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Chapter 1 9/17/15 8:44 PM
Populations
A collection of individuals who have one or more personal or
environmental characteristics in common
← Prevention
Anticipatory action taken to prevent the occurrence of an event or
minimize its effect after it has occurred
← The Determinants of Health
Factors that influence the health of individuals, families, and populations
← Health of Populations
Historically gains in the health of populations have come largely from
public health changes
o Improved sanitation, control of disease, immunizations
o Gain in life expectancy
← Public Health
Scientific discipline
Community-oriented
Population-focused
Mission is to organize community efforts to use scientific and technical
knowledge to prevent disease and promote health
← Public Health Nursing
Public health nursing is the practice of promoting and protecting the
health of populations using knowledge from nursing, social, and public
health sciences (APHA, 1996).
Guided by an assessment of health status
o Community assessment
Considers the determinants of health-
o What makes some people healthy and others unhealthy?
o How can we create a society in which everyone has a chance to live
long healthy lives?
Committed to Communities, Families, and Individuals
o Social Justice
Relationship Based
← Public Health Nurses:
Practice in a variety of public and private organizations
Partners with communities and populations
Must understand and apply concepts from various disciplines
Practice in partnership with the community and numerous other groups
Are proactive with respect to social and health care concerns, policy, and
legislative activities
← Levels of Public Health Nursing Practice
Individual / Family Level of Practice
o A family is defined as two or more people who identify them selves
as family
o Share emotional bonds
o carry out the functions of a family
Community/ Level of Practice
o A community can refer to :
A group of people or population group
Physical place and time in which the population lives and
works
Cultural group that has shared beliefs, values, institutions
and social systems
Systems Level of Practice
o A system is an institution or organization that can be in one of more
communities. Key systems include:
Health care systems
Public health systems
Schools
Churches
Government Agencies
Non Profits
Businesses
← Core Functions of Public Health
Assessment
o Systematic data collection about a population
Includes monitoring the population’s health status and
providing/ disseminating information about the health of the
community
Policy Development
o Developing policies that support the health of the population
through leadership and research
Assurance
o Making sure that essential community-oriented health services are
available
Includes providing essential personal health services for individuals as
well as a competent PH workforce
← PHN’s and Core PH Functions: Assessment
Participate in and provide leadership for:
o Assessing community needs, health status of populations within the
community, and environmental and behavioral risks
o Look at trends in the health determinants
o Identify priority health needs
o Determine the adequacy of existing resources within the
community
o Engage in policy-development efforts
← PHN’s and Core PH Functions: Assurance
Focuses on the responsibility of public health agencies to make certain
that activities have been appropriately carried out to meet public health
goals and plans
Includes the development of partnerships between public and private
agencies
← PHN’s and Core PH Functions: Policy Development
Core function AND core intervention strategy
Seeks to build constituencies that can help bring about change in public
policy
Examples:
o Development of Healthy People 2020 state objectives
o National effort to control acquired immunodeficiency syndrome
(AIDS)
o Anti-smoking ordinances
← The Ten Essential Public Health Services
1. Monitor health status to identify community health problems.
2. Diagnose and investigate health problems and health hazards in the
community.
3. Inform, educate, and empower people about health issues.
4. Mobilize community partnerships and action to identify and solve
health problems.
5. Develop policies and plans that support individual and community
health efforts.
6. Enforce laws and regulations that protect health and ensure safety.
7. Link people to needed personal health services and assure the
provision of health care when otherwise unavailable.
8. Assure competent public and personal health care workforce.
9. Evaluate effectiveness, accessibility, and quality of personal and
population-based health services.
10. Research for new insights and innovative solutions to health
problems.
← Public Health Nursing as a Field of Practice
Public health nursing is a specialty because it has a distinct focus and
scope of practice and requires a special knowledge base.
o Population focused and community oriented
o Concerned with health of all members of population or community
o Focus on health, prevention, and interventions at the community
and population levels
o Public Health Nursing : Scope and Standards of Practice (ANA)
Educational preparation
o Baccalaureate—beginning staff public health nurse
o Master’s—assumed for specialist in public health nursing who has
expertise in population focused care
o DNP
← Core Competencies of Public Health Professionals
Necessary skills to implement the core functions and the 10 essential
services.
o 8 domains include: Analytic assessment, basic public health
sciences, Cultural competency, Communication, Community
dimensions of practice, Financial planning & mgmt, Leadership &
systems thinking, Policy development/program planning skills.
o Quad council has list of skills PHN’s should attain for each of the
competencies
o IOM document in 2003 identifies 8 new areas PH workers should
know: informatics, genomics, cultural competence, community-
based participatory research, policy and law, global health, &
ethics
← Distinguishing Public Health Nursing from Other Nursing Specialties
The client or unit of care is the population
The primary obligation is to achieve the greatest good for the greatest
number of people or the population as a while.
The processes used by public health nurses include working with the client
as an equal partner
Primary prevention is the priority in selecting appropriate activities
Public health nursing focuses on strategies that create healthy
environmental, social, and economic conditions in which populations may
thrive.
A public health nurse is obligated to actively identify and reach out to all
who may benefit from a specific activity or service.
Optimal use of available resources to assure the best overall improvement
in the health of the population is a key element of the practice.
Collaboration with a variety of other professions, populations,
organizations, and other stakeholder groups is the most effective way to
promote and protect the health of the people.
← Public Health Nursing: Focuses on Health Promotion and Disease Prevention
PH Nursing considers all levels of prevention, with a preference for
primary prevention
Levels of Prevention
o Primary
o Secondary
o Tertiary
← Primary Prevention
Measures that actively promote health, prevent illness, and provide
protection
o Health Promotion and Education
o Specific Protective Measures
o Is implemented before a problem develops
o Targets essentially well populations
← Secondary Prevention
Early diagnosis and prompt interventions to limit disabilities
o Identifies risks or hazards and modifies, removes, or treats them
before a problem becomes more serious
o Targets populations that have risk factors in common
o Screenings
o Testing
← Tertiary Prevention
Reduce impairments and disabilities, minimize suffering, promote
adjustment to immediate condition, and rehab
o Limits further negative effects from a problem
o Prevent complications, keeps existing problems from getting worse
o Seeks to restore person to optimal level of functioning
o Target prevention after a disease or injury has occurred
← Population-Focused Practice Versus Individual-Focused Practice
Population-Focused Practice:
o Diagnoses, interventions, and treatments are carried out for
population or subpopulation
Levels of prevention (primary, secondary, tertiary)
o Population-level decision making is different
o Concerned with more than one subpopulation
Individual-Focused Practice:
o Diagnoses, interventions, and treatments are carried out at
individual client level
← Community Health Nursing VS. Public Health Nursing
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← Community-Based Nursing
Managing acute or chronic conditions among individual clients and
families
Care is family-centered
Setting is community-based
Goal
o Manage acute and chronic conditions
Focus in on “illness care” of individuals and families across the life span
o Provide acute and chronic illness care and the provision of
comprehensive, coordinated, and continuous care
o A setting-specific practice, care is provided where people live, work,
and attend school
← Community-Oriented Nursing
Goal
o Prevent disease and disability; promote, protect, and maintain
health
Focus is on “health care” of individuals, families, and groups in community
as a whole
o Provide health care to promote quality of life
o Community diagnosis, health surveillance, monitoring and
evaluation of community and population
o Coordination of health care, disease prevention, health promotion,
health education.
← Community Oriented versus Community-Based Nursing
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← Looking to the Future
Barriers to specialization in PH Nursing
o Mindset of only role: direct care
o Few nurses with graduate-level preparation
Need to establish population-focused nurse leaders
o Organizational changes occurring in the delivery system offer
opportunities for new roles and population thinking.
o Need for more masters and doctoral programs in public health
nursing
Health Care System Overall
o We can anticipate the focus of the health care systems of the
future to be on community oriented strategies for health promotion
and disease prevention and community- based strategies for
primary care and much of secondary care.
← Healthy People 2020
Healthy People provides science-based, 10-year national objectives for
improving the health of all Americans.
For 3 decades, Healthy People has established benchmarks and monitored
progress over time in order to:
o Encourage collaborations across sectors.
o Guide individuals toward making informed health decisions.
o Measure the impact of prevention activities.
Vision
o A society in which all people live long, healthy lives.
Mission
o Healthy People 2020 strives to:
Identify nationwide health improvement priorities.
Increase public awareness and understanding of the
determinants of health, disease, and disability and the
opportunities for progress.
Provide measurable objectives and goals that are applicable
at the national, State, and local levels.
Engage multiple sectors to take actions to strengthen policies
and improve practices that are driven by the best available
evidence and knowledge.
Identify critical research, evaluation, and data collection
needs.
Overarching Goals
o Attain high-quality, longer lives free of preventable disease,
disability, injury, and premature death.
o Achieve health equity, eliminate disparities, and improve the health
of all groups.
o Create social and physical environments that promote good health
for all.
o Promote quality of life, healthy development, and healthy behaviors
across all life stages.
← National Prevention Strategy
Called for under the Patient Protection and Affordable Care Act
Developed by the National Prevention Council
Four Strategic Directions:
o Building Healthy and Safe Community Environments: .
o Expanding Quality Preventive Services in Both Clinical and
Community Settings
o Empowering People to Make Healthy Choices:
o Eliminating Health Disparities:
← Definitions
Health Disparity- A type of difference in health that is closely linked with
social or economic disadvantage. Health disparities negatively affect
groups of people who have systematically experienced greater social or
economic obstacles to health. These obstacles stem from characteristics
historically linked to discrimination or exclusion such as race or ethnicity,
religion, socioeconomic status, gender, mental health, sexual orientation,
or geographic location. Other characteristics include cognitive, sensory, or
physical disability.
Health Equity- When all people have "the opportunity to 'attain their full
health potential' and no one is 'disadvantaged from achieving this
potential because of their social position or other socially determined
circumstance'".
Social Determinants of Health- The complex, integrated, and
overlapping social structures and economic systems that are responsible
for most health inequities. These social structures and economic systems
include the social environment, physical environment, health services,
and structural and societal factors. Social determinants of health are
shaped by the distribution of money, power, and resources throughout
local communities, nations, and the world.
Chapter 18 9/17/15 8:44 PM
← Community Defined
“A group of people, often living in a defined geographical area, who may
share a common, culture, values and norms, and are arranged in a social
structure according to relationships which the community has developed
over a period of time. Members of a community gain their personal and
social identity by sharing common beliefs, values and norms which have
been developed by the community in the past and may be modified in the
future” (World Health Organization [WHO], 2004, p 16).
Traditionally thought of as people in a given geographical location, really
can refer to any group of people sharing something in common
o People in relationship with others
o Bounded geographical setting and/or common values or interests
o Emotional or functional relationships
Community specified
o People, place, and function dimensions
Population
o may or may not interact , typically share a geographic location
Aggregate-
o a mass of individuals considered as a whole
← Community as Client
The community client
o Nursing practice—community oriented
o The community is client ONLY when the nursing focus is the
collective or common good of the population NOT individual health
Relevance of the community client to nursing practice
o Nursing goal—improved health of the collective
A community practice setting is insufficient reason for saying that practice
is oriented toward the community client
o When the location of the practice is in the community but the focus
of practice is the individual or family, the nursing client remains the
individual or family, not the whole community
Nursing focus is on the collective or common good of the population
instead of on individual health
Nurse may work with individuals; families; other interacting groups,
aggregates, or institutions; or within a population but the resulting
changes are intended to affect the whole community
← Community Assessment
One of the core functions of public health
The process of thinking critically about the community
A logical, systematic approach to identify community needs, clarify
problems, identify strengths and resources
Is an ongoing process
The primary goal of community assessment is to identify the health needs
of a community
Community Assessments are used to:
o Document needs and gaps in service
o Identify potential resource
o Help to establish a vision, goals and strategies to meet community
needs
o Build consensus and buy-in to change
o Increase a community’s readiness and ability to change by
promoting collaboration among partners
o Identify benchmarks to measure progress in meeting goals
o Provide information for problem and asset identification and policy
formulation, implementation, and evaluation.
Involves getting to know and understand the community as client and
partner
Steps to assessing community health:
o Gathering relevant existing data and generating missing data
o Developing a composite database
o Interpreting the composite database to identify community
problems and strengths
o Analyzing the problem
The process of community assessment will help you
o Understand the context in which people live and issues they want
addressed
o Locate strengths or underutilized resources that could be developed
o Help you design effective, collaborative strategies to engage people
o Empower people by giving them a role in designing and
implementing the strategies that improve their health
← Community Health Needs Assessments and the Affordable Care Act
Community health needs assessments (CHNA) and implementation
strategies are newly required of tax-exempt hospitals as a result of the
Patient Protection and Affordable Care Act.
CHNA must be done every 3 years, include an in depth analysis of the
community’s needs and an implementation strategy outlining how you
propose to address those needs in the coming years.
By statute, the CHNAs must take into account input from “persons who
represent the broad interests of the community served by the hospital
facility, including those with special knowledge of or expertise in public
health.”
← Define the Community
What are the boundaries for the assessment?
1. County
2. City
3. Neighborhood
4. Day Care Center
5. School
6. Worksite
7. Specific population group
8. Other?
← Data Collection
Acquire usable information about community health problems and health
strengths
← Community Assessment Data
Data collection and interpretation
Data gathering
Data generation
o Informant interviews
o Community forum
o Focus groups
o Participant observation
o Windshield surveys
Collection of reported data
o Secondary analysis
o Surveys
← Profile of the Community
Brief history including a health-related history
Natural physical characteristics
Population per square mile
Existing form of government
Traditions, values, and beliefs
Cultural traditions and norms
Strengths and liabilities
← Data about the People
Age and sex distribution
Ethnic and religious composition
Education and socioeconomic status
Income, occupation, unemployment
← Environmental Data
Geography
Climate
Purity of air and water
Toxins, pollutants
Adequacy of housing
Police, fire and civil defense
Waste disposal
Transportation systems and patterns
← Channels of Communication
Formal and Informal
Key community leaders
Service, religious, and voluntary health organizations
Newspapers, TV, radio, postal services
Centers for congregating
Resources and services
← Health and Illness Patterns
Vital statistics
Disease incidence and prevalence
Leading causes of death
Rate of births
← Health Facilities
Facilities, resources, and personnel
Current and adequately equipped?
Accessibility
Health-related planning groups
← Analysis of Community Assessment Data
Gather all your collected data
Identify and generate any missing data
Synthesize data and identify themes
Identify community needs and problems
Identify community strengths and resources
Next, state your identified problems as nursing diagnoses
← Community Nursing Diagnosis
Developing the community health diagnosis helps clarify the problem and
is an important first step to planning.
Community diagnoses clarify who receives the care, provide a statement
identifying problems faced by who is receiving the care, and identify the
factors contributing to the identified problem.
o Risk of
o Among
o Related to
o * You do not need to use your NANDA DX book for this*
← Nursing Diagnosis
“Risk for or actual”
o identifies the specific problem or risk faced by the community
“Among”
o The specific population that is affected by the problem or risk
“Related to”
o identifies factors/strengths/weaknesses influencing the problem or
risk
← Examples of Nursing Diagnosis
Risk of violent crime among African-American youth in Orange Mound
related to poverty and high levels of unemployment
Risk of increased infant mortality among residents of North Memphis
related to high levels of teen pregnancy
← Planning for Community Health
The planning phase
o analyzes the community health problems identified in the
community nursing diagnoses
o establishes priorities among them
o establishes goals and objectives
o identifies intervention activities that will accomplish the objectives
← Community Health Planning Process
1. Problem analysis and prioritization
o Clarify nature of the problem
o Rank- start with highest priority
o Priority given to problem that has greatest impact on health of all
Criteria for ranking problem:
Community awareness of the problem
Community motivation to solve the problem
Availability of expertise to solve problem
Severity of outcomes if problem not resolved
Speed with which the problem can be solved
2. Establish goals and objectives
o Goal - global statement of the desired outcome
o Objective - more specific, precise, behaviorally stated, incremental
and measurable.
o *SMART* objectives- specific, measurable, achievable, realistic,
timetable
3. Identify intervention activities
o The means by which the objectives are met
← Implementing in the Community
Involves the work and activities aimed at achieving the goals and
objectives
May be made by the person or group who established the goals and
objectives, or they may be shared with, or even delegated to, others
Nurse as content expert and as process expert
o Change agent
o Change partner
← Evaluating Community Health Intervention
The appraisal of the effects of some organized activity or program
Begins at the planning stage when goals and objectives are established
Must decide whether the costs in money and time are worth the resulting
benefits
Role of outcomes
← Personal Safety in Community Practice
Personal safety is a prerequisite for effective community-oriented practice
Awareness of the community and common sense
Three clear sources of information that will help answer personal safety
questions
o Other nurses, social workers, or health care providers who are
familiar with the dynamics of a given community
o Community members
o Nurse’s own observations
←
Chapter 25 9/17/15 8:44 PM
← Program management consists of assessing, planning,
implementing, and evaluating a program
The program management process is parallel to the nursing process:
o when to make a decision to develop a program (through needs
assessment and defining a problem)
o where they want to be at the end of the program (goal setting)
o how to decide what to do to have a successful program (planning)
o how to develop a plan to go from where they are so they will know
where they want to be (implementing)
o how to know that they are getting there (formative evaluation)
o and what to measure to know that the program has successful
outcomes (summative evaluation)
← Definitions
A Program is an organized approach designed to meet the assessed
needs of individuals, families, groups, or communities by reducing or
eliminating one or more health problems. Community health programs
are planned to meet the needs of designated populations or
subpopulations.
Programs are ongoing organizational activities as compared with
projects, which are organizational activities with a limited time frame.
Planning is defined as selecting and carrying out a series of actions
designed to achieve desired improvements
Evaluation is an ongoing process of accountability and is defined as
determining whether a service is needed and can be used, whether it is
conducted as planned, and whether the service actually helps people in
need.
Program evaluation is used to make judgments about improving,
managing, and continuing programs. It addresses such areas as
relevance, adequacy, progress, efficacy, effectiveness, impact, and
sustainability of program activities.
← Goals
Program planning: Ensure that health care services are acceptable,
equal, efficient, and effective.
Program evaluation: Determine the relevance, adequacy, progress,
efficiency, effectiveness, impact, and sustainability of program activities.
← Benefits of Program Planning
Ensures that available resources are used to address the actual needs of
people
Focuses attention on what the organization and health provider are
attempting to do for patients
Assists in identifying the resources and activities that are needed
Reduces role ambiguity
Reduces uncertainty within the program environment
Increases the abilities of the provider and the agency to cope with the
external environment.
Allows for quality decision making and better control over the actual
program results by setting specific goals
← Assessment of Need
Planning for effective and efficient programs must be based on identifying
the needs of populations within the community and is often essential if
funding is sought for implementation
o Community assessment
o Population needs assessment
← Planning Process
Formulating is the initial and most critical step
o It includes defining the problem
o the target population
o the target population boundaries
o assessing the need for, availability of, accessibility of, and
acceptability of the program (needs assessment)
o determining the availability of program resources
Conceptualizing
o creates options for solving the problem
o considers several solutions along with their risks, consequences,
and potential outcomes.
o Involves reviewing the literature and synthesizing the evidence-
based practice available.
Detailing involves both the provider and client in a consideration of the
possibilities to solve the problem as it relates to costs, resources, and
program activities.
Evaluating each possible solution allows for each alternative to be
weighed (cost, benefits, and acceptance) and ranked for choice with
emphasis on the desired outcome.
Implementing requires obtaining and managing the resources to
operationalize the program in a way that is consistent with the plan and
also requires accountability and responsibility.
← Planning
Formulating written objectives is critical to both the program planning and
evaluation process
o providing direction for conducting the program
o mechanism for evaluating the specific activities and total program
Goal - global statement of the desired outcome
Objective - more specific, precise, behaviorally stated, incremental and
measurable.
*SMART* objectives- specific, measurable, achievable, realistic,
timetable
← Benefits of Program Evaluation
Ensuring that a program has met its goals
Documenting accountability by the program managers to the patients and
the funding sources
Shows whether the program is fulfilling its purpose
Used to make judgments about a program and may be used to justify
sustaining the program, making adjustments in the program, expanding
or reducing the program, or even discontinuing it
← Sources of Program Evaluation
Both quantitative and qualitative methods may be used.
Qualitative methods
o Site visits, structured observations of interventions, open-ended
interviews
Quantitative methods
o Program records
o Epidemiological data
← Aspects of Evaluation
Relevance—Need for the program
Adequacy—Program addresses the extent of the need
Progress—Tracking of program activities to meet program objectives
Efficiency—Relationship between program outcomes and the resources
spent
Effectiveness—Ability to meet program objectives and the results of
program efforts
Impact—Long-term changes in the patient population
Sustainability—Enough resources to continue the program
← Cost Studies Applied to Program Management
Cost Accounting: Cost-accounting studies are performed to find the
actual budgetary cost of a program, procedure, or technique.
Cost-Benefit: Cost-benefit studies are a way of assessing the desirability
of a program, procedure, or technique by placing a specific quantifiable
value on all costs and all benefits of the variables to be evaluated.
Cost-Effectiveness: Cost-effectiveness analysis is a measure of the
quality of a program, procedure, or technique as it relates to costs.
Cost Efficiency: Cost-efficiency analysis involves the analysis of actual
costs to perform a number of services at different volumes if the same
standards are applied.
← Program Funding
Can be a challenge to obtain adequate funding
Gifts
Contracts
Grants
o A grant proposal is a means of documenting plans for establishing,
managing, and evaluating a program and including specific
components (target population, problem definition, program
description, evaluation plan, operating budget).
Chapter 15 9/17/15 8:44 PM
← Introduction
Evidence based practice (EBP) is an approach to providing the highest
quality of health care in all settings to improve health outcomes
The Institute of Medicine has set a goal that by 2020, the best available
evidence will be used to make 90% of all health care decisions, yet most
nurses continue to be inconsistent in implementing EBP.
← Definitions of EBP
Evidence-based practice (EBP)
o the conscientious, explicit, and judicious use of current best
evidence in making decisions about the care of individual clients
Evidence-based public health
o a public health endeavor in which there is an informed, explicit, and
judicious use of evidence that has been derived from any of a
variety of science and social science research and evaluation
methods
Evidence-based nursing
o “an integration of the best evidence available, nursing
expertise, and the values and preferences of the
individuals, families, and communities who are served.”
(Sigma Theta Tau, 2005)
External evidence
o Research and other evidence
Internal evidence
o Includes the nurses clinical experiences and the client’s preferences
← Factors Leading to Change or Barriers to EBP
Knowledge of research and current evidence
Ability to interpret the meaning of the evidence
Individual professional’s characteristics
Time needed to implement EBP and to engage in education and directed
practice
Hierarchy of the practice environment, level of support of managers, and
ability to engage in autonomous practice
Philosophy of the practice environment and the willingness to embrace
EBP
Resources available to engage in EBP
Practice characteristics
Links to outside supports, such as teaching facilities
Political constraints and the lack of relevant and timely public health
practice research
← Steps in the EBP Process
Cultivating a spirit of inquiry
Asking clinical questions
Searching for the best evidence
Critically appraising the evidence
Integrating the evidence with clinical expertise, client preferences, and
values
Evaluating the outcomes of the practice decisions or changes based on
evidence
Disseminating EBP results
← Approaches to Evaluating Evidence
Grading the strength of evidence
o Quality
Sample selection, randomization, blinding, sample size,
description of intervention, outcomes, length of followup,
attrition, confounding variables, statistical analysis
o Quantity
o Consistency
← Approaches to Implementing EBP
First step is recognizing the current status of one’s own practice
EBP is new concept for many practicing nurses
Will only be successful when practicing in an environment that supports
evidence-based care
← Current Perspectives
Cost versus quality
Individual differences
Appropriate EBP methods for population-centered nursing practice
← Healthy People 2020
Objectives offer a systematic approach to health improvement.
Several objectives are devoted to improving clients’ understanding of EBP
and how they can contribute to health care decisions.
← Examples
The Intervention Wheel
o Originally developed using a qualitative, grounded theory process
but did not include a systematic review of evidence to support the
interventions or their application to practice
Systematic review done later to examine the evidence
underlying the interventions and levels of practice
o The 17 interventions grew out of an extensive analysis of the actual
work of 200 practicing public health nurses in a variety of work
settings.
Chapter 9 9/17/15 8:44 PM
← The Intervention Wheel: Origins and Evolution
Original version resulted from a grounded theory process carried out by
public health nurse consultants at the Minnesota Department of Health in
the mid-1990s
A wheel-shaped graphic was developed to illustrate the set of
interventions and the levels of practice
Since first published in 1998, adoption of the model has been rapid and
worldwide
← The 17 Interventions
Surveillance
Disease and health event investigation
Outreach
Screening
Case finding
Referral and follow up
Case management
Delegated functions
Health teaching
Counseling
Consultation
Collaboration
Coalition building
Community organizing
Advocacy
Social marketing
Policy development and enforcement
← Assumptions Underlying the Intervention Wheel
Defining public health nursing practice
Public health nursing practice focuses on populations
Public health nursing practice considers the determinants of health
Public health nursing practice is guided by priorities identified through an
assessment of community health
Public health nursing practice emphasizes prevention
Public health nurses intervene at all levels of practice
Public health nursing utilizes the nursing process at all levels of practice
Public health nursing uses a common set of interventions regardless of
practice setting
Public health nursing practice contributes to the achievement of the ten
essential services
Public health nursing values and beliefs
← Using the Intervention Wheel in Public Health Nursing Practice
Component 1: Population based
o The upper portion of the Wheel illustrates that all levels of practice
are population based.
Component 2: Levels of practice
o Community level
You want to change community norms, attitudes, awareness,
practices and behaviors
o Systems level
You want to change organizations, laws, policies, and power
structures
o Individual/Family level
You want to change behaviors, knowledge, attitudes,
practices, and beliefs
Component 3: Public health interventions
o The Intervention Wheel encompasses 17 interventions
o All interventions except case finding, coalition building, and
community organizing are applicable at all three levels of practice.
o Community organizing and coalition building cannot occur at the
individual level. Case finding is the individual level of surveillance,
disease and other health event investigation, and outreach and
screening.
← Adoption of Intervention Wheel
In practice
In education
In management
Chapter 2 9/17/15 8:44 PM
← Colonial Period
Household members (usually women) tend to the sick
o Urbanization in the early 1800s causes this system to became
insufficient
England’s Elizabethan Poor Law of 1601
o 1751 Pennsylvania Hospital founded
Early colonial PH efforts
After American Revolution
o First PH committee was established
← After American Revolution
Public Health Service (PHS)
o Established in 1798 as the Marine Hospital Service
Early experiments in providing nursing care at home
o Ladies Benevolent Society of Charleston (1813)
o Philadelphia lay nurses
o Roman Catholic Sisters of Charity (1854)
Shattuck Report (1850) by the Massachusetts Sanitary Commission
← Nightingale and the Origins of Trained Nursing
Need for nurses
Origins of organized nursing
o Pastor Theodor Fliedner
o Crimean War
Improved soldiers’ health using a population-based approach
Principles of nursing
o “Health of the unity is the health of the community”
o Differentiated “sick nursing” for “health nursing
o Proper nutrition, rest, sanitation, and hygiene necessary
William Rathbone
o Founded first district nursing association in Liverpool, England
o Rathbone and Nightingale recommended steps to provide nursing
in the home, and district nursing was organized throughout England
Florence Sarah Lees Craven
o “Guide to District Nurses”
← America Needs Trained Nurses
Need for PH nursing
o Increase of women in workforce
o More economical to have home-visiting nurses
Origins of organized nursing
o 1870s – First Nightingale model nursing schools started
o 1877 – Women’s Board of the New York City Mission hired Frances
Root
o 1878 – Ethical Culture Society of New York hired four nurses to work
in dispensaries
o 1885-1886 – Visiting nurse associations were established
← District Nursing and Settlement Houses
Deplorable environmental conditions in immigrant tenement housing and
sweatshops
District nursing and settlement houses established
Rural Nursing Service
Occupational Health
← School Nursing in America
Grew out of school absences caused by the prevalence of infections and
communicable diseases
Lina Rogers—first United States school nurse
o Worked with children in New York City schools
o She and her other school nurses found illness was often not the
reason for absence.
Significant and positive impact
o More nurses hired
o School nursing soon implemented in Los Angeles, Philadelphia,
Baltimore, Boston, Chicago, and San Francisco
← The Profession Comes of Age in the United States in the Twentieth Century
National Organization for PHN (NOPHN)
o Sought to standardize PHN education
o 1914 – First post-training school course in PHN offered at Teachers
College in New York City
o 1920s to 1930s – Many newly hired PHNs had to verify completion
in a certificate program in PHN,
American Public Health Association (APHA)
o Established in 1872
o Sought to facilitate interprofessional efforts and promote the
“practical application of public hygiene”
← PHN in Official Health Agencies and in WWI
Late 1800s – local health departments formed
Federal role in PH gradually expanded
o 1912 – U.S. Public Health Service role defined
o NOPHN loaned a nurse to the U.S. Public Health Service
First federal government sponsorship of nurses
WWI depleted the ranks of PHNs
1918 worldwide influenza pandemic
← Paying the Bill for PHNs
Metropolitan Life Insurance Company
Sheppard-Towner Act
Individual commitment and private financial support
o Frontier Nursing Service
← African-American Nurses in PHN
1919: National Health Circle for Colored People
o Bessie M. Hawes
1936: PHN certificate program for African-American nurses
Wage discrimination in the South
Nursing education segregated until 1960s
← Between the Two World Wars
Economic depression
o Agencies and communities not prepared to address the increased
needs and numbers of impoverished
Decreased funding
o Agencies that helped to support nurse employment
Federal Emergency Relief Administration (FERA)
Works Progress Administration (WPA)
Relief Nursing Service
Civil Works Administration (CWA) programs
1932 survey found only 7% of nurses working in PH were adequately
prepared
← Increasing Federal Action for the Public’s Health
Social Security Act of 1935
o Funded opportunities for education and employment of PHNs
o Funded assistance to states, counties, and medical districts in
establishing adequate health services
o Provided funds for research and investigation of disease
← World War II
Accelerated need for nurses, both for war effort and at home
Nursing Council on National Defense
Many nurses joined the Army and Navy Nurse Corps.
Bolton Act of 1943 established Cadet Nurses Corps
Some expansion of PHN scope of practice
o Emergency Maternity and Infant Care Act of 1943
Job opportunities
← Rise in Chronic Illness
National crude mortality rate decreased by 47%
Change in leading cause of death from communicable diseases to chronic
diseases
Aged population grew as did prevalence of chronic disease
Some visiting nurse associations provide home-care programs
o Reimbursable by commercial health insurance and later by
Medicare and Medicaid
Resurgance in combination agencies
← Declining Financial Support for Practice and Professional Organizations
Hospitals preferred for illness and childbirth
Funding stopped for visiting nurse services
Consolidation of national nursing organizations
o National League for Nursing
o American Nurses Association
← Professional Nursing Education for PHN
National League for Nursing adopted Esther Lucile Brown’s Nursing for the
Future (1948)
o Recommended to establish basic nursing preparation colleges and
universities
Included PHN concepts in all baccalaureate programs;
however, these were very brief components of the curricula
1950s – PHN practice increased focus on the psychological elements of
client, family, and community care
← 1960s
Medicare and Medicaid
o Did not include coverage for preventive services
o Home health care only reimbursed if ordered by a physician
Increase in for-profit home health agencies
Reduction in health promotion and disease prevention by local and state
health departments
← Community Organization and Professional Change
Civil Rights Movement
Funding increases in certain areas
Economic Opportunity Act
← 1970s
Nurses made significant contributions to:
o The hospice movement
o The development of birthing centers
o Day care for older adults and disabled persons
o Drug abuse programs
o Rehabilitation services in long-term care
← 1990s
Health care debate focused on cost, quality, and access to direct care
services
o Nursing organizations joined to support health care reform
← 2000s
Health Care Reform finally passed in 2010 with the federal Patient
Protection and Affordable Care Act
PHN organizations develop position papers on:
o Graduate education for advanced practice PHN
o Faculty qualifications for community/public health nursing
educators
o Importance of PHN within PH systems
Chapter 45 9/17/15 8:44 PM
← The Role of Federal Public Health Agencies
Federal: develop regulations that implement policies formulated by
Congress and provide a significant amount of funding to state and
territorial health agencies to:
o Provide public health services
o Survey the nation’s health status and health needs
o Set practice and standards
o Provide expertise that facilitates evidence-based practices
o Coordinate public health activities that cross state lines
o Support health services research
← Role of State Public Health Agencies
State: responsible for monitoring health status and enforcing laws and
regulations that protect and improve the public’s health
o Distribute federal and state funds to local public health agencies to
implement programs at the community level
Examples of programs: communicable disease programs,
maternal and child health programs; chronic disease
prevention programs; injury prevention programs
o Provide oversight and consultation for local public health agencies
← State Health System
Tennessee Department of Health
Office of Minority Health
Office of Rural Health
License and Regulate Professionals
Health Care Facilities Regulation
Division of Vital Records
Alcohol, drug, and mental health services
Maternal and Child Health
Immunization
Communicable Diseases
BT/ Emergency Preparedness
← Roles of Local Public Health Agencies
Local: responsibilities vary depending on the locality and are responsible
for implementing and enforcing local, state, and federal public health
codes and ordinances and providing essential public health programs to a
community
o Goal: to safeguard the public’s health and to improve the
community’s health status
← Roles of Local, State, and Federal Public Health Agencies
The majority of local, state, and federal agencies are involved in the
following functions:
o Collecting and analyzing vital statistics
o Providing health education and information to the population
served
o Receiving reports about and investigating and controlling
communicable diseases
o Protecting the environment to reduce the risk to health
o Providing some health services to particular populations at risk or
with limited access to care
o Identifying public health problems for at-risk and high-risk
populations
o Partnering with other organizations to develop and implement
responses to identified public health concerns
← Factors influencing Public Health Nurses Role
1) health reform and the impact upon public health
2) budget cuts
3) new definition of competencies
4) recommendations from the Institute of Medicine 2010 report, The
Future of Nursing: Leading Change, Advancing Health, including that 80
percent of nurses achieve bachelor-level degrees by 2020
5) public health agency accreditation and adoption of quality
improvement measures
6) emphasis on chronic disease prevention
7) interventions targeted at improvement of conditions in the community
that are conducive to health for all populations
8) Multiple determinants of health
← Tennessee’s Big Three
Tobacco Use
Physical Inactivity
Obesity
← Determinants of health
Health care is not the primary driver of an individual’s overall health and
well-being
Improving Health requires comprehensive focus: a public health approach
← RWJF Forum on the Future of Public Health Nursing Summary Report January
2013
“Public health nurses constitute the largest professional segment of the
public health workforce, and they assume a wide variety of roles in health
departments, including providing clinical care to individuals, health
planning, surveillance, management, and serving as directors at the local
and state levels.”
← PHN Roles in Tennessee Health Departments
Clinic managers
State/Regional program managers
Regional and local county directors
Direct patient care providers
Home visitors
Care Coordinators
Disease investigators
Educators
← Nurses in Communities
“Nurses are considered the most trustworthy professionals in the US”
(2014 Gallup Poll)
o Schools
o Parish Nurses
o Educators
o Worksite Wellness
o Care Coordinators
← Current Challenges and Future Needs
Knowledge
o Quad Council-Public Health Nursing Core Competencies
o Population health focus
o Applied epidemiology
o Public Health accreditation
o Social and environmental health determinants
o Legislation- process and laws affecting both nursing practice and
population health
Skills
o Leadership skills to engage internal and external community
partners
o Tech Savvy-statistical software, EMR, Health Information exchange
o Public speaking skills
o Emergency preparedness- local disaster shelters and global health
issues
o Enhanced Preceptor training for nurses working with students in PH
clinics
Abilities
o Assess the needs of the community served
o Identification and elimination of health inequality and disparity in
the population and in the workforce
o Develop and utilize population specific and evidence based health
strategies
o Inform key stakeholders of population health needs
← Recruitment and Retention
60% of PHN’s in Tennessee eligible for retirement in the next 10 years
Generate interest in Public Health
o Affiliation Agreements- precept student nurses
o County and Regional PHN leader presentations
o Attend job fairs- share application process
← Educational Needs
BSN preferred entry level into PHN in Tennessee Health Department
Clinics
Masters level preparation preferred for administrative leadership positions
and for Advanced Practice Nurses in clinic settings
Explore MSN and MPH dual programs
Doctoral level programs for nurse epidemiologists, researchers, and
advanced clinical practice
← PHN Education
Programs to incorporate public health concepts throughout each course in
addition to traditional community health courses
Enhanced instruction of population health concepts at all levels of nursing
education
Encourage nurses to apply prevention and public health concepts in all
settings to improve the health of individuals, families and communities.
← Next Step Strategies
Explore strategies to demonstrate value PHN practice
Promote educational resources supporting changing PHN role and
disseminate broadly
PHN engagement in strategic local, state and national partnerships
Promote leadership development opportunities
Support attainment of BSN and advanced degrees by PHNs
Support academic-practice partnerships
← Lillian Wald
“Nursing is love in action, and there is no finer manifestation of it than the
care of the poor and disabled in their own homes.”
← Florence Nightingale
"It is cheaper to promote health than to maintain people in sickness."
(1894)
"The work we are speaking of has nothing to do with nursing disease, but
with maintaining health by removing the things which disturb it . . . dirt,
drink, diet, damp, draughts, and drains.“
← Key Findings of Workforce Survey
There is significant need to strengthen the education and training of
public health nurses.
Provision of clinical services continues to be a major activity of RNs in
state and local health departments.
The national public health nurse workforce in state and local health
departments is not as racially and ethnically diverse as the country’s
population. Further, few minority public health nurses serve in leadership
positions.
The public health nurse workforce is aging; however, most RNs do not
intend to retire within the next 5 years.
Recruitment and hiring of RNs into public health nurse positions can be
challenging, particularly for state health departments.
Lack of promotion opportunities is a concern to both health departments
and RN’s.
Public health nurses report high levels of job satisfaction, despite
reporting high levels of dissatisfaction with salary compensation.
Chapter 3 9/17/15 8:44 PM
← Current Health Care System
Indicators which demonstrate continued disparities within our current
health care system
o Cost
The United States spends more money on health care than
any other country in the world.
o Access to care
The 2003 US Census reported 45 million people without
health insurance.
o Quality
In 1998 IOM estimated 98,000 deaths / year from
preventable medical errors
← Cost
Aging Baby Boomer population
o Will increase Medicare expenditures
Medicaid recipients can be expected to decline as jobs are added to the
economy.
Percentage of workers covered by employer-sponsored insurance should
rise.
o Premiums increase
o Higher co-pay and deductible expenses
Costs will rise
o Rise in percentage of uninsured-
← Access
48.9 million uninsured in 2009 , 42.0 million in 2014 ( ACA has started!)
In 2013, 34.3 percent of the population was covered by government
health insurance ( Medicare, Medicaid,Tricare, etc)
Government programs play significant role in meeting the needs of the
uninsured
o Increasing demands leave some states struggling with budget
Strong relationship between health insurance coverage and access to
health care services
Groups who face greatest barriers to access:
o Poor
o Minority group members
o Non-English speakers
Medically underserved
o 56 million in the United States lack adequate access to primary
health care (2007)
Safety net
o Community health centers
← Quality
To Err is Human: Building a Safer Health System (IOM, 2000)
o 98,000 deaths a year attributed to preventable medical errors
7,000 of which are due to preventable medication errors
Keeping Patients Safe: Transforming the Work Environment of Nurses
(IOM, 2003)
o Long work hours pose most serious threat
Cultivating a culture of safety
o Look at the system- stop blaming individuals
o Sentinel events reporting (unexpected occurrences)
o Hospital Compare: website for consumers thru CMS website
← Trends Affecting the Health Care System
Demographics
Technology
Global Influences
← Demographics
Aging Baby Boomer generation
o Cost of Medicare expected to rise
Rise in foreign-born population
o The U.S. is more diverse than ever
Lack of diversity in health care workforce
o Minorities are underrepresented
o Pew Commission- we need more minority health care providers.
Health professionals who have the same culture and language with
patients they serve can provide more effective care.
← Technology
Examples:
o Telehealth: use of electronic communication networks to transmit
patient-related information
o Electronic medical records
o Personal Health Record (PHR)
o Health Information Exchanges (HIEs):regional network of integrated
data incorporating patient information from local hospitals as well
as clinics or provider practices within one database.
Benefits:
o Cost-effective
o Improved care
o Reduce medical errors
Pitfalls:
o Concerns about privacy and security
o Unclear reimbursement for services provided at distance
← Global Influences
Globalization
o process of change and development across national boundaries and
oceans, involving economics, trade, politics, technology, and social
welfare.
Infectious disease outbreaks
o With immigration, trade, and air travel, no country on earth is
completely safe from infectious disease
World Health Organization (WHO)
o comprised of 192 member countries, provides leadership on global
health, shapes worldwide research and policy agendas, and
monitors trends and responses to disease threats on a global level.
← Organization of the Health Care System
Primary health care system
o Comprehensive range of services
o Encourages self-care and self-management
o Emphasis on prevention
o Care provided at the community level that is accessible and
acceptable to the community and invites community participation
o Community or population focused
o 1977: Declaration of Alma Ata: Basis for global efforts in public
health
Primary care
Public health system
The federal system
The state system
The local system
← Primary Care Versus Primary Health Care
Primary Care
o Component of the private health care system
o Care provided by health care professional
o Care provided at the individual level
Primary Health Care (PHC)
o Focus of the public health system in the U.S.
o Broad range of services
o Emphasis is on prevention
o Care provided at the community level
o Accessible, acceptable to the community
o Invites community participation
← PHC Workforce
Multidisciplinary team of health care providers.
Team members include:
o Primary care generalists
and public health physicians
o Nurses
o Dentists
o Pharmacists
o Optometrists
o Nutritionists
o Community outreach workers
o Mental health counselors
o Translators
o Other allied health professionals
o Community members also important to the team
← PHC Initiative
Declaration of Alma Ata (1978)
o Basis for the PHC initiative. Goal of attaining a level of health that
permitted all citizens of the world to live socially and economically
productive lives
Healthy People 2020
o National health objectives which serve as a roadmap for improving
the health of all people in the U.S.
← Organization of the Health Care System
Primary care system
o Strategy of choice
o Provides first contact, continual, comprehensive, and coordinated
care
o Addresses most needs of clients
o Focus is on pathophysiological process
o Variety of community settings
o Focus on the individual
o Emphasizes cost containment
← Primary Care
First level of the private health care system
Delivered in a variety of community settings
Americans access it through insurance programs
Managed care
o defined as a system in which care is delivered by a specified
network of providers who agree to comply with the care approaches
established through a case management process, was a strategy
chosen by the federal government as a means to control the rising
costs of traditional fee-for-service health care.
o Managed Care Act of 1973
o HMOs, PPOs, and POS
o Medicare Advantage Program
← Primary Care Workforce
Primary care developed in the 1960s
o Needed to reexamine role of general practitioner
Primary care generalists include:
o Family physicians
o General internists
o General pediatricians
o Nurse practitioners (NPs)
o Clinical nurse specialists (CNSs)
o Physician assistants (PAs)
o Certified nurse-midwives (CNMs)
o Doctorate in Nursing Practice (DNP)
← Public Health System
Mandated through laws that are developed at the national, state, or local
level
Organized into many levels in the federal, state, and local systems
At the local level, health departments provide care that is mandated by
state and federal regulations.
← Organization of the Health Care System
Public health system—mandated through laws
Federal system
o U.S. Department of Health and Human Services (HHS)
o Office of Global Health Affairs
o U.S. Public Health Service (PHS)
o Health Resources and Services Administration (HRSA)
o National Institutes of Health (NIH)
o Agency for Health Care Research and Quality (AHRQ)
o Food and Drug Administration (FDA)
o Centers for Disease Control and Prevention (CDC)
o Centers for Medicare and Medicaid Services (CMS)
o Departnent of Homeland Security (DHS)
State Health Department
o Stand ready for disaster prevention or response
o Health care financing and administration
o Direct assistance to local health departments
Ongoing assessment of health needs
o Board of examiners of nurses
Local Health Department
o Direct responsibility to the citizens on its community or jurisdictions
o Variety of services and programs offered depending on the state
and local health codes that must be followed, the needs of the
community, and available funding and other resources
9/17/15 8:44 PM
← Population Health
Population health is defined as the health outcomes of a group of
individuals, including the distribution of such outcomes within the group
(Kindig and Stoddart,2003)
These groups are often geographic populations such as nations or
communities, but can also be other groups such as employees, ethnic
groups, disabled persons, prisoners, or any other defined group.
Kindig and Stoddart propose that population health is concerned with both
the definition of measurement of health outcomes and the pattern of
determinants. Determinants include medical care, public health
interventions, genetics, and individual behavior, along with components of
the social (e.g., income, education, employment, culture) and physical
(e.g., urban design, clean air, water) environments
← Population Health versus Public Health
Traditionally, public health has been understood by many to be the critical
functions of state and local public health departments such as preventing
epidemics, containing environmental hazards, and encouraging healthy
behaviors.
Public health, can be defined as what “we as a society do collectively to
assure the conditions in which people can be healthy” (Institute of
Medicine, 1988). Federal and state public health policies and programs
play an important role in the health of the overall population of a nation
and its states; however, as noted in the definition above public health is
not the same as population health. Population health tends to be more
concerned with outcomes.
← IHI Triple Aim
Starting in October 2007, IHI developed an innovative approach to
improving health and health care called “the Triple Aim.” The three
simultaneous goals of the Triple Aim are:
o Improve the health of the population
o Enhance the patient experience of care (including quality, access,
and reliability)
o Reduce, or at least control, the per capita cost of care
← ACA and Population Health
The ACA addresses population health in four ways
o 1. Provisions to expand insurance coverage
Individual mandate, Medicaid expansions, state insurance
exchanges, support for community health centers
o 2. Provisions aimed at improving the quality of care offered
National Strategy for Quality Improvement, CMS Center for
Medicare and Medicaid Innovation, Patient-Centered
Outcomes Research Institute
o 3. Provisions which seek to enhance prevention and health
promotion measures within the health care delivery system
Accountable Care Organizations (ACO’s ) to incentivize
providers to take responsibility for population health
outcomes, requirements that private health plans, Medicare,
and Medicaid provide specific preventive services (USPSTF
rec’s) without cost sharing, expansion of preventive services
o 4. Provisions aimed at promoting community and population-based
activities
National Prevention Health promotion and Public Health
Council, which produced National Prevention Strategy,
funding for Community Transformation Grants, incentives for
workplace wellness programs in the form of small grants for
use in developing comprehensive workplace wellness
programs
← National Prevention Strategy
Called for under the Patient Protection and Affordable Care Act
Developed by the National Prevention Council
Four Strategic Directions:
o Building Healthy and Safe Community Environments: .
o Expanding Quality Preventive Services in Both Clinical and
Community Settings
o Empowering People to Make Healthy Choices:
o Eliminating Health Disparities
←
