NUR330-602 Population & Community Health
We are bridging tech and touch. From hospital to home, from screen to soul.
Self-Reflective Journal: Community Health in Practice
This course helped me pause and take a step back from my daily nursing responsibilities. I am usually focused on my patients—what they need, how they are feeling, what is urgent. However, through the various experiential assignments, I began to see not just the individual needs, but also the patterns and gaps that shape their lives long before we ever meet. It gave language to things I have witnessed in the field and deepened my understanding of how to assess and advocate for the communities I serve.
CAN Sim Community Assessment
This simulation reminded me that community health begins with considering the whole picture. It helped me understand how large-scale data can reveal where breakdowns are occurring and who is most at risk. It felt familiar to me because I work closely with virtual monitoring platforms like CareVio. However, the difference is that I now see how important it is to ask better questions. Not just “What is the data?” but “What is missing?” and “Who is not showing up until it is too late?” This changed how I view epidemiology in a very real-world way.
Windshield Survey
This was probably the most meaningful assignment for me. I do not live in Wilmington’s 19805 zip code, but I work there every week. I have done countless admissions in this area. Doing the Windshield Survey helped me pay closer attention to the streets I thought I already knew. I saw the difference between blocks—some homes freshly painted, others falling apart. I saw broken sidewalks, food insecurity, and isolation. It gave me context, and once I had that, I could not unsee it.
This project highlighted the impact of social determinants and prompted me to reevaluate the questions I ask during assessments. Now, I ask more about mobility and safety. Can they get to the store? Do they have someone who checks in? Do they feel safe enough even to open their front door? These are not just side questions—they’re central to care planning.
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Sexual Orientation and Gender Identity Nurse Course
This module reminded me that being inclusive is more than just having good intentions; it is about taking action. It is about creating an environment where every patient feels respected and safe without needing to explain or justify who they are. I have met patients who hesitate to share their full story because they have been judged in the past. This training helped me identify areas where I still needed improvement. I now make more space in my assessments and documentation to reflect and honor identity. Every person deserves to feel seen in their care plan.
CastleBranch & Google Form Submission
These assignments helped bring attention to the systems and structures that surround our work. CastleBranch made me reflect on how much staying organized and compliant protects both patients and nurses. The Google Form brought policy into the conversation. Community health is not just care at the bedside—it is also about knowing what is available and how to get it. I have started keeping a list of resources that go beyond medical needs, including transportation, housing, and meals. That is the kind of support that changes outcomes.
What I Learned About Community Health Nursing
Community health nurses are often the first to notice problems before anyone else. We see the early signs. We are at home, seeing the reality. We listen to the family member who is overwhelmed or the patient who is afraid to ask for help. This course showed me that those small moments are public health moments. And that being a connector between systems is not just a nice add-on, it is the whole job.
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How I’m Bringing This Into Practice
- I ask about social support, transportation, and emotional well-being up front.
- I notice isolation early, especially in older adults living alone.
- I document in a way that reflects not just symptoms but context.
- I share what I have learned with newer nurses and help them think beyond the task list.
Looking Ahead: ROOTS
This course helped me give structure to something I had been thinking about for a while. Through my work, I noticed how virtual nursing teams and home health teams often worked in parallel. We were seeing the same patients, often with the same concerns, but we were not communicating in real-time. That disconnect led to repeated phone calls, missed educational opportunities, and unnecessary delays.
That is where ROOTS comes in—my idea of a care model that connects Relationships, Outcomes, Oversight, Transitions, and Support. It focuses on creating one system of communication between virtual nurses and in-person home health teams. We already have the technology. We already have the goals. What we need is structure, shared access, and a mindset that values collaboration over redundancy.
The Agency for Healthcare Research and Quality (AHRQ) recently profiled a virtual nursing model that echoed this same idea. In their report, nurses used technology to support admissions, patient education, discharge planning, and mentoring in-hospital staff—all done remotely but with purpose and impact (Sanford et al., 2023). It showed what is possible when experienced nurses are used not just as a backup system, but as a core part of care delivery.
ROOTS follows that same thinking. It strengthens transitions of care by giving virtual teams visibility into what is happening on the ground, and it provides in-person teams with a second set of eyes when the plan of care changes suddenly. Instead of having more hands do the same tasks, it divides the labor in a way that builds trust, improves outcomes, and supports both the nurse and the patient. But more than anything, ROOTS is a reflection of who we are as nurses.
We are the first to show up when the system breaks down. We are the thread that holds the plan together when no one else follows through. And when we are supported to work together—when we are connected and trusted—we become the roots of our communities: steady, strong, and constantly growing toward healing.
References
American Nurses Association. (2015). Code of Ethics for Nurses. American Nurses Association; American Nurses Association. https://www.nursingworld.org/coe-view-only
Centers for Disease Control and Prevention. (2019). Social Determinants of Health. Centers for Disease Control and Prevention. https://www.cdc.gov/socialdeterminants/index.htm
National Academies of Sciences, Engineering, and Medicine. (2021). The future of nursing 2020-2030: Charting a path to achieve health equity. National Academies Press. https://doi.org/10.17226/25982
Safer, J. D., & Tangpricha, V. (2019). Care of the Transgender Patient. Annals of Internal Medicine, 171(1), ITC1. https://doi.org/10.7326/aitc201907020
Sanford, K., Schuelke, S., Lee, M., & Mossburg, S. (2023). Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges. Psnet.ahrq.gov. https://psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workforce-challenges
Williams, D. R., Lawrence, J. A., & Davis, B. A. (2019). Racism and Health: Evidence and Needed Research. Annual Review of Public Health, 40(1), 105–125. https://doi.org/10.1146/annurev-publhealth-040218-043750
Technology should never be a barrier-it should be a window. A window into someone's story, someone's home, someone's fear, and someone's strength. When we turn the screen into a window, we bring humanity back into healthcare. We turn data into people, tasks into relationships, and care into community.
We are the ROOTs of our Community
Community health is crucial for the well-being of our society, and nursing is at the heart of this incredible movement I was fortunate enough to explore a particular area of our community, discovering insights that significantly affect the amazing patients I encounter daily. It brings me so much joy to support and advocate for individuals as we journey through healthcare together, building a healthier community for all! Together, we can make a meaningful impact in the lives of those we serve!
A Community Health Plan for Older Adults in Wilmington, DE (19805)
Health in Wilmington’s 19805 ZIP code is shaped by daily reality. For older adults, health is not defined by a primary care provider or insurance status. It is discovered during a potentially hazardous walk to the bus stop, in their ability to afford groceries, and whether someone follows up after discharge are also important considerations. In this community, aging means navigating through disjointed systems that often do not see the whole person.
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This plan reflects what nurses already know. Community health does not start at the clinic. It begins with noticing what is missing—a half-empty fridge. A medication bottle was untouched. An appointment was missed without a call. Nurses already bridge these moments. This strategy turns those instincts into a structured plan. It begins with nutrition, home safety, and access to care. And builds from presence, relationship, and trust.
Conclusion
Community health is not a program. It is a promise. A promise that care will not just arrive during a crisis. A promise that care will remain when things are quiet. In Wilmington’s 19805 ZIP code, older adults are not just patients; they are also community leaders. They are neighbors. They are storytellers. They are the roots of this community.
The ROOTS model—Relationships, Oversight, Outcomes, Transitions, Support—is not just a framework; it is a comprehensive approach to addressing complex issues. It is a bridge. A bridge between fragmented healthcare systems and real lives. A bridge between technology and people. A bridge between isolation and support.
When virtual care and in-person nursing work together, they do more than fill a gap. They grow something deeper. Something trusted. When that care comes from Delaware, for Delaware, it changes the story.
This is what it means to grow healthcare from the roots. Not through abstraction. Through a relationship. Through presence. Through care that knows its roots.
Role as a Nurse
Role of the Nurse
Nurses serve as the connective tissue of the healthcare system. Their presence is often the only constant in a patient's care journey. While providers rotate and platforms change, the nurse remains. In the homes of older adults, nurses witness what the chart does not capture. They see the expired food in the refrigerator, the stack of unopened discharge papers, and the hesitation when a patient tries to stand from a worn-out chair. These observations do not require a formal assessment. They come from being present. They come from noticing. They come from knowing what is normal for the person in front of them.
In Wilmington’s 19805 ZIP code, where many residents live alone and carry complex medical diagnoses, the role of the nurse extends far beyond taking vitals or documenting patient information. Nurses explain discharge instructions. Nurses reconcile medications. Nurses teach symptom awareness. Nurses listen long enough to hear what is unsaid. The nurse becomes a translator. The nurse makes fragmented care plans that make sense in real life.
Barriers to care are rarely simple. A missed appointment may result from a broken phone charger, a forgotten password, or fear of being misunderstood. Nurses address these minor disruptions before they become medical events. Nurses sit beside patients and show them how to check a portal. Nurses call a clinic to confirm transportation. Nurses remind someone that they are not navigating this system alone.
Nurses build relationships that last. Not because they are expected to. Because the work demands it. In communities where providers are stretched thin and resources are inconsistent, the nurse becomes the anchor. That presence brings familiarity where there has been fear. That consistency builds trust where the system has lost it. Through every home visit, phone call, and moment of advocacy, nurses shape the foundation of community health. Not through tasks. Through connection.