I recently joined a transitional care nurse, Senior Staff Nurse Yang Lee Fung, when she visited a patient at his home. Mr Tan is 78 years old and has been unable to talk since a stroke 10 years ago. He has multiple health issues, including heart failure and diabetes, and has to take more than 10 types of medication every day.

In the past few years, Mr Tan has been admitted to the National University Hospital several times. He returned home from hospital recently after recovering from a lung infection and "fluid overload".

In the one hour that Ms Yang and I were at Mr Tan's home, she did a physical examination, made sure his family members understood his heart condition and went through with them the amount of fluids he should be drinking and the medication he had to take. She highlighted the signs and symptoms of potential problems and what to do if they happened.

Ms Yang also noticed that Mr Tan's four-room flat in Bukit Merah was cluttered. Mr Tan risked having a fall and another trip to hospital because he has had an unsteady gait since his stroke and has not fully regained his physical functions after his recent hospitalisation. She suggested some modifications to make the space safer, such as clearing away unused items and stacks of magazines and newspapers, especially along the route he takes to the toilet.

During her next visit a week later, Ms Yang will review Mr Tan's fall risk and expand on prevention strategies and rehabilitative exercises.

Her work does not end after leaving his home. The family members know they can contact her if they need advice.

This kind of care in the home is part and parcel of what community nurses like Ms Yang do. And this role is becoming critical as nursing services in Singapore evolve from predominantly hospital-based care to community care.

NURSING SCIENCE

What may not be apparent in community nursing - where nurses work with individuals, families and communities where they live and work - is the thought processes or nursing science that goes into it.

Nursing science calls for understanding human health and response to illness, and applying that knowledge to influence healing. The focus is on the whole person - his physical, mental, social and spiritual well-being, and his environment.

At the heart of this is providing the best possible care for patients.

Friends have said to me: "You mean there's such a thing as nursing science? I thought nurses just take care of patients and carry out medical orders."

Nursing frameworks and theories offer different perspectives on how we view our patients, interact with them and make clinical decisions. Such knowledge allows nurses to make sense of an individual's condition to determine what they need.

For instance, a nurse who uses the self-care concept will gather data by interviewing and assessing a patient's ability to care for himself. If she decides that he has poor understanding of his condition, she will come up with a plan and make sure the patient can care for himself and prevent potential health problems.

This is considered successful if future complications are avoided. Otherwise, the plan has to be modified. This problem-solving approach forms a chief component of the nursing practice.

Another example is how community nurses identify health, social or safety issues in the home or community and understand how these may affect individuals.

In Mr Tan's case, for instance, Ms Yang also found out that his family members were extremely dedicated in looking after him. His brother, the sole breadwinner, works from home and makes sure that either he or his wife is with Mr Tan at all times.

Understanding the family dynamics, as well as its financial status, allows nurses like Lee Fung to suggest a better care plan to help patients recover, stay healthy and enjoy a good quality of life.

Community nurses understand that family and the community will have a role in whether the patient sticks to his health regimen and what resources are available to monitor and care for him.

Besides home nursing, community nurses also contribute to primary or preventive care, for instance, through health education programmes. These are based on promoting healthy living, preventing health problems and restoring health.

They may work alongside family medicine doctors to help patients better manage chronic diseases such as diabetes and hypertension. Such services complement medical care by ensuring patients keep to their prescribed treatment. The nurses also counsel individuals to help them improve their general health through disease prevention, nutrition and exercise.

Nursing science explores strategies to give patients a greater say in their care, so they can better make decisions regarding their health. It directs nurses to recognise the impact of family and community in order to deliver effective preventive care.

This results in greater satisfaction, fewer complications and hospital visits. As more individuals make effective health decisions, the overall health of the community will improve.

Advances in medicine and technology mean that people live longer and often with multiple chronic conditions and complex needs. Coupled with an ageing population and declining birth rates, these pose an unprecedented challenge to Singapore.

In response, we are moving from hospital-centric care towards one within the community, with emphasis on "ageing in place" - the ability to live independently and comfortably at home or in a community. Nursing, too, has evolved in tandem.

Nursing science provides critical thinking structures for the clinical decision-making process in patient care. It builds sustained partnerships with individuals and empowers them to make better decisions.

The health and well-being of individuals and communities depend greatly on how nurses effectively apply nursing science.

As we celebrate Nurses' Day on Monday, we should see the changing healthcare landscape as an opportunity for nurses to affect health outcomes and cost effectiveness. When we appreciate how we can apply nursing science to support our practice, then those we care for will be closer to being healthy - and happy.