Community Health Nursing: A Canadian Perspective, 4th Edition

Chapter 1 History

Answers to Study Questions

1. The two forms of community health nursing that evolved in Canada in the early 20th
century were public health nursing and visiting/district nursing. PHNs were employed by civic,
provincial, or federal health departments to carry out preventive programs in the community. In
the later part of the 20th century, PHNs took on new roles in health promotion and community
development. Visiting/district nurses offered nursing services including the provision of services
for people who were experiencing illness at home. They were most frequently employed by
charitable organizations. Visiting nursing is now more commonly referred to as home health or
home care nursing. It is important to note that early forms of community health nursing
combined aspects of public health and home health care, particularly in rural and remote
communities. Over time, community health nursing has evolved and become increasingly
specialized according to the needs of the population and with health system changes.

2. Community health nursing evolved in ways that provided access to essential nursing and
health care services for people in their communities. Nurses developed and provided a
comprehensive array of services including care of the sick, prevention of illness and health
promotion. Early community health nursing were resourceful in harnessing the technologies
available to them at the time. Community health nurses understood the importance of the social
determinants of health and worked to influence conditions of living associated with poverty.

3. Early community health nursing programs focused on women, children, the poor, the
working class, and immigrants. There were several interrelated reasons for this emphasis. All
these groups were vulnerable within a society where political and economic power was held by
elite and middle-class males. Their vulnerability was clearly demonstrated by the higher
mortality rates these groups experienced. Another reason for the focus on these groups was the
need to create a strong and healthy pool of future citizens to establish Canada’s pre-eminence in
the 20th century and a focus on new families and early childhood provided opportunities for
health promotion. Immigrants were an important target group because elite and middle-class
reformers believed that they needed to adopt Canadian beliefs and practices rather than retain
those of their countries of origin.

4. The earliest public health programs that employed nurses were tuberculosis (TB) control,
school health, and infant welfare. TB was a leading cause of death in early 20th-century Canada
and a particular problem among the urban poor. Early efforts to control TB were based on the
belief that a reduction in the incidence of this disease would, as well as alleviating suffering,
reduce the costs of public welfare and healthcare programs. Community health nurses
contributed significant knowledge and skill in the area of TB control, strengthened through their
close relationships with people in their communities.
School-health programs were established to identify health problems among school-age children.
As working-class children entered the public school system, it became apparent that they
suffered from many preventable health problems that detracted from their capacity to learn.

Infant welfare programs were established to reduce infant mortality rates. In the early 20th
century, immigration, industrialization, and urbanization created problems for families with
children. Well Baby Clinics provided access to essential health assessment, immunization and
counseling for mothers with preschool children. These programs remain a cornerstone of modern
public health nursing programs.

5. The British North America Act reflected 19th-century beliefs about the role of the state.
In keeping with the philosophy of laissez faire, the state had no role to play in the provision of
healthcare and social welfare for its citizens. These were private matters, which were the
responsibility of individuals and families. Those who could not provide for their families were
compelled to obtain charitable assistance from local governments or, more likely, voluntary
philanthropic agencies. The BNA Act left responsibility for healthcare in the hands of the
provinces, which also took only a limited interest in this area. Enabling legislation for the
establishment of health departments was passed by several provinces prior to the end of the 19th
century, but permanent health departments were not established in most Canadian cities and
provinces until the 20th century. Prior to the end of World War II, local and provincial health
departments received no assistance from the federal government. Their capacity to respond to the
health needs of the communities for which they were responsible was constrained by their ability
to fund programs from local tax revenues.

6. Early on, the Red Cross working with nurse leaders of the day recognized that nursing
education programs must be sufficiently broad to prepare community health nurses with a view
of health and illness prevention required to work in diverse community settings. Competencies in
health promotion, prevention, health assessment, teaching and counseling were not developed in
existing hospital based nursing education programs. This recognition was the impetus for the
development of the first certificate programs in public health nursing offered in Canadian
universities, and was a major factor in advancing university based education in nursing.

In the 1940s, 1950s, and 1960s, a series of cost-sharing arrangements enabled the federal
government to establish a national healthcare system by creating incentives for the provinces to
spend more money in this area and to extend those services to all citizens regardless of their
ability to pay. The National Health Grants Program (1948), the National Hospital Insurance and
Diagnostic Services Act (1957), and the Medical Care Insurance Act (1968) were key elements
in the increased federal role in the provision of healthcare.

7. First, they often pioneered community health nursing programs, thus demonstrating both
the need for and the effectiveness of these programs. Second, they advocated for community
health programs in communities where local governments were either unable or unwilling to do
so. Third, they created educational programs in universities to prepare nurses to practise in this
area. Fourth, they provided funding to support local initiatives to create community health
nursing programs.