to strengthen community action” (Thornbory 2009, p.24).
Health Promotion
Obesity is not easy to treat. According to Tulchinsky and Varavikova (2009, p.313), primary prevention of obesity is one of the best solutions to the rising endemic. This has also been set as the prime health target by governments of developed countries, since obesity is rising at a fast rate in these countries. The foremost step in primary prevention of obesity is to give proper education and awareness to people about healthy nutritional attitudes (Tulchinsky & Varavikova 2009, p.313). In this case, Sarah came from a background where obesity was a sign of well-being. As part of my counselling to Sarah regarding the need to bring down her weight, I was faced with the challenge of changing her belief which she has had for years that obesity was bad for health. Sarah had only attended school till grade 6th, so I had to bring myself down to her level of understanding to make her comprehend the health problem. Good communication is a prerequisite for good counselling (Kushner & Kushner 2008, p.1). Thus, I tailored my approach to suit Sarah’s belief that obesity is good for health and to encourage reduction in weight.
According to Tessmer, Hagen and Beecher (2006, p.53) a good diet and exercise are integral to the reversal of the bad effects of obesity. As bad as the negative effects of obesity and diabetes are combined together, reduction of weight and burning of the excess fat deposits can go a long way in improving the health of the person (Westveer & Jordan 2009, p.26). This is because reducing weight entails that the heart has to pump less; thus decreasing the workload on the heart, the blood pressure and bringing the heart rate to a healthy level (Westveer & Jordan 2009, p. 26). Therefore, my first line of counselling was explaining Sarah why obesity, combined with diabetes, was bad for her health. I brought her weight reduction pamphlets that delineated the bad effects of obesity with a lot of convincing power. Initially, she was reluctant to accept my counsel. However, on subsequent visits, she admitted that she is realizing how quickly her health has deteriorated due to her negligence to take her health condition seriously. I took this as an optimistic sign and pursued my counselling with greater persistence and persuasion. I showed her empathy and was responsiveness to her dilemma. However, I kept telling her that with the advancement of technology and extensive research that has been conducted, obesity is being regarded as deleterious to one’s health. After a few visits to check-up on her insulin injections, Sarah showed signs of changing and taking steps to reduce her weight. I encouraged her to take a walk in the park every day for at least half an hour. Another aspect of my counselling included was the dietary reduction of cholesterol, salt and fatty foods of the patient and her family. For this, I asked Sarah, her son and his wife to sit with me. We discussed the benefits of good cholesterol and the havoc that starts to occur in the body if cholesterol intake increases its nutritional requirement. I advised them to reduce the consumption of fatty foods to a minimal and to eat a healthy balanced diet constituting of carbohydrates, proteins, fats etc. I also asked Sarah’s son and daughter-in-law to keep a check on Sarah and if she is taking her medicines regularly. I also asked Sarah’s son and daughter-in-law to improve their lifestyle as well by exercising daily and to give their son healthy foods to eat.
Conclusion
The role of public health is the protection and promotion of the health and safety of the people (Florida Department of Health 2010). Counselling by nurses and other allied health care professionals is a vital aspect of the public health reaction to the obesity epidemic. The best way to tackle with obesity is through primary prevention. This means both health education and health promotion. The role of a nurse working in the community not only entails treating the apparent health condition but also addressing any other health risks identifiable in the patient or his/her surroundings. In fact, Stanhope and Lancaster (2004, p. 16) state that a public health nurse is responsible for not only health education and health promotion but also for the prevention of injury and illness and for the provision of primary health care for communities. Caring for Sarah has made me acutely aware of the diverse attitudes that are present in the community and how preventing health risks at the root level can significantly contribute to the health of the individual.
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