Chapter 3: Community Nursing Roles & Practice Settings

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Welcome back to the Deep End, everyone.

You are plugged into another edition of the Deep Dive.

Great to be here.

Today we have a mission that honestly it feels a bit like we're trying to map an invisible continent.

I like that.

We are tackling a subject that I think, you know, 90 % of the population thinks they understand, but once you start to peel back the layers, you realize they're actually just looking at it through a keyhole.

We are looking at community health nursing in Canada.

It is a massive topic, a really massive topic.

And to be specific, our source today is chapter three of community health nursing,

a Canadian perspective, the fifth edition.

And I'm glad you use that word invisible because the scope of what we're about to discuss is so often hidden in plain sight.

It's all around us, but we don't always see it.

Exactly.

I think when most people hear community health nursing, they have a very specific and maybe a slightly limited image in their heads.

They think, oh, that's the nurse who comes to visit my grandmother to check her blood pressure.

And look, that is part of it.

A very important part.

A very important part.

But today we are going to kind of explode that definition.

We are going to decode the roles, the functions and the just wild variety of settings where these nurses operate.

We really are.

We're going to see that this isn't just about home care.

This is a complex dynamic field that touches people.

And I love how the text puts us where they live, work, worship and play.

Live, work, worship and play.

That is such a key phrase.

It sounds lovely, but it also sounds, well, overwhelmingly broad.

It is broad.

That's the point.

So before we get lost in the weeds here, let's ground ourselves.

How does the text actually define a community health nurse?

Because my grandmother is home care nurse and, say, a nurse running a needle exchange program downtown seem like they have absolutely nothing in common.

On the surface, sure.

You're right.

They look very different.

But the definition provided by the community health nurses of Canada, the CHNC, it really ties them together.

A community health nurse or a CHN is defined as a nurse who works with people in their own environments to promote health.

But here's the crucial distinction, and this is where people really get tripped up.

When they say client, they don't just mean one person sitting in a chair.

Right.

This was the first aha moment for me in the reading.

The client isn't necessarily a person.

Exactly.

The client in this context is, well, it's a hierarchy.

It refers to individuals, yes.

But also families, groups, entire communities, populations, and even systems.

Systems.

So a CHN isn't just treating a patient.

They might be treating a neighborhood.

They might be.

Or they might be treating a policy that's causing lead poisoning in a city's water supply.

The client is the system that's making people sick.

That immediately reframes the job description.

You aren't just fixing a broken leg.

You're fixing the sidewalk that caused the break in the first place.

That's a perfect way to view it.

And to understand why this matters so much right now, you really have to look at the history, which the text lays out really, really well.

There's this fascinating pendulum swing in the profession.

I was so surprised by the numbers here.

It really challenges the whole idea of what a traditional nurse even is.

It does.

It's a very telling historical arc.

If you go way back, before World War II, about 60 % of all nurses were actually community -based.

60 %?

Yeah.

They were in private homes.

They were out in the world.

The hospital was a place of last resort.

So the traditional nurse was actually a community nurse.

Historically, yes.

That was the norm.

But then fast forward to 1989.

You have the post -war boom, the rise of high -tech modern medicine, and the way Medicare was structured in Canada, which really favored institutions.

And suddenly the gravity shifted.

By 1989, a staggering 85 % of nurses were employed by hospitals.

The hospital became the son of the medical solar system.

Everything orbited around.

But reading this chapter, it feels like the gravity is shifting back again slowly, but it's shifting.

It is.

The text notes that as of 2014,

about 62 % were in hospitals.

So the number is dropping.

There is a distinct push, driven by changes in primary health care, the sheer cost of acute care, and of course the needs of an aging population, to move expertise back out into the community.

The Canadian Nurses Association is actually recommending this exact realignment.

It just makes sense, doesn't it?

If you want to keep people healthy, you have to go where they are.

You can't just wait for them to crash and burn and end up in your ER.

You can.

It's not sustainable.

So, here is our roadmap for this deep dive.

We're going to walk through this chapter linearly, because it builds a really logical, compelling argument.

We're going to start with the big frameworks, this thing called the blueprint for action, and the professional practice model.

The big picture stuff.

Exactly.

Then we'll get into the standards of practice, you know, the rules of the road.

And then we get to the really fun part, the specific roles.

We're going to break down everything from street nursing to military nursing.

Which is a huge range.

And finally, we'll wrap up with the regulations and the future trends that are reshaping this whole landscape.

So let's jump in.

The blueprint for action.

This sounds like a superhero movie title.

It does have that ring to it.

But it's actually a very serious document from 2011.

Okay.

It was developed by the Community Health Nurses of Canada.

And you should think of it as the strategic framework, or as you said earlier, the to -do list for the entire profession.

It's not just about what nurses do today, but what they need to do to survive and thrive in the future.

And the text outlines six specific areas of action.

Let's run through these, because they really show where the friction points are, where the challenges lie.

Sure.

Number one is work at full scope.

And this is a huge issue in nursing generally, not just in the community.

What does that mean in plain English, full scope?

It means we have a systemic problem where nurses are trained and licensed to do A, B, C, and D, but their employers or, you know, the bureaucracy only lets them do A and B.

So they're being held back.

They are.

Working at full scope means taking the handcuffs off.

It means allowing nurses to utilize their full education and their full training to deliver care.

It's about efficiency and respect for the profession.

Right.

Don't hire a Ferrari and then tell them they can only drive it in first gear.

Exactly.

That's a great way to put it.

Then number two is support leadership development.

You need strong voices at the policy table to advocate for these changes.

It's not enough to just want change.

You need leaders to fight for it.

And number three.

Number three is build collaboration and partnerships.

This is key.

You can't do community health alone in a silo.

You have to work with other sectors.

Education, housing, social services, law enforcement.

Which leads perfectly to number four, which for me was the most profound one.

Transform the system into a system for health.

This is my favorite one.

It draws this brilliant distinction between a system for health and what we mostly have now, which is a system for illness.

Explain that.

Well, most of our hospitals are systems for illness.

They're designed to fix you when you're already broken.

The blueprint wants to build a system that keeps you healthy in the first place.

It's a fundamental philosophical shift from being reactive to being proactive.

That is a massive, massive undertaking.

And the last two.

Number five is support strong education.

Which we will definitely talk about more later because there's some big gaps there.

And number six is improve access to professional development so nurses can keep their skills sharp.

Now there was a specific note in the text, a really important one, regarding this blueprint and its relationship with Indigenous nursing.

Yes, and this is critical.

The text explicitly mentions that while this blueprint was developed through a lot of consultation,

there is a recognized, an urgent need to collaborate directly with the Canadian Indigenous Nurses Association or C -Titan A for all future versions.

So it's emitting a blind spot or an area for improvement.

Essentially, yes.

It's a really honest acknowledgement that the framework needs to be much more inclusive of Indigenous perspectives and worldviews.

And that ties right into a call to action that's mentioned alongside the blueprint.

It talks about cultural safety.

Not just sensitivity, but safety.

Exactly.

The wording is important.

It calls on CHNs to actively recognize racist behaviors and stereotypes in the system and in themselves and to understand and respect traditional healing.

It's moving beyond just being nice or culturally sensitive to actively practicing cultural humility and safety.

It's about power dynamics and recognizing the very painful history of the health care system in relation to Indigenous peoples.

That feels like a foundational piece of the puzzle.

It has to be.

Okay, so that's the blueprint, the strategy.

Now let's look at the visual, the professional practice model.

This is figure 3 .1 in the text.

For our listeners who are driving or working out, imagine a circle.

Imagine a series of concentric circles, actually.

It's a bit like a target or a doughnut shape, if you will.

I'm always down for a doughnut analogy.

So what's in the jelly center?

The client.

That is the absolute core.

The model is completely 100 % centered on the client.

Again, that's individuals, families, groups, communities, populations, and systems.

Everything, absolutely everything revolves around them.

Okay, that's the center.

And what's the first layer wrapping around the client?

The next layer out is nursing practice.

This holds the profession's code of ethics.

It's theoretical foundations and its values.

It's the how of the nursing care.

It's the professional bubble that protects the client.

Then we move outward again.

The next ring is community organizations.

And this is so important because it recognizes that nurses don't work in a vacuum.

Their practice is influenced by management, by delivery structures, by the professional relationships within their organization.

If the organization is dysfunctional, it presses in on the practice and affects the client.

Right, it's the context they work in and the outer crust of our doughnut.

That's the system.

This is the biggest circle.

It includes government support, policy, and the social determinants of health.

It's the big sociopolitical environment that holds everything else.

So why do they need a model like this?

Is it just to have a pretty graphic for a textbook?

No, it's actually about identity and cohesion.

The text mentions a survey where nurses reported that having this model gives them a unified voice.

It provides a common framework, a common language, so that a nurse working in a school and a nurse working in a shelter can look at this model and say, okay, we're doing the same fundamental thing, just in very different contexts.

That makes a lot of sense.

It unifies a very diverse profession.

Okay, let's move from the model to the rules, the standards of practice.

These are the backbone.

The text mentions the most recent revisions were in 2019, and there are seven of them.

They exist to define the scope of practice, to measure performance, and to guide education.

Seven standards, let's walk through them, because these really define what a CHN does day to day.

So standard number one, health promotion.

This is the big one.

It's defined as the process of enabling people to increase control over their own health.

And you have to notice that word enabling.

It's not just telling people to eat their veggies.

It's figuring out why they can't afford veggies in the first place, or if there's even a grocery store in their neighborhood.

It's about addressing the barriers.

Okay, that makes sense.

Standard two, prevention and health protection.

This is distinct from promotion, which is about overall well -being.

Prevention is about minimizing the occurrence of a specific disease or injury.

Think vaccinations,

seatbelt laws, clean water surveillance.

It's about stopping the bad thing from happening before it starts.

Standard three, health maintenance, restoration, and palliation.

This is the more traditional care aspect that people recognize.

Maximizing function for someone with a chronic illness, helping someone recover from surgery at home, or critically, helping them die with dignity in their own home through palliative care.

Now, standard four is really interesting because the text notes, it was moved up the list in recent revisions.

It's professional relationships.

Yes, the reordering is significant.

It's not just a clerical change.

It reflects the realization that you cannot do capacity building.

You can't do health promotion if you haven't built a relationship of trust first.

The relationship is the initial step.

You can't just parachute in.

Absolutely not.

If the community doesn't trust you, you can have the best vaccine program in the world and no one will show up.

Trust is the currency of community health.

Okay, that's powerful.

Standard five, capacity building.

Helping communities help themselves.

It's the old teach a person to fish idea.

It's about not creating dependency, but about working with the community to identify its own strengths and build on them, leaving the community stronger than you found it.

Ideally, a great CHN works themselves out of a job in that specific area.

Standard six is a crucial addition in recent years, health equity.

This focuses explicitly on access and justice.

It's a recognition that it's not enough to provide great care.

You have to ensure that the people who need it most can actually get it.

It means fighting for fair policies and against systemic barriers.

And finally,

standard seven, evidence -informed practice.

Using the best research and the best evidence available.

We aren't just guessing out there.

We are using science.

We're using data.

We're using proven methods.

And lurking underneath all of these is a sort of ghost standard, right?

The text mentions an eighth element.

Right.

The text mentions professional responsibility as the underlying foundation for all the others.

It's not listed as number eight.

It's just it's the bedrock.

It basically means you are accountable for your own practice, your own ethics, and your own learning.

So we have the blueprint, the model, and the standards.

This is a legitimate defined specialty.

It absolutely is.

In fact, it's a recognized specialty with the Canadian Nurses Association.

There has been a certification exam offered since 2006.

So if you see a nurse with CHNC after their name, that C stands for certified.

That's a board certified expert in this field.

That is good to know.

Now I want to clear up some confusion.

The text has this section called clarifying roles, and it talks about the difference between community oriented and community based.

And it refers to figure three point two.

This feels like a tongue twister waiting to happen.

Help us unpack this matrix.

It is a common stumbling block for students, for sure.

But it's vital for understanding the scope.

So imagine a graph with two axes.

The vertical axis is the approach.

OK, vertical is the approach.

On one end of that axis, you have community oriented.

This approach focuses on populations and on health promotion.

So if I am designing a disease prevention program for the entire city of Toronto, I am being community oriented.

I'm looking at the whole forest, not the individual trees.

Got it.

Big picture.

And the other end of that vertical axis.

That's community based.

This approach focuses on individuals or families where they live.

So if I am going into a specific home to do wound care for Mrs.

Jones, I am practicing community based nursing.

It's care delivered in the community setting.

OK,

so oriented is the big picture strategy and based is the hands on care in a specific location.

Roughly, yes.

And then the horizontal axis is just the client, which you've already discussed.

It ranges from individual to family to group all the way up to community and population.

The matrix just shows how you can mix and match these.

You can be a community based nurse working with a family or a community oriented nurse working with a whole population.

That clarifies it.

It's about the lens you're using and who you're focusing on.

Now, right next to this matrix, the text has a research box titled Yes, But Why?

And I love this part because it addresses the elephant in the room,

the stereotype of community health nursing.

Oh, the pearls and pumps stereotype.

Pearls and pumps.

I laughed out loud when I read that.

You have to explain this.

It's a quote from a nursing student in the text and it perfectly captures the myth.

The perception is that CHNs are the ones who dress pretty, carry a nice bag and don't get their hands dirty.

Yeah.

There's this pervasive myth that because they aren't in the ER stopping a massive bleed or in the ICU managing 10 different drips, they aren't doing real nursing.

Yeah.

It's often seen as the poor cousin to acute care or, you know, a slower paced job for nurses nearing retirement.

Which is wildly inaccurate from everything we've just discussed.

It's dangerously inaccurate.

Yeah.

The reality, as the text emphasizes, is that CHN work is incredibly complex and autonomous.

In a hospital, you have a controlled environment.

You have security.

You have resources down the hall.

You have a doctor on call 24 -7.

Right.

There's a whole system around you.

A huge system.

Yeah.

In the community, you are autonomous.

You are walking into completely uncontrolled environments, hoarding situations, homes with domestic violence, isolated farmhouses, gang territory.

And you are making high level critical thinking decisions completely on your own.

You're working without a net.

So why does the stereotype persist so strongly?

The text blames a few things.

Media is a huge.

When shows like Grey's Anatomy or ER make the hospital look like the center of the entire universe, it's where all the action is.

But also, nursing education itself has a role to play.

The text points out that students often don't get good mentorship in community settings or they get placements that don't show the full scope.

Maybe just sit in an office for six weeks and do paperwork.

The fix, according to the text, is better mentorship and earlier, more meaningful exposure in nursing programs to show students just how rigorous and challenging this field really is.

I think that's a perfect segue.

If we want to shatter that Pearls and Pumps myth, we need to look at what these nurses actually do.

And now we're going to go into the deep dive of specific practice settings.

This is the longest part of the chapter.

And for very good reason, the variety is just staggering.

It really is.

And we should start where the text starts, which is with indigenous health nursing.

Now, there is a very careful distinction made here between the terms.

Yes.

And it is so important to be precise with the language.

Indigenous nursing refers to the who refers to First Nation, Inuit and Metis nurses themselves.

Indigenous health nursing, on the other hand, refers to the how it's the way care is provided.

It's a practice that focuses on empowerment, on incorporating traditional knowledge and on addressing the specific unique health needs of indigenous communities, often in a way that is self -determined by those communities.

The text points to Chapter 22 for the full details, but it makes a point of acknowledging right here in Chapter three that this is a specific vital area of practice.

Exactly.

It's not just nursing for indigenous people.

It's a distinct practice that incorporates cultural wisdom and respects indigenous sovereignty.

Let's move to one of the biggest umbrellas.

Public health nursing or PHM.

This is what many people think of when they hear community health, but specifically, PHM's focus on population health.

Their client is the entire community.

Their goal is health promotion, disease prevention and health surveillance.

Surveillance sounds a bit like spy work.

In a way it is.

They are the medical detectives.

They are the ones tracking outbreaks of influenza or foodborne illness, looking for patterns in disease, monitoring immunization rates.

If there is a measles outbreak in a school, the PHN's are the ones mapping it, doing the contact tracing and stopping it from spreading.

OK.

In Canada, this role typically requires a baccalaureate degree.

They use something called the population health promotion framework to guide their work.

They aren't usually treating one sick person.

They are trying to keep the whole town from getting sick.

And let's contrast that with home health nursing or HHN.

HHN is where the rubber meets the road for individuals.

The setting is right in the name.

Homes, but also schools or workplaces.

The function is chronic disease management, palliation or rehabilitation.

This is the nurse you might see visiting your grandmother.

And the goal here is interesting.

It's not just to do the care forever.

Right.

The ultimate goal is empowerment.

If an HHN does their job perfectly, the patient and their family eventually don't need them anymore.

They want to teach the client or the caregiver how to take charge of their own care, how to change the dressing, how to manage the insulin, how to use the equipment so they can stay in the community and out of the hospital.

It's about maintaining independence and dignity.

OK.

Next up in the text, primary care nursing.

This is often the first point of contact, isn't it?

Yes, absolutely.

These are the nurses you'll find in physician's offices, family health teams or walk in clinics.

Their scope is incredibly broad prevention, cure, rehab, support.

They do it all.

And the text makes a point to note they often work with vulnerable groups.

Correct.

Primary care nurses are often on the front lines, working with new immigrants, with refugees or with other marginalized populations, usually as part of a multidisciplinary team.

They are the front door of the health care system.

And if that door is closed or unwelcoming, people just don't get care until it's a full blown emergency.

Now, here is a field that is just exploding, especially post -pandemic telehealth nursing.

Remote delivery of care using video, phone, email, all sorts of tech.

The text calls out a specific and very difficult challenge here.

Triage over the phone.

This is incredibly difficult work.

Imagine trying to assess how sick a child is without being able to see them, to touch their skin, to check for fever or to listen to their lungs.

You lose all those nonverbal cues.

I can't even imagine.

The text emphasizes that this requires extremely high level communication and assessment skills.

You have to be able to paint a very clear clinical picture in your mind just by asking the right questions in the right way.

But the benefit is huge.

Oh, massive.

It's cost effective.

And crucially, it improves access for people in remote and indigenous communities who might be hundreds of miles from a doctor or nurse.

It bridges that geography gap.

Speaking of geography and access, let's talk about outreach or street nursing.

This feels like the absolute polar opposite of pearls and pumps.

It is the gritty, on the ground reality of nursing.

The origins here are fascinating.

It really grew post -WWII, but exploded as a formal role during the HIV AIDS epidemic in Vancouver around 1988.

And the philosophy is meeting people where they are.

Literally and figuratively.

You're on the street, in the alleyways, under bridges, in shelters.

It's about building relationships based on trust and maintaining dignity.

No matter what, if you judge a client on the street, you've lost them forever.

What are the actual activities they're doing?

Everything.

STI checks, handing out clean needles, harm reduction education, advocating for housing, treating wounds, connecting people to social services.

It's survival nursing.

You're keeping people alive day to day and trying to build enough trust to maybe, just maybe, get them connected into the wider system.

It takes a very special kind of resilience.

From the inner city to the wide open spaces, rural nursing.

And the text gives this great historical nod to the Grenfell mission, which involved nurses on dog sleds in Newfoundland and Labrador.

Dog sleds.

That is hardcore.

It is.

The Red Cross also played a big role in establishing rural nursing outposts.

But the defining characteristic of the rural nurse today is that they are the ultimate generalist.

Meaning they have to do a bit of everything.

A lot of everything.

In a big city hospital, you specialize.

You're a cardiac nurse or a renal nurse in a small rural outpost.

One minute you are the public health nurse doing a baby check.

The next minute you are the home health nurse doing palliative care for an elder.

And 10 minutes later, you are the emergency nurse handling a major trauma from a farm accident until the helicopter arrives.

You have to know it all.

The text mentions blurred boundaries as a specific challenge here.

What does that mean?

That's the fishbowl effect.

You know, everyone in town, the patient you are treating for an STI might be your kid's teacher or the person bagging your groceries.

Managing confidentiality and professional boundaries when you live next door to your patients is a unique and constant stressor that city nurses rarely face.

Let's shift gears to the workplace.

Occupational health nursing.

This role focuses on the worker and the work environment.

But environment here is defined very broadly in the text.

Not just is the floor slippery.

It includes chemical hazards, physical hazards like noise, but also the political and social factors in the workplace like stress and bullying.

So they are protecting the worker from the work in a way.

Essentially, it's about injury prevention, safety, health education and helping injured workers get back on the job safely and sustainably.

And then we have one that might be new to some listeners, parish nursing.

It's a fascinating niche.

The founder mentioned in the text is a Reverend Granger Westberg.

The whole concept is about integrating faith and health to promote wholeness.

So is it just praying with patients?

That can be part of it, for sure.

Yeah, the spiritual care component is central.

But the role is also that of a health educator, a personal health counselor and a referral agent.

A parish nurse might run a blood pressure clinic after the Sunday service or help a congregation member navigate the very confusing health care system to find the right specialist.

It bridges that gap between the medical community and the spiritual community.

Now, let's talk about a role that sounds like it's straight out of a TV show.

Forensic nursing.

This is where health intersects directly with the law.

It's a very specialized field.

The goal is dual.

You have to care for the patient and you have to collect evidence for the legal system.

And those two goals can sometimes feel like they're in conflict.

The text highlights a specific type of forensic nurse, saying nurses, sexual assault, nurse examiners.

Yes, these nurses work in ERs or specialized community centers, and they have a profoundly difficult job.

They must be completely nonjudgmental.

They have to explain the complex legal implications of reporting or not reporting.

And they have to meticulously collect objective evidence, DNA, photos, detailed documentation, all while trying to return some sense of control to a survivor who has just been through a horrific trauma.

It sounds like an incredible balancing act of compassion and legal precision.

It absolutely is.

One tiny mistake in the documentation can ruin a court case, but one mistake in their manner or approach can re -traumatize the patient.

It requires immense skill.

Moving on to community mental health nursing.

The history here is tied directly to deinstitutionalization.

Starting in the 1950s with the arrival of the first antipsychotic meds, but really accelerating in the 80s and 90s, we moved thousands of people out of large psychiatric hospitals and back into the community.

But did the support follow them?

That's always a big criticism.

That is the eternal caution, isn't it?

Community mental health nurses are the ones trying to be that support.

They often work on what are called ACT teams, assertive community treatment teams.

They go to the clients.

They don't wait for a client in crisis to come to the clinic.

The text mentions a study with a really key finding about what these nurses spend most of their time on.

Yes, and it's a bit concerning, honestly.

The study showed they spend the most time on coordination of care, which is basically logistics, phone calls, paperwork, booking appointments.

But unfortunately, much less time on direct health promotion,

like counseling on diet and lifestyle and smoking cessation.

And that's a problem.

It's a huge gap because people with severe and persistent mental illness often have very poor physical health outcomes.

They die decades earlier than the general population from preventable diseases.

They desperately need that health promotion.

But the nurses are often too bogged down in bureaucracy to provide it.

That is a critical insight into the systemic challenges.

Finally, for our specific settings,

military nursing.

The historical nugget here is that the first recorded military nursing in Canada was way back during the 1885 Northwest Rebellion.

Wow, 1885.

Yeah.

The role today involves serving Canadian forces, members, of course, but also insurgents or civilians during overseas operations under the rules of the Geneva Convention.

And the requirements are incredibly high.

Extremely high.

You must be physically fit.

You have to be socially adaptable and you must be ready to deploy on short notice anywhere in the world.

The text mentions everything from responding to Ebola outbreaks in Africa to providing perioperative care in field hospitals in a war zone.

It's acute care, but in a very community based, mobile and often dangerous setting.

So that is the tour of the settings.

It is exhaustive.

It just proves the point that community health is not one thing.

It's a dozen different things.

It's everything outside the hospital walls.

And even that's not quite right, because some of these roles, like forensic nurses, are based in the hospital, but serve the community.

Good point.

Now, let's look at who is doing this work.

We've talked mostly about registered nurses, but the chapter has a section on expansion and regulation, specifically looking at licensed or registered practical nurses, LRPNs and nurse practitioners, NPs.

This is a really important demographic shift to understand.

The text points out that between 2008 and 2012, the number of LRPNs grew by 18 percent compared to just a four percent growth for RNs.

The workforce is changing.

That is a fast growing segment of the workforce.

What is their scope in the community?

Generally, the regulation varies by province.

But the rule of thumb is complexity and predictability.

LRPNs are educated to focus on stable clients with predictable outcomes.

If a case becomes complex or unstable or the outcomes are unpredictable, they're supposed to consult with an RN.

But they are becoming a huge and vital part of the home health workforce because they are more cost effective.

And on the other end of the spectrum, nurse practitioners.

NPs are registered nurses who have gone back to school for graduate education, a master's degree or higher.

They have much wider scope of practice.

They can autonomously diagnose conditions, order tests like x -rays and blood work and prescribe medications.

The text mentioned something called the CNPI.

What was that?

The Canadian Nurse Practitioner Initiative.

This was a big federally funded push to standardize the NP role across all the provinces and territories to make sure their education and their scope of practice were consistent.

So an NP from B .C.

could move to Nova Scotia and practice without a lot of red tape.

And where do they work?

All over.

But the text says about 32 percent of NP's work in the community in community health centers, remote nursing outposts, sexual health clinics.

They're often filling the primary care gaps where there just aren't enough doctors.

OK, we are in the home stretch here.

We've covered the what, the where and the who.

Now let's look at the what's next.

The trends in community health nursing.

The text lists four big ones that are shaping the future.

These are the forces that are pushing the profession forward.

Trend number one, health equity and social justice.

This loops all the way back to our discussion on the standards.

The trend is moving beyond just treating patients to actively changing conditions.

It is an explicit recognition that you cannot fix health if you don't fix poverty, inadequate housing and systemic racism.

The text says CHN's must be advocates to change policies.

The goal is health for all, not just health for the wealthy.

Trend number two, ICT information communication technology.

We touched on telehealth, but this goes much further.

It's things like telemonitoring, checking a diabetic's blood sugar remotely or looking at a post -op wound via a secure camera.

It's also about using social networking for health promotion campaigns.

But there is a risk mentioned, a big one.

Privacy is the huge one.

How do you keep all that sensitive health data secure?

And the other challenge is verifying information.

If a patient gets their health advice from a random unvetted Facebook group, the CHN has to navigate that world of misinformation.

It's a whole new battlefield for health education.

Trend number three, adapting to practice and system changes.

There are a few key things under this umbrella.

First, the Truth and Reconciliation Commission's calls to action.

The text is very clear.

Integrating indigenous traditional knowledge and practicing cultural humility isn't optional anymore.

It's a core professional and ethical necessity.

And the shift in home care.

The philosophy driving policy now is that home is better.

We're trying to keep frail older adults and people with complex conditions out of expensive institutions.

That requires a massive system shift to support them at home.

It's cheaper for the system and usually much better for the patient's quality of life.

But only if the support is actually there.

And finally, under this trend, collaboration.

This is about breaking down the silos,

specifically merging public health and primary care.

They use tools the text mentions like the toolkit to collaborate.

We need the different parts of the system to talk to each other so the patient doesn't fall through the cracks between them.

And the final trend, number four, education.

And this brings us right back to that pearls and pumps problem.

It really does.

The fundamental problem, according to the text, is that undergraduate nursing programs still tend to value acute care, hospital care over community care.

The glamour, the excitement, the prestige is still perceived to be in the E .R.

or the ICU.

So what's the solution?

How do you fix that?

The text says we need faculty champions, professors who are passionate about community health and consult the students, show them how exciting it is.

We also need high quality placements so students don't just sit in an office, but actually get out there and see the complexity and autonomy of the work.

The Canadian Association of Schools of Nursing, CASN, has developed national guidelines for public health competencies to try and fix this.

But it's a slow moving ship to turn.

So we have traveled from the high level blueprint all the way down to the gritty details of the streets.

We have.

It's been quite a journey.

If we try to synthesize all of this, what is the single biggest takeaway for someone listening?

For me, the big takeaway is that community health nursing is not a slower pace.

That is the fundamental myth.

The reality is that it is arguably the most autonomous, complex and essential part of the entire Canadian health system.

It requires a massive breadth of knowledge.

You aren't just treating a liver or a kidney or a broken leg.

You are working with the whole person in their environment with all the messiness and complexity that entails.

It's the difference between studying a lion in a highly controlled zoo versus studying a lion out on the savanna.

That is a fantastic analogy.

That's perfect.

In the hospital, the zoo, the variables are controlled.

You know when feeding time is, you know the environment is safe.

In the community, the savanna, anything can happen at any time.

And you have to be ready for it all.

So here is our final provocative thought for you, our listener today.

The text mentions that student nurses often enter school with that Grey's Anatomy view of nursing, all drama, surgery, hospitals.

But based on everything we've just discussed, the aging population, the crushing cost of hospitals, the push for prevention,

the future of health care is clearly undeniably moving into the community.

It is undeniable.

It has to.

So the question to leave you with is this.

If the future of health care is in the community, why do we still train our nurses?

And why does the public still imagine nurses as if the hospital is the center of the universe?

That is the multibillion dollar question that our system needs to answer if we want it to be sustainable for the next generation.

Something to chew on.

Thank you so much for joining us on this deep dive into community health nursing.

A big warm thank you from the entire last minute lecture team.

We will see you on the next one.

Take care, everyone.

Stay curious.