Community Health Nurses: The historical context and current reality in the COVID-19 pandemic
This blog post by Ruth Schofield, Michelle Johnson and Shona Lalonde is the first in a two-part series that describe the work of Community Health Nurses (CHNs) as they respond to the COVID-19 pandemic. These blog posts reflect the voices of CHN across Canada — their experiences, challenges and innovations, as well as ethical dilemmas they face.
Community Health Nurses (CHNs)
COVID-19 was declared a pandemic by the World Health Organization on March 11, 2020.  Community health nurses (CHNs) are at the front line when it comes to pandemic planning and response; they are experts in preventing the transmission of COVID-19, as well as protecting and promoting the health of individuals, families and communities across Canada.
In urban, rural and remote settings, coast to coast to coast, CHNs work directly with populations who are at higher risk for COVID-19 due to poverty and environments where physical distancing and hygiene cannot be maintained — as well as rural and northern locations where there is limited access to screening and health services and may have other illnesses and health issues. 
For more than a century, CHNs have provided essential education, care and leadership during outbreaks, epidemics and pandemics. Since the 17th century, CHNs have organized and provided care in communities, understood how inequities have disadvantaged populations, advocated for social justice and provided outreach services to rural and remote communities and isolated populations within urban settings. 
During the 1918 Spanish influenza pandemic, the significant and visible work of nurses earned recognition, especially for their central role in community and public health systems.  A reform of nursing education followed and led to baccalaureate preparation for nurses and the integration of public health nursing content into the curriculum. 
This evolution built upon the work and leadership of Florence Nightingale, whose principles of hygiene, cleanliness and advocacy to address health inequities are foundational to modern-day community health nursing. [3,5,6]
Voices of CHNs
Over the decades, CHNs have promoted health and equity in Canada during serious outbreaks and pandemics including Swine Flu, SARS, H1N1 and now COVID-19. Community Health Nurses of Canada (CHNC) is a voluntary national professional association that advances CHN practice and the health of Canadians and is an associate member of the Canadian Nurses Association (CNA).
In preparation for a March 2020 webinar sponsored by CNA, CHNC asked CHNs in home health and public health from several provinces to share their current reality in the COVID-19 pandemic.
Four questions were circulated by email and included:
- What has been your experience of COVID 19 pandemic response?
- What are the challenges?
- What are the successes?
- What are the ethical dilemmas you have faced?
In this blog post we share highlights from the responses to the first three questions. A second blog post will explore the ethical dilemmas reported by those who responded .
CHN responses to the COVID-19 pandemic
CHNs described the reality of their experience in the COVID 19 response as overwhelming due to the rapid and constant changes to their usual practice. Redeployment to other programs, longer work hours and the use of multiple documentation and information systems were noted as some of the most significant changes.
Service changes reported included delays in school immunization programs and reprioritizing of home support services to clients with COVID-19. Communication with clients changed significantly with it being now primarily through virtual means, most often over the telephone.
Clients with chronic conditions receiving care in their homes require constant monitoring of their health with astute vigilance to infection preventive and control measures.
In this context of uncertainty, CHNs reported feelings of burn out, fear of COVID-19 infection for themselves and their family, and concern for personal protective equipment restrictions. Managers described challenges with timely communication to their staff as well as interpreting shifting policy and protocol directives.
Other challenges include rushed and inadequate training for new roles when redeployed, adhering to physical distancing in small workspaces and dealing with disconnected documentation systems. Some observed an erosion of the public health nursing role prior to the pandemic in several provinces/territories.
Moving to virtual care had unique challenges, as clients can lack access to reliable internet, phones and radios, or are not able to use the technology because of dementia or physical disabilities.
Concern for health inequities was recognized for pregnant women isolated in rural and remote communities and for families with infants who were unable to access formula.
Finally, those who responded reported a wide range of challenges including:
- responding to increased disclosures of intimate partner violence as shelters reached capacity;
- supporting First Nations’ community leaders in decision-making about ceremonial gatherings; and
- reassuring clients who were angry due to delayed testing results.
Despite challenges, the responses reflected CHNs’ amazing resilience, flexibility, adaptability and ability to innovate. CHNs redesigned clinics from multi- to single-nurse presence, used text-in requests for contraception (then arranged delivery to the client), used videoconferencing to assess the safety of client homes and carried out newborn assessments in their vehicle while parents watched from their windows. CHN acknowledged that success was knowing each visit supported a vulnerable person to remain safe at home and in their community.
Relationships were strengthened with leaders in First Nations and new partnerships were developed with allied health workers. CHN commented on the support they received from their organizations through ongoing updates and guidance.
The voices of CHNs articulate the constant change and challenges of responding to the inequities of COVID-19, as well as an excellent ability to innovate and be responsive.
In the next blog post, titled Ethical dilemmas faced by Community Health Nurses in the COVID 19 pandemic, we will highlight the ethical dilemmas CHNs encountered as they responded to COVID-19 pandemic, as well as ways to address them.
For more information
Canadian Nurses Association
- Visit the CNA website
- Listen to the following webinar recording: Community Health Nurses: Facing the reality of COVID-19 pandemic (2020)
Community Health Nurses of Canada (CHNC)
About the authors
Ruth Schofield, RN, MSc(T), is an assistant clinical professor at McMaster University in Hamilton, Ontario. She is also the former president of Community Health Nurses of Canada.
Michelle Johnson, RN, BN, MSc (Inf Dis), is a public health nurse with the Public Health Branch of Manitoba Health, Seniors and Active Living in Winnipeg, Manitoba.
Shona LaLonde, RN, MN, is a nurse tutor at Camosun College in Victoria, BC.
[1.] World Health Organization. WHO Timeline - COVID-19 [Internet]. Geneva: WHO; 2020 April 12 [updated 2020 April 27; cited 2020 June 29]. [7 screens]. Available from: https://www.who.int/news-room/detail/08-04-2020-who-timeline---covid-19
[2.] Government of Canada. Coronavirus disease (COVID-19): vulnerable populations and COVID-19 [Internet]. Ottawa (ON): Government of Canada; 2020 Apr 9 [cited 2020 May 6]. 2 p. Available from: https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases-conditions/coronavirus/covid-19-vulnerable-populations/covid-19-vulnerable-populations-eng.pdf
[3.] Vukic A, Dilworth K. The history of community health nursing in Canada. In Stamler L, Yiu L, Dosani A, Etowa J, Van Daalen-Smith C. Community health nursing: a Canadian perspective. 5th ed. North York: Pearson Canada Inc; 2019. p 1-17.
[4.] Bauer S. 5 questions: how the 1918 Spanish flu pandemic changed the nursing profession. [Internet]. [location unknown]: The Philadelphia Inquirer; 2018 Nov 9 [cited 2020 May 6]. [11 screens]. Available from: https://www.inquirer.com/philly/health/5-questions-how-the-1918-spanish-flu-pandemic-changed-the-nursing-profession-20181109.html
[5.] Gill JC, Gill CG. Nightingale in Scutari: her legacy reexamined. Clinical Infectious Diseases [Internet]. 2005 [cited 2020 May 6];40(12):1799-1805. Available from: https://academic.oup.com/cid/article/40/12/1799/314039
[6.] Burrows M. Florence Nightingale show presents nursing pioneer who told us to wash hands [Internet]. [location unknown]: Reuters World News; 2020 Mar 5 [cited 2020 May 6]. [4 screens]. Available from: https://www.reuters.com/article/us-exhibition-florencenightingale/florence-nightingale-show-presents-nursing-pioneer-who-told-us-to-wash-hands-idUSKBN20S2LP?feedType=RSS&feedName=lifestyleMolt