Nursing

http://healthyamericans.org/assets/files/TFAH-2015-InvestIn%0aAmericaRpt-FINAL.pdf

http://www.cdc.gov/nchs/data/hus/hus14.pdf

14 PART 1 Perspectives in Health Care Delivery and Nursing

National Prevention Council: National prevention strategy, Washington,

DC, 2011, USDHHS, Ofice of the Surgeon General.

Public Health Functions Steering Committee: Public health in

America, Rockville, MD, 1994, US Public Health Service

agencies.

Singh GK: Child mortality in the United States, 1935–2007: large

racial and socioeconomic disparities have persisted over time, a

75th anniversary publication, Rockville, MD, 2010, USDHHS,

Health Resources and Services Administration, Maternal and

Child Health Bureau.

Trust for America’s Health: Prevention for a healthier America: invest-

ments in disease prevention yield signiicant savings, stronger

communities, July 2008. Retrieved June 2012 from http://

healthyamericans.org/reports/prevention08/.

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the Surgeon General’s report on health promotion and disease

prevention, DHEW Pub. No. 79-55071, Washington, DC, 1979,

U.S. Government Printing Ofice.

US Department of Health and Human Services: Healthy people 2000:

National health promotion and disease prevention objectives, DHHS

Pub. No. 91-50212, Washington, DC, 1991, US Government

Printing Ofice.

US Department of Health and Human Services: Healthy people 2010:

Understanding and improving health, Washington, DC, 2000, US

Government Printing Ofice.

U.S. Department of Health and Human Services: Healthy People

2020 [Internet], Washington, DC, (cited March 22, 2016), Ofice

of Disease Prevention and Health Promotion. Available from

https://www.healthypeople.gov/.

U.S. Department of Health and Human Services: Health US: 2000,

Washington, DC, 2002, National Center for Statistics.

US Department of Health and Human Services: National Center for

Statistics, Washington, DC, 2010a, USDHHS.

US Department of Health and Human Services: Healthy people 2020,

Washington, DC, 2016, Ofice of Disease Prevention and Health

Promotion. Retrieved from https://www.healthypeople.gov/.

US Public Health Service: For a healthy nation: return on investments

in public health. The core functions project, Washington, DC,

1994 (update 2008), Ofice of Disease Prevention and Health

Promotion, USDHHS.

http://healthyamericans.org/reports/prevention08/

https://www.healthypeople.gov/

C H A P T E R O U T L I N E

Early Public Health

Public Health During America’s Colonial Period and the

New Republic

Nightingale and the Origins of Trained Nursing

Continued Growth in Public Health Nursing

Public Health Nursing During the Early 20th Century

African American Nurses in Public Health Nursing

Economic Depression and the Impact on Public Health

From World War II until the 1970s

Public Health Nursing from the 1970s to the Present

K E Y T E R M S

American Association of Colleges of

Nursing (AACN), 26

American Nurses Association

(ANA), 26

American Public Health Association

(APHA), 21

American Red Cross, 20

Breckinridge, Mary, 22

district nursing, 17

district nursing association, 18

Frontier Nursing Service (FNS), 22

instructive district nursing, 18

Metropolitan Life Insurance

Company, 21

National League for Nursing

(NLN), 26

National Organization for Public

Health Nursing (NOPHN), 20

Nightingale, Florence, 17

oficial health agencies, 24

Rathbone, William, 18

settlement houses, 18

Shattuck Report, 17

Social Security Act of 1935, 24

visiting nurse associations, 18

visiting nurses, 18

Wald, Lillian, 18

O B J E C T I V E S

After reading this chapter, the student should be able to:

1. Discuss historical events that have inluenced how current

health care is delivered in the community.

2. Trace the ongoing interaction between the practice of

public health and that of nursing.

3. Explain signiicant historical trends that have inluenced

the development of public health nursing.

4. Examine the contributions of Florence Nightingale, Lillian

Wald, and Mary Breckinridge and the inluence these

three nursing leaders had on current public health and

nursing.

5. Examine the ways in which nursing has been provided in

the community, including settlement houses, visiting nurse

associations, oficial health organizations, and schools.

6. Discuss the status of public health nursing in the 21st cen-

tury, including the major organizations that have contrib-

uted to the current state of public health nursing.

2 The History of Public Health and Public

and Community Health Nursing

Janna Dieckmann

C H A P T E R

One of the best ways to understand today and plan for tomor-

row is to examine the past. This is certainly true for public

health and public health nursing. Nurses use historical ap-

proaches to examine both the profession’s present and its

future. Questions are asked: What worked in the past? What did

not work? What lessons can be learned about health care, nurs-

ing, and the communities in which care is provided? During

times of rapid social change, it is important to examine history

and try to learn from the events of the past and build on the

events and actions that were effective. This chapter serves as

an introduction to an examination of the past in terms of

both public health and nursing.

For nearly 125 years, public health nurses in the United

States have worked to develop strategies to respond effectively

to public health problems. Public health is an interdisciplinary

specialty that emphasizes prevention. Nurses have worked in

communities to improve the health status of individuals, fami-

lies, and populations, especially those who belong to vulnerable

groups. This work has not been easy for many reasons. One

reason is that it is more dificult to measure the effects of pre-

vention than it is to measure the effects of treatment. In recent

years, as health care costs have grown, it has become increas-

ingly important to emphasize prevention.

Many varied and challenging public health nursing roles origi-

nated in the late 1800s, when public health efforts focused on

environmental conditions such as sanitation, control of commu-

nicable diseases, education for health, prevention of disease

and disability, and care of aged and sick persons in their homes.

16 PART 1 Perspectives in Health Care Delivery and Nursing

Although the threats to health have changed over time, the foun-

dational principles and goals of public health nursing have re-

mained the same. Many communicable diseases, such as diphthe-

ria, cholera, and typhoid fever, have been largely controlled in

the United States, but others, such as HIV, tuberculosis, and hepa-

titis, continue to affect many lives around the world. Emerging

communicable diseases, such as the varying types of inluenza,

illustrate the global nature of health threats. Even though environ-

mental pollution in residential areas has been reduced, communi-

ties are now threatened by emissions from the many vehicles on

their roads, overcrowded garbage dumps, and pollutants in the air,

water, and soil. Natural disasters continue to challenge public

health systems, and bioterrorism, natural disasters, and the many

human-made disasters threaten to overwhelm existing resources.

Research has identiied means to avoid or postpone chronic dis-

ease, and nurses play an important role in helping implement

strategies to modify individual and community risk factors and

behaviors. Finally, with the increased numbers of older adults in

the United States and their preference to remain at home, addi-

tional nursing services are required to sustain the frail, the disabled,

and the chronically ill in the community.

Nurses who have worked in the community have done so to

improve the health status of individuals, families, and popula-

tions. They have spent time, energy, and effort working with

high-risk or vulnerable groups. Part of the appeal of public

health nursing has been its autonomy of practice and indepen-

dence in problem solving and decision making, in addition to

the interdisciplinary nature of the specialty. This chapter de-

scribes the beginnings of public health, the role of nursing in

the community, the contributions made by nurses to public

health, and the inluence of nurses on community health.

EARLY PUBLIC HEALTH

People in all cultures have been concerned with the events sur-

rounding birth, illness, and death. They have tried to prevent,

understand, and control disease. Their ability to preserve health

and treat illness has depended on their knowledge of science, the

use and availability of technologies, and the degree of social or-

ganization. For example, ancient Babylonians understood the

need for hygiene and had some medical skills. The Egyptians in

approximately 1000 bce (before the Common Era) developed a

variety of pharmaceutical preparations and constructed earth

privies and public drainage systems. In England, the Elizabethan

Poor Law of 1601 guaranteed assistance for poor, blind, and

“lame” individuals. This minimal care was generally provided in

almshouses supported by local government. The goal was to

regulate the poor and provide a refuge during illness.

The Industrial Revolution in 19th-century Europe led to social

changes while making great advances in technology, transporta-

tion, and communication. Previous caregiving structures, which

relied on families, neighbors, and friends, became inadequate

because of migration, urbanization, and increased demand. During

this period, small numbers of Roman Catholic and Protestant

religious women provided nursing care in institutions and some-

times in the home. Many lay women who performed nursing

functions in almshouses and early hospitals in Great Britain were

poorly educated and untrained. As the practice of medicine be-

came more complex in the mid-1800s, hospital work required a

more skilled caregiver. Physicians and community advocates

wanted to improve the quality of nursing services. Early experi-

ments led to some improvement in care, but it was because of the

efforts of Florence Nightingale that health care was revolutionized

when she founded the profession of nursing.

PUBLIC HEALTH DURING AMERICA’S COLONIAL PERIOD AND THE NEW REPUBLIC

In the early years of America’s settlement, as in Europe, the care

of the sick was usually informal and was provided by women.

The female head of the household typically supervised care dur-

ing sickness and childbirth and also grew and gathered healing

herbs to use throughout the year. This traditional system of care

became insuficient as the number of urban residents grew in the

early 1800s.

British settlers in the New World inluenced the American

ideas of social welfare and care of the sick. Just as American law

is based on English common law, colonial Americans established

systems of care for the sick, poor, aged, mentally ill, and depen-

dents based on England’s Elizabethan Poor Law of 1601. Early

county or township government was responsible for the care of

all dependent residents but provided almshouse charity carefully,

economically, and only for local residents. Travelers and people

who lived elsewhere were returned to their native counties for

care. Few hospitals existed and then only in the larger cities.

Pennsylvania Hospital was founded in Philadelphia in 1751 and

was the irst hospital in what would become the United States.

Early colonial public health efforts included the collection of

vital statistics, improvements to sanitation systems, and control

of any communicable diseases brought in at the seaports. The

colonists did not have a system to ensure that public health

efforts were supported or enforced. Epidemics often occurred

and strained the limited local organization for health during

the 17th, 18th, and 19th centuries (Rosen, 1958).

After the American Revolution, the threat of disease, especially

yellow fever, led to public support for establishing government-

sponsored, or oficial, boards of health. By 1800, New York

City, with a population of 75,000, had established public health

services, which included monitoring water quality, constructing

sewers and a waterfront wall, draining marshes, planting trees

and vegetables, and burying the dead (Rosen, 1958).

Industrialization attracted increasing numbers of urban

residents, leading to inadequate housing and sanitation compli-

cated by epidemics of smallpox, yellow fever, cholera, typhoid,

and typhus. Tuberculosis and malaria were always present, and

infant mortality was approximately 200 per 1000 live births

(Pickett and Hanlon, 1990). American hospitals in the early

1800s were generally unsanitary and staffed by poorly trained

workers. Physicians had limited education, and medical care was

scarce. Public dispensaries, similar to outpatient clinics, and

private charitable efforts tried to provide some care for the poor.

The federal government focused its early public health work

on providing health care for merchant seamen and protecting

seacoast cities from epidemics. The Public Health Service, still

17CHAPTER 2 The History of Public Health and Public and Community Health Nursing

the most important federal public health agency in the 21st

century, was established in 1798 as the Marine Hospital Service.

The irst Marine Hospital opened in Norfolk, Virginia, in 1800.

Additional legislation to establish quarantine regulations for

seamen and immigrants was passed in 1878.

In the irst half of the 1800s, some agencies began to provide

lay nursing care in clients’ homes, including the Ladies’ Benevo-

lent Society of Charleston, South Carolina (Buhler-Wilkerson,

2001); lay nurses in Philadelphia; and visiting nurses in Cincin-

nati, Ohio (Rodabaugh and Rodabaugh, 1951). Although these

programs provided useful services, they were not adopted else-

where. Table 2.1 presents milestones of public health efforts that

occurred during the 17th, 18th, and 19th centuries.

During the mid-1800s, national interest increased in address-

ing public health problems and improving urban living condi-

tions. New responsibilities for urban boards of health relected

changing ideas of public health as the boards began to address

communicable diseases and environmental hazards. Soon after it

was founded in 1847, the American Medical Association (AMA)

formed a hygiene committee to conduct sanitary surveys and

develop a system to collect vital statistics. The Shattuck Report,

published in 1850 by the Massachusetts Sanitary Commission,

was the irst attempt to describe a model approach to the organi-

zation of public health in the United States. This report called

for broad changes to improve the public’s health: the establish-

ment of a state health department and local health boards in

every town; sanitary surveys and collection of vital statistics; en-

vironmental sanitation; food, drug, and communicable disease

control; well-child care; health education; tobacco and alcohol

control; town planning; and the teaching of preventive medicine

in medical schools (Kalisch and Kalisch, 1995). It took 19 years

for these recommendations to be implemented in Massachusetts,

and they were added in other states much later.

In some areas, charitable organizations addressed the gap

between known communicable disease epidemics and the lack

of local government resources. For example, the Howard Asso-

ciation of New Orleans, Louisiana, responded to periodic yellow

fever epidemics between 1837 and 1878 by providing physicians,

lay nurses, and medicine for the sick. The Howard Association

established inirmaries and used sophisticated outreach strate-

gies to locate cases (Hanggi-Myers, 1995).

NIGHTINGALE AND THE ORIGINS OF TRAINED NURSING

Even with the growth of technology during this time, cities

lacked important public health systems, such as sewage disposal,

and also depended on private enterprise for water supply. Previ-

ous caregiving structures, which relied on the assistance of fam-

ily, neighbors, and friends, became inadequate in the early 19th

century because of human migration, urbanization, and chang-

ing demand. During this period, a few groups of Roman Catho-

lic and Protestant women provided nursing care for the sick,

poor, and neglected in institutions and sometimes in the home.

For example, Mary Aikenhead, also known by her religious

name Sister Mary Augustine, organized the Irish Sisters of

Charity in Dublin, Ireland, in 1815. These sisters visited the poor

at home and established hospitals and schools (Kalisch and

Kalisch, 1995).

Florence Nightingale’s vision of trained nurses and her

model of nursing education inluenced the development of

professional nursing and, indirectly, public health nursing in

the United States. In 1850 and 1851, Nightingale studied nurs-

ing “system and method” during an extended visit to Pastor

Theodor Fliedner at his Kaiserwerth, Germany, School for Dea-

conesses. Her work with Pastor Fliedner and the Kaiserwerth

Lutheran deaconesses, with their systems of district nursing,

later led her to promote nursing care for the sick in their homes.

During the Crimean War (1854–1856), the British military

established hospitals for sick and wounded soldiers in Scutari in

Asia Minor. The care of soldiers was poor, with cramped quarters,

poor sanitation, lice and rats, not enough food, and inadequate

medical supplies (Kalisch and Kalisch, 1995; Palmer, 1983). When

the British public demanded improved conditions, Florence

Nightingale asked to work in Scutari. Because of her wealth, social

and political connections, and knowledge of hospitals, the British

government sent her to Asia Minor with 40 women, 117 hired

nurses, and 15 paid servants. In Scutari, Nightingale progressively

improved the soldiers’ health using a population-based approach

that improved both environmental conditions and nursing care.

Using simple epidemiology measures, she documented a de-

creased mortality rate from 415 per 1000 at the beginning of the

war to 11.5 per 1000 at the end (Cohen, 1984; Palmer, 1983). Like

Nightingale and her efforts in Scutari, public health nurses today

identify health care needs that affect the entire population. They

then mobilize resources and organize themselves and the com-

munity to meet these needs.

After the Crimean War, Nightingale returned to England in

1856. Her fame was established. She organized hospital nursing

practices and nursing education in hospitals to replace untrained

Year Milestone

1601 Elizabethan Poor Law written

1617 Sisterhood of the Dames de Charité organized in France by

St. Vincent de Paul

1789 Baltimore Health Department established

1798 Marine Hospital Service established; later became Public Health

Service

1812 Sisters of Mercy established in Dublin, Ireland, where nuns visited

the poor

1813 Ladies Benevolent Society of Charleston, South Carolina, founded

1836 Lutheran deaconesses provided home visits in Kaiserwerth, Germany

1851 Florence Nightingale visited Kaiserwerth, Germany, for 3 months

of nurse training

1855 Quarantine Board established in New Orleans; beginning of

tuberculosis campaign in the United States

1859 District nursing established in Liverpool, England, by William

Rathbone

1860 Florence Nightingale Training School for Nurses established at

St. Thomas Hospital in London

1864 Beginning of Red Cross

TABLE 2.1 Milestones in the History of Community Health and Public Health Nursing: 1600–1865

18 PART 1 Perspectives in Health Care Delivery and Nursing

lay nurses with Nightingale nurses. Nightingale thought that

nursing should promote health and prevent illness, and she

emphasized proper nutrition, rest, sanitation, and hygiene

(Nightingale, 1894, 1946).

In 1859 British philanthropist William Rathbone founded

the irst district nursing association in Liverpool, England. His

wife had received excellent care from a Nightingale nurse dur-

ing her terminal illness. He wanted to provide similar care to

poor and needy people. Together the work of Nightingale and

Rathbone led to the organization of district nursing in England

(Nutting and Dock, 1935).

During the last quarter of the 1800s, the number of jobs for

women rapidly increased. Educated women became teachers,

secretaries, or saleswomen, and less-educated women worked in

factories. As it became more acceptable to work outside the home,

women were more willing to become nurses. The irst nursing

schools based on the Nightingale model opened in the United

States in the 1870s. The early graduate nurses worked as private

duty nurses or were hospital administrators or instructors. The

private duty nurses often lived with the families for whom they

cared. Because it was expensive to hire private duty nurses, only

the well-to-do could afford their services. Community nursing

began in an effort to meet urban health care needs, especially for

the disadvantaged, by providing visiting nurses. In 1877 in New

York City, trained nurse Francis Root was hired by a New York

City mission to visit and care for the sick poor in their homes.

Visiting nurses took care of several families each day (rather

than attending to only one client or family as the private duty

nurse did), which made their care more economical. The visit-

ing nurse became the key to communicating the prevention

campaign, through home visits and well-baby clinics. Visiting

nurses worked with physicians, gave selected treatments, and

kept temperature and pulse records. Visiting nurses emphasized

education of family members in the care of the sick and in per-

sonal and environmental prevention measures, such as hygiene

and good nutrition (Fig. 2.1). The movement grew, and visiting

nurse associations were established in Buffalo (1885), Philadelphia

(1886), and Boston (1886). Wealthy people interested in charitable

activities funded both settlement houses and visiting nurse associa-

tions. Wealthy upper-class women who were freed at this time from

social restrictions were instrumental in doing charitable work and

in supporting the early visiting nurses.

The public wanted to limit disease among all classes of

people, partly for religious reasons, partly as a form of charity,

but also because the middle and upper classes were afraid of

diseases that were prevalent in the large communities of Euro-

pean immigrants. During the 1890s in New York City, about

2,300,000 people were packed into 90,000 tenement houses.

The environmental conditions of immigrants in tenement

houses and sweatshops were familiar features of urban life

across the northeastern United States and upper Midwest. From

the beginning, community nursing practice included teaching

and prevention (Fig. 2.2). Community interventions led to im-

proved sanitation, economic improvements, and better nutri-

tion. These interventions were credited with reducing the inci-

dence of acute communicable disease by 1901.

In 1886 in Boston, two women, to improve their chances

of gaining inancial support for their cause, coined the term

instructive district nursing to emphasize the relationship of

nursing to health education. Support for these nurses was also

secured from the Women’s Education Association, and the

Boston Dispensary provided free outpatient medical care. In

February 1886 the irst district nurse was hired in Boston, and

in 1888 the Instructive District Nursing Association was incor-

porated as an independent voluntary agency (Brainard, 1922).

Other nurses established settlement houses and neighbor-

hood centers, which became hubs for health care and social

welfare programs. For example, in 1893 trained nurses Lillian

Wald (Fig. 2.3) and Mary Brewster began visiting the poor on

FIG. 2.1 Public health nurse demonstrating well-child care dur-

ing a home visit. (Courtesy Visiting Nurse Service of New York.)

FIG. 2.2 Teaching well-child care was a signiicant public health

nursing role. (Courtesy Instructional Visiting Nurse Association

of Richmond, Virginia.)

19CHAPTER 2 The History of Public Health and Public and Community Health Nursing

New York’s Lower East Side. They established a nurses’ settle-

ment that became the Henry Street Settlement and later the

Visiting Nurse Service of New York City. By 1905, public health

nurses had provided almost 48,000 visits to more than 5000

clients (Kalisch and Kalisch, 1995). Lillian Wald emerged as a

prominent leader of public health nursing during these decades

(Box 2.1). Lillian Wald demonstrated an exceptional ability to

develop approaches and programs to solve the health care and

social problems of her times. We can learn much from her that

can be applied to today’s nursing practice.

Jessie Sleet (Scales), a Canadian graduate of Provident Hospi-

tal School of Nursing (Chicago), became the irst African

American public health nurse when she was hired in 1900 by the

New York Charity Organization Society. Although it was hard

for her to ind an agency willing to hire her as a district nurse,

she persevered and was able to provide exceptional care for her

clients until she married in 1909. At the Charity Organization

Society in 1904 to 1905, she studied health conditions related

to tuberculosis among African American people in Manhattan

using interviews with families and neighbors, house-to-house

canvassing, direct observation, and speeches at neighborhood

churches. Sleet reported her research to the Society board, rec-

ommending improved employment opportunities for African

Americans and better prevention strategies to reduce the excess

burden of tuberculosis morbidity and mortality among the

African American population (Buhler-Wilkerson, 2001; Hine,

1989; Mosley, 1994; Thoms, 1929). FIG. 2.3 Lillian Wald. (Courtesy Visiting Nurse Service of

New York.)

BOX 2.1 Lillian Wald: First Public Health Nurse in the United States

Public health nursing evolved in the United States in the late 19th and early 20th

centuries largely because of the pioneering work of Lillian Wald. Born on March

10, 1867, Lillian Wald decided to become a nurse after Vassar College refused

to admit her at 16 years of age. She graduated in 1891 from the New York

Hospital Training School for Nurses and spent the next year working at the

New York Juvenile Asylum. To supplement what she thought had been inade-

quate training in the sciences, she enrolled in the Woman’s Medical College in

New York (Frachel, 1988).

Having grown up in a warm, nurturing family in Rochester, New York, her work

in New York City introduced her to an entirely different side of life. In 1893, while

conducting a class in home nursing for immigrant families on the Lower East

Side of New York, Wald was asked by a small child to visit her sick mother. Wald

found the mother in bed after childbirth, having hemorrhaged for 2 days. This

home visit conirmed for Wald all of the injustices in society and the differences

in health care for poor persons versus those persons able to pay (Frachel, 1988).

She believed poor people should have access to health care. With her

friend Mary Brewster and the inancial support of two wealthy laypeople,

Mrs. Solomon Loeb and Joseph H. Schiff, she moved to the Lower East Side and

occupied the top loor of a tenement house on Jefferson Street. This move

eventually led to the establishment of the Henry Street Settlement. In the be-

ginning, Wald and Brewster helped individual families. Wald believed that the

nurse’s visit should be friendly, more like a visit from a friend than from some-

one paid to visit (Dolan, 1978).

Wald used epidemiological methods to campaign for health-promoting social

policies to improve environmental and social conditions that affected health. She

not only wrote The House on Henry Street to describe her own public health

nursing work, but she also led in the development of payment by life insurance

companies for nursing services (Frachel, 1988).

In 1909, along with Lee Frankel, Lillian Wald established the irst public health

nursing program for life insurance policyholders at the Metropolitan Life Insurance

Company. She advocated that nurses at agencies such as the Henry Street Settle-

ment provide complex nursing care. Wald convinced the company that it would be

more economical to use the services of public health nurses than to employ its own

nurses. She also convinced the company that services could be available to anyone

desiring them, with fees scaled according to the ability to pay. This nursing service

complishments to public health nursing, including the following (Frachel, 1988):

1. Providing home nursing care on a fee-for-service basis

2. Establishing an effective cost-accounting system for visiting nurses

3. Using advertisements in newspapers and on radio to recruit nurses

4. Reducing mortality from infectious diseases

Lillian Wald also believed that the nursing efforts at the Henry Street Settle-

ment should be aligned with an oficial health agency. She therefore arranged

for nurses to wear an insignia that indicated that they served under the auspices

of the Board of Health. Also, she led the establishment of rural health nursing

services through the Red Cross. Her other accomplishments included helping to

establish the Children’s Bureau and ighting in New York City for better tenement

living conditions, city recreation centers, parks, pure food laws, graded classes

for mentally handicapped children, and assistance to immigrants (Backer, 1993;

Dock, 1922; Frachel, 1988; Zerwekh, 1992).

Data from Backer BA: Lillian Wald: connecting caring with action, Nurs Health Care 14:122-128, 1993; Dock LL: The history of public health

nursing, Public Health Nurs 14:522, 1922; Dolan J: History of nursing, ed 14, Philadelphia, 1978, Saunders; Frachel RR: A new profession: the

evolution of public health nursing, Public Health Nurs 5:86-90, 1988; and Zerwekh JV: Public health nursing legacy: historical practical wisdom,

Nurs Health Care 13:84-91, 1992.

20 PART 1 Perspectives in Health Care Delivery and Nursing

The American Red Cross, through its Rural Nursing Service

(later the Town and Country Nursing Service), initiated home

nursing care in areas outside larger cities. Lillian Wald secured

the initial donations to support this agency, which provided

care to the sick, instruction in sanitation and hygiene in rural

homes, and improved living conditions in villages and farms.

These nurses dealt with diseases such as tuberculosis, pneumo-

nia, and typhoid fever. By 1920, 1800 Red Cross Town and

Country Nursing Services were in operation. This number

eventually grew to almost 3000 programs in small towns and

rural areas.

The emphasis of community nursing has varied and changed

over time. In recent years, federal and state inancing has inlu-

enced the growth. In addition to visiting nurse associations and

settlement houses, a variety of other organizations sponsored

visiting nurse work, including boards of education, boards of

health, mission boards, clubs, churches, social service agencies,

and tuberculosis associations. With tuberculosis then respon-

sible for at least 10% of all mortality, visiting nurses contributed

to its control through gaining “the personal cooperation of pa-

tients and their families” to modify the environment and indi-

vidual behavior (Buhler-Wilkerson, 1987, p 45). Most visiting

nurse agencies depended inancially on the philanthropy and

social networks of metropolitan areas. As today, fund-raising

and service delivery in less densely populated and rural areas

were challenging. Learning about the history of a practice

agency, such as a visiting nurse association, can provide impor-

tant perspectives on current agency values, decision-making

structures, funding, clinical priorities and service areas, and

obstacles to success.

Occupational health nursing, originally called industrial

nursing, grew out of early home visiting efforts. In 1895 Ada

Mayo Stewart began work with employees and families of the

Vermont Marble Company in Proctor, Vermont. As a free ser-

vice for the employees, Stewart provided obstetrical care, sick-

ness care (e.g., for typhoid cases), and some postsurgical care in

workers’ homes. However, she provided few services for work-

related injuries. Although her employer provided a horse and

buggy, she often made home visits on a bicycle. Before 1900 a

few nurses were hired in industry, such as in department stores

in Philadelphia and Brooklyn. Between 1914 and 1943, indus-

trial nursing grew from 60 to 11,220 nurses, relecting increased

governmental and employee concerns for health and safety at

work (American Association of Industrial Nurses, 1976; Kalisch

and Kalisch, 1995).

School nursing was also an extension of home visiting. In

New York City in 1902 more than 20% of children might be

absent from school on a single day because of conditions such

as pediculosis, ringworm, scabies, inlamed eyes, discharging

ears, and infected wounds. Physicians began to make limited

inspections of school students in 1897. They focused on exclud-

ing infectious children from school rather than on providing

or obtaining medical treatment to enable children to return

to school. Familiar with this community-wide problem from

her work with the Henry Street Settlement, Lillian Wald intro-

duced the English practice of providing nurses for the schools.

Lina Rogers, a Henry Street Settlement resident, became the

irst school nurse. She worked with the children in New York

City schools and made home visits to teach parents and to fol-

low up on children absent from school. The school nurses

found that many of the children were absent because they did

not have shoes or clothing; many were hungry, and others had

to take care of the younger children in the family (Hawkins,

Hayes, and Corliss, 1994). School nursing was a success;

New York City soon added 12 more nurses. School nursing was

soon implemented in Los Angeles, Philadelphia, Baltimore,

Boston, Chicago, and San Francisco. The scope of school nurs-

ing remains highly variable in the United States in the 21st

century, and most school nurses are employed directly by a

board of education.

CONTINUED GROWTH IN PUBLIC HEALTH NURSING

The Visiting Nurse Quarterly, begun in 1909 by the Cleveland

Visiting Nurse Association, initiated a professional communi-

cation medium for clinical and organizational concerns. Also

in 1909, the University of Minnesota began the irst continu-

ing nursing program given on a university campus. In 1911 a

joint committee of existing nurse organizations convened,

under the leadership of Wald and Mary Gardner, to standard-

ize nursing services outside the hospital. They recommended

the formation of a new organization to address public health

nursing concerns. Their committee invited 800 agencies in-

volved in public health nursing activities to send delegates to

an organizational meeting in Chicago in June 1912. After a

heated debate on its name and purpose, the delegates estab-

lished the National Organization for Public Health Nursing

(NOPHN) and chose Wald as its irst president (Dock, 1922).

Unlike other professional nursing organizations, the NOPHN

membership included both nurses and their lay supporters.

The NOPHN, which worked “to improve the educational and

services standards of the public health nurse, and promote

public understanding of and respect for her work” (Rosen,

1958, p 381), soon became the dominant force in public

health (Roberts, 1955).

The NOPHN sought to standardize public health nursing

education. At that time, newly graduated nurses often were

unprepared for home visitation because the diploma schools

emphasized care of hospital clients. Thus public health nurses

needed education in how to care for the sick at home and to

design population-focused programs. In 1914 Mary Adelaide

Nutting, working with the Henry Street Settlement, began the

irst course for postdiploma school training in public health

nursing at Teachers College in New York City (Deloughery,

1977). The American Red Cross provided scholarships for

graduates of nursing schools to attend the public health nursing

course. Its success encouraged the development of other pro-

grams, using curricula that might seem familiar to today’s

nurses. During the 1920s and 1930s, many newly hired public

health nurses had to verify completion or promptly enroll in a

certiicate program in public health nursing. Others took leave

for a year to travel to an urban center to obtain this further

education. Correspondence courses (distance education) were

21CHAPTER 2 The History of Public Health and Public and Community Health Nursing

even acceptable in some areas, for example, for public health

nurses in upstate New York.

Public health nurses were also active in the American Public

Health Association (APHA), which was established in 1872 to

facilitate interprofessional efforts and promote the “practical

application of public hygiene” (Scutchield and Keck, 1997,

p 12). The APHA focused on important public health issues,

including sewage and garbage disposal, occupational injuries,

and sexually transmitted diseases. In 1923 the Public Health

Nursing Section (PHNS) was formed within the APHA to pro-

vide nurses with a national forum to discuss their concerns and

strategies within the larger context of the major public health

organization. The PHNS continues to serve as a focus of leader-

ship and policy development for public health nursing.

Public health nursing in voluntary agencies and through the

Red Cross grew more quickly than public health nursing sup-

ported by local, state, and national government. In the late

1800s, local health departments were formed in urban areas to

target environmental hazards associated with crowded living

conditions and dirty streets and to regulate public baths, slaugh-

terhouses, and pigsties (Pickett and Hanlon, 1990). By 1900,

38 states had established state health departments, following

the lead of Massachusetts in 1869; however, these early state

boards of health had limited impact because only three states—

Massachusetts, Rhode Island, and Florida—annually spent more

than 2 cents per capita for public health services (Scutchield

and Keck, 1997).

The federal role in public health gradually expanded. In

1912 the federal government redeined the role of the US

Public Health Service, empowering it to “investigate the causes

and spread of diseases and the pollution and sanitation of

navigable streams and lakes” (Scutchield and Keck, 1997,

p 15). The NOPHN loaned a nurse to the US Public Health

Service during World War I to establish a public health nursing

program for military outposts. This led to the irst federal gov-

ernment sponsorship of nurses (Shyrock, 1959; Wilner, Walkey,

and O’Neill, 1978).

During the 1910s public health organizations began to

target infectious and parasitic diseases in rural areas. The

Rockefeller Sanitary Commission, a philanthropic organization

active in hookworm control in the southeastern United States,

concluded that concurrent efforts for all phases of public health

were necessary to successfully address any individual public

health problem (Pickett and Hanlon, 1990). For example, in

1911 efforts to control typhoid fever in Yakima County,

Washington, and to improve health status in Guilford County,

North Carolina, led to the establishment of local health units to

serve local populations. Public health nurses were the primary

staff members of local health departments. These nurses assumed

a leadership role on health care issues through collaboration with

local residents, nurses, and other health care providers.

The experience of Orange County, California, during the

1920s and 1930s illustrates the growing importance of the nurse

in the community. Based on the work of a private physician,

social welfare agencies, and a Red Cross nurse, the county board

created the public health nurse’s position in 1922. Presented

with a shining new Model T car sporting the bright orange seal

of the county, the nurse began her work by dealing with the

serious communicable disease problems of diphtheria and scar-

let fever. Typhoid became epidemic when a drainage pipe over-

lowed into a well, infecting those who drank the water and

those who drank raw milk from an infected dairy. Almost 3000

residents were immunized against typhoid. At weekly well-baby

conferences, the nurse weighed infants and gave them immuni-

zations and taught mothers how to care for the infants. Also,

children with orthopedic disorders and other disabilities were

identiied and referred for medical care in Los Angeles. The irst

year of this public health nursing work was so successful that

the Rockefeller Foundation and the California Health Depart-

ment provided funds for more public health professionals.

PUBLIC HEALTH NURSING DURING THE EARLY 20TH CENTURY

The personnel needs of World War I in Europe depleted the

ranks of public health nurses, even as the NOPHN identiied a

need for second and third lines of defense within the United

States. Jane Delano in 1909 was appointed both as superinten-

dent of the Army Nurse Corps and chairman of the National

Committee on Red Cross Nursing services. She was instrumen-

tal in preparing nurses to serve in the military, and she also

supported the need for public health nurses to stay at home

and serve the needs of those not serving in the military. Over

3 weeks in 1918 the worldwide inluenza pandemic swept

across the United States. A coalition of the NOPHN and the

Red Cross worked to turn houses, churches, and social halls

into hospitals for the immense numbers of sick and dying.

Some of the nurse volunteers died of inluenza.

Limited funding during the early 20th century was the major

obstacle to extending nursing services in the community. Most

early visiting nurse associations relied on contributions from

wealthy and middle-class supporters. Consistent with the goal

of encouraging economic independence, poor families were

asked to pay a small fee for nursing services. In 1909 with en-

couragement from Lillian Wald in collaboration with Dr. Lee

Frankel, the Metropolitan Life Insurance Company began a

program using visiting nurse organizations to provide care for

sick policyholders. The nurses assessed illness, taught health

practices, and collected data from policyholders. By 1912, 589

Metropolitan Life nursing centers provided care through exist-

ing agencies or visiting nurses hired directly by the company. In

1918 Metropolitan Life calculated an average decline of 7%

in the mortality rate of policyholders and almost a 20% decline

in the mortality rate of policyholders’ children under the age of

3 years. The insurance company attributed this improvement

and its reduced costs to the work of visiting nurses.

Nurses also inluenced public policy by advocating for the

Children’s Bureau and the Sheppard-Towner Program. Wald

and other nursing leaders urged that the Children’s Bureau be

established in 1912 to address national problems of maternal

and child welfare. Children’s Bureau experts conducted exten-

sive scientiic research on the effects of income, housing, em-

ployment, and other factors on infant and maternal mortality.

Their research led to federal child labor laws and the 1919

22 PART 1 Perspectives in Health Care Delivery and Nursing

White House Conference on Child Health. The Sheppard-

Towner Act of 1921, which focused on maternal and infant

health, was credited with saving many lives. This act provided

federal matching funds to establish maternal and child health

divisions in state health departments. Education during home

visits by public health nurses emphasized promoting the health

of the mother and child and encouraged mothers to seek

prompt medical care during pregnancy. Although credited with

saving many lives, the program ended in 1929 in response to

charges by the AMA and others that the legislation gave too

much power to the federal government and too closely resem-

bled socialized medicine (Pickett and Hanlon, 1990). Just as we

see today, there has long been an inability to provide public

health services because of the lack of funds.

Some nursing innovations were the result of individual

commitment and private inancial support. In 1925 Mary

Breckinridge established the Frontier Nursing Service (FNS).

This creative service was based on systems of care in Scotland

(Box 2.2 and Fig. 2.4). The pioneering spirit of the FNS inlu-

enced the development of public health programs to improve

the health care of the rural and often inaccessible populations

in the Appalachian region of southeastern Kentucky (Browne,

1966; Tirpak, 1975). Breckinridge introduced the irst nurse-

midwives into the United States when she deployed FNS nurses

trained in nursing, public health, and midwifery. Their efforts

BOX 2.2 Mary Breckinridge and the Frontier Nursing Service

Born in 1881 into the fifth generation of a well-to-do Kentucky family, Mary

Breckinridge devoted her life to the establishment of the Frontier Nursing

Service (FNS). Learning from her grandmother, who used a large part of

her fortune to improve the education of Southern children, Breckinridge

later used money left to her by her grandmother to start the FNS (Browne,

1966).

Tutored in childhood and later attending private schools, Mary Breckinridge did

not consider becoming a nurse until her husband died. At that time she wanted

to have more adventure in her life and to ind opportunities to do something

useful for others (Hostutler et al, 2000). In 1907 she enrolled at St. Luke’s Hospi-

tal School of Nursing in New York. She later married for a second time and had

two children. Her second marriage ended after her daughter died at birth and her

son died at age 4. From the time of her son’s death in 1918, she devoted her

energy to promoting the health care of disadvantaged women and children

(Browne, 1966).

After World War I and work in postwar France, she returned to the United

States, passionate about helping the neglected children of rural America. To

prepare herself for what would become her life’s work, she studied for a year at

Teacher’s College, Columbia University, to learn more about public health nursing

(Browne, 1966).

Early in 1925 she returned to Kentucky. She decided that the mountains of

Kentucky were an excellent place to demonstrate the value of community health

nursing to remote, disadvantaged families. She thought that if she could estab-

lish a nursing center in rural Kentucky, this effort could then be duplicated any-

where. The irst health center was established in a ive-room cabin in Hyden,

Kentucky. Establishing the center took not only nursing skills but also the

construction of the center and later the hospital and other buildings; it required

extensive knowledge about developing a water supply, disposing of sewage,

getting electric power, and securing a mountain area in which landslides oc-

curred (Browne, 1966). Despite many obstacles inherent in building in the

mountains, six outpost nursing centers were established between 1927 and

1930. The FNS hospital was built in Hyden, Kentucky, and physicians began en-

tering service. Payment of fees ranged from labor and supplies to funds raised

through annual family dues, philanthropy, and the fund-raising efforts of Mary

Breckinridge (Holloway, 1975).

The FNS established medical, surgical, and dental clinics; provided nursing and

midwifery services 24 hours a day; and served nearly 10,000 people spread over

700 square miles. Baseline data were obtained on infant and maternal mortality

before beginning services. FNS services are especially remarkable considering

the environmental conditions in which rural Kentuckians lived. Many homes had

no heat, electricity, or running water. Often physicians were located more than

40 miles from their patients (Tirpak, 1975).

During the 1930s, nurses lived in one of the six outposts, from which they

traveled to see clients; they often had to make their visits on horseback. Like her

nurses, Mary Breckinridge traveled many miles through the mountains of

Kentucky on her horse, Babette, providing food, supplies, and health care to

mountain families (Browne, 1966).

Over the years, several hundred nurses have worked for the FNS. Although

Mary Breckinridge died in 1965, the FNS has continued to grow and provide

needed services to people in the mountains of Kentucky. This service continues

today as a vital and creative way to deliver community health services to rural

families.

Data from Browne H: A tribute to Mary Breckinridge, Nurs Outlook 14:54-55, 1966; Goan MB: Mary Breckinridge: the frontier nursing service and

rural health in Appalachia, Chapel Hill, NC, 2008, The University of North Carolina Press; Holloway JB: Frontier Nursing Service 1925-1975, J Ky

Med Assoc 73:491-492, 1975; Hostutler J, Kennedy MS, Mason D, et al: Nurses: then and now and models of practice, Am J Nurs 100:82-83,

2000; Tirpak H: The Frontier Nursing Service: ifty years in the mountains, Nurs Outlook 33:308-310, 1975.

FIG. 2.4 Mary Breckinridge, founder of the Frontier Nursing

Service. (Courtesy Frontier Nursing Service of Wendover,

Kentucky.)

23CHAPTER 2 The History of Public Health and Public and Community Health Nursing

led to reduced pregnancy complications and maternal mortal-

ity and to one-third fewer stillbirths and infant deaths in an

area of 700 square miles (Kalisch and Kalisch, 1995). Today the

FNS continues to provide comprehensive health and nursing

services to the people of that area and sponsors the Frontier

Nursing University.

AFRICAN AMERICAN NURSES IN PUBLIC HEALTH NURSING

African American nurses seeking to work in public health nurs-

ing faced many challenges. Nursing education was absolutely

segregated in the South until at least the 1960s and elsewhere

was also generally segregated or rationed until the mid-20th

century. Even public health nursing certiicate and graduate

education programs were segregated in the South; study out-

side the South for Southern nurses was dificult to afford, and

study leaves from the workplace were rarely granted. The situa-

tion improved somewhat in 1936 when collaboration between

the US Public Health Service and the Medical College of

Virginia (Richmond) established a certiicate program in public

health nursing for African American nurses for which the fed-

eral government paid nurses’ tuition. Discrimination continued

during nurses’ employment: African American nurses in the

American South were paid lower salaries than their white coun-

terparts for the same work. In 1925 only 435 African American

public health nurses were employed in the United States, and in

1930 only six African American nurses held supervisory posi-

tions in public health nursing organizations (Buhler-Wilkerson,

2001; Hine, 1989; Thoms, 1929).

African American public health nurses signiicantly inlu-

enced the communities they served (Fig. 2.5). The National

Health Circle for Colored People was organized in 1919 to pro-

mote public health work in African American communities in

the South. One strategy adopted was providing scholarships to

assist African American nurses in pursuing university-level

public health nursing education. Bessie M. Hawes, the irst

recipient of the scholarship, completed the program at Colum-

bia University (New York) and was then sent by the Circle to

Palatka, Florida. In this small, isolated lumber town, Hawes’s

irst project was to recruit schoolgirls to promote health by

dressing as nurses and marching in a parade while singing com-

munity songs. She conducted mass meetings, led clubs for

mothers, provided school health education, and visited the

homes of the sick. Eventually she gained the community’s trust,

overcame opposition, and built a health center for nursing care

and treatment (Thoms, 1929).

ECONOMIC DEPRESSION AND THE IMPACT ON PUBLIC HEALTH

The economic depression of the 1930s affected the development

of nursing. Not only were agencies and communities unpre-

pared to address the increased needs and numbers of the impov-

erished, but decreased funding for nursing services reduced the

number of employed nurses in hospitals and in community

agencies. Federal funding led to a wide variety of programs ad-

ministered at the state level, including new public health nursing

programs; as a result of NOPHN’s enormous efforts, public

health nursing was included in federal relief programs.

The Federal Emergency Relief Administration (FERA) sup-

ported nurse employment through increased grants-in-aid for

state programs of home medical care. FERA often purchased

nursing care from existing visiting nurse agencies, thus sup-

porting more nurses and preventing agency closures. The FERA

program focus varied among states; the state FERA program in

New York emphasized bedside nursing care, whereas in North

Carolina, the state FERA prioritized maternal and child health

and school nursing services. The public health nursing pro-

grams of the FERA and its successor, the Works Progress Ad-

ministration (WPA), were sometimes later incorporated into

state health departments.

In another Depression-era initiative, more than 10,000 nurses

were employed by the Civil Works Administration (CWA) pro-

grams and assigned to oficial health agencies. “While this facili-

tated rapid program expansion by recipient agencies and gave

the nurses a taste of public health, the nurses’ lack of ield expe-

rience created major problems of training and supervision for

the regular staff ” (Roberts and Heinrich, 1985, p 1162).

A 1932 survey of public health agencies found that only 7%

of nurses employed in public health were adequately prepared

for that role (Roberts and Heinrich, 1985). Basic nursing educa-

tion emphasized the care of individuals, and students received

little information on groups and the community as a unit of

service. Thus in the 1930s and early 1940s, new graduates re-

quired considerable remedial education when they were hired

into public health work (NOPHN, 1944).

During this period the tension persisted between preventive

care and care of the sick and the related question of whether

nursing interventions should be directed toward groups and

communities or toward individuals and their families. Although

each nursing agency was unique and services varied from region

to region, voluntary visiting nurse associations tended to empha-

size care of the sick, and oficial public health agencies provided

FIG. 2.5 A New Orleans nurse visiting a family on the doorstep

of their home. (Courtesy New Orleans Public Library WPA Pho-

tograph Collection.)

24 PART 1 Perspectives in Health Care Delivery and Nursing

more preventive services. Not surprisingly, this splintering of

services led to a rivalry between “visiting,” or community, and

“public health” nurses and interfered with the development

of comprehensive community nursing services (Roberts and

Heinrich, 1985). For example, one household could receive ser-

vices from several community nurses representing different agen-

cies, with separate visits for a postpartum woman and new baby,

for a child sick with scarlet fever, and for an elderly bedridden

person. This was confusing and costly, with duplicated services.

One solution was to establish the “combination service,” which

merged sick-care services and preventive services into one com-

prehensive agency by combining visiting nurse and oficial public

health agencies. However, in contrast to visiting nurse organiza-

tions, public health nurses in oficial health agencies often had

less control of the program because physicians and politicians

determined services and the assignment of personnel. The “ideal

program” of the combination agency was hard to administer, and

many of the combination services implemented between 1930

and 1965 later reverted to their former, divided structures of visit-

ing nurse agencies and oficial health departments.

Expansion of federal government programs during the

1930s affected the structure of community health resources and

led to “the beginning of a new era in public nursing” (Roberts

and Heinrich, 1985, p 1162). In 1933 Pearl McIver became the

irst nurse employed by the US Public Health Service. In pro-

viding consultation services to state health departments, McIver

was convinced that the strengths and ability of each state’s

director of public health nursing would determine the scope

and quality of local health services. Together with Naomi

Deutsch, director of nursing for the federal Children’s Bureau,

and with the support of nursing organizations, McIver and her

staff of nurse consultants inluenced the direction of public

health nursing. Between 1931 and 1938 over 40% of the in-

crease in public health nurse employment was in local health

agencies. Even so, nationally, more than one-third of all coun-

ties still lacked local public health nursing services (Fig. 2.6).

The Social Security Act of 1935 was designed to prevent

reoccurrence of the problems of the Depression. Title VI of this

act provided funding for expanded opportunities for health

protection and promotion through education and employment

of public health nurses. In 1936 more than 1000 nurses com-

pleted educational programs in public health. Title VI also

provided $8 million to assist states, counties, and medical dis-

tricts to establish and maintain adequate health services, as well

as $2 million for research and investigation of disease (Buhler-

Wilkerson, 1985, 1989; Kalisch and Kalisch, 1995).

In the late 1930s and especially in the late 1940s, Congress sup-

ported categorical funding to provide federal money for priority

diseases or groups rather than for a comprehensive community

health program. In response, local health departments designed

programs to it the funding priorities. This included maternal and

child health services and crippled children (1935), venereal disease

control (1938), tuberculosis (1944), mental health (1947), indus-

trial hygiene (1947), and dental health (1947) (Scutchield and

Keck, 1997). This pattern of funding continues today.

World War II increased the need for nurses both for the war

effort and at home. Many nurses joined the US Army and Navy

Nurse Corps. US Representative Frances Payne Bolton of Ohio

led Congress to pass the Bolton Act of 1943, which established

the Cadet Nurses Corps. This legislation supported increased

undergraduate and graduate enrollment in schools of nursing.

Funding became more available to educate nurses by providing

inancial support for them to go to school, with many focusing

on public health.

Because of the number of nurses involved in the war, civilian

hospitals and visiting nurse agencies shifted care to families and

nonnursing personnel. “By the end of 1942, over 500,000

women had completed the American Red Cross home nursing

course, and nearly 17,000 nurse’s aides had been certiied”

(Roberts and Heinrich, 1985, p 1165). By the end of 1946, more

than 215,000 volunteer nurse’s aides had received certiicates.

During this time, community health nursing expanded its

scope of practice. For example, more community health nurses

practiced in rural areas, and many oficial agencies began to

provide bedside nursing care (Buhler-Wilkerson, 1985; Kalisch

and Kalisch, 1995).

After the war the need increased for services from local

health departments to respond to sudden increases in demand

for care of emotional problems, accidents, alcoholism, and

other responsibilities new to oficial health agencies. Changes in

medical technology improved the ability to screen and treat

infectious and communicable diseases. Penicillin, which was

developed during the war, became available to treat civilians

with rheumatic fever, venereal diseases, and other infections.

Job opportunities for public health nurses increased, and nurses

were a major portion of health department staff. More than

20,000 nurses worked in health departments, visiting nurse as-

sociations, industry, and schools. Table 2.2 highlights signii-

cant milestones in community and public health nursing from

the mid-1800s to the mid-1900s.

FIG. 2.6 A public health nurse talks with a young woman and

her mother about childbirth as they sit on a porch. (US Public

Health Service photo by Perry. Images from the History of

Medicine, National Library of Medicine, Image ID 157037.)

25CHAPTER 2 The History of Public Health and Public and Community Health Nursing

FROM WORLD WAR II UNTIL THE 1970s

Between 1900 and 1955, the national crude mortality rate decreased

by 47%. Many more Americans survived childhood and early

adulthood to live into middle and older ages. Although in 1900 the

leading causes of mortality were pneumonia, tuberculosis, diarrhea,

and enteritis, by midcentury the leading causes had become heart

disease, cancer, and cerebrovascular disease. Nurses helped reduce

communicable disease mortality through immunization cam-

paigns, nutrition education, and provision of better hygiene and

sanitation. Additional factors included improved medications, bet-

ter housing, and innovative emergency and critical care services.

Increasing numbers of older adults also increased the popula-

tion at risk for increasing prevalence of chronic diseases. Nurses

now dealt with challenges related to chronic illness care, long-term

illness and disability, and chronic disease prevention. In oficial

health agencies, categorical programs focusing on a single chronic

disease emphasized narrowly deined services, which might be

poorly coordinated with other community programs. Screening for

chronic illness was a popular method of both detecting undiag-

nosed disease and providing individual and community education.

Some visiting nurse associations adopted coordinated home-

care programs to provide complex, long-term care to the chronically

ill, often after long-term hospitalization. These home-care pro-

grams established a multidisciplinary approach to complex client

care. For example, beginning in 1949, the Visiting Nurse Society

of Philadelphia provided care to clients with stroke, arthritis,

cancer, and fractures using a wide range of services, including

physical and occupational therapy, nutrition consultation, social

services, laboratory and radiographic procedures, and transpor-

tation. During the 1950s, often in response to family demands

and the shortage of nurses, many visiting nurse agencies began

experimenting with auxiliary nursing personnel, variously called

housekeepers, homemakers, or home health aides. These innova-

tive programs provided a substantial basis for an approach to

bedside nursing care that would be reimbursable by commercial

health insurance (such as Blue Cross) and later by Medicare and

Medicaid.

During the 1930s and 1940s, more Americans chose to ob-

tain care in hospitals because this was where physicians worked

and where technology was readily available to diagnose and

treat illness. Health insurance programs now allowed middle-

class people to pay for care in hospitals. In 1952 the Metropoli-

tan Life Insurance Company and the John Hancock Life Insur-

ance Company ended their support of visiting nurse services

(Fig. 2.7) for their policyholders, and the American Red Cross

ended its programs of direct nursing service.

Nursing organizations also continued to change. The func-

tions of the NOPHN, the National League for Nursing Educa-

tion, and the Association of Collegiate Schools of Nursing were

Year Milestone

1866 New York Metropolitan Board of Health established

1872 American Public Health Association established

1873 New York Training School opened at Bellevue Hospital, New York

City, as irst Nightingale-model nursing school in the United States

1877 Women’s Board of the New York Mission hired Frances Root to

visit the sick poor

1885 Visiting Nurse Association established in Buffalo

1886 Visiting nurse agencies established in Philadelphia and Boston

1893 Lillian Wald and Mary Brewster organized a visiting nursing service

for the poor of New York, which later became the Henry Street

Settlement; Society of Superintendents of Training Schools of

Nurses in the United States and Canada was established (in 1912

it became known as the National League for Nursing Education)

1896 Associated Alumnae of Training Schools for Nurses established (in

1911 it became the American Nurses Association)

1902 School nursing started in New York; Lina Rogers was the irst

school nurse

1903 First nurse practice acts

1909 Metropolitan Life Insurance Company initiated the irst insurance

reimbursement for nursing care

1910 Public health nursing program instituted at Teachers College,

Columbia University, in New York City

1912 National Organization for Public Health Nursing formed, with

Lillian Wald as the irst president

1914 First undergraduate nursing education course in public health

offered by Adelaide Nutting at Teachers College

1918 Vassar Camp School for Nurses organized; US Public Health Ser-

vice (USPHS) established division of public health nursing to

work in the war effort; worldwide inluenza epidemic began

1919 Textbook Public Health Nursing written by Mary S. Gardner

1921 Maternity and Infancy Act (Sheppard-Towner Act)

1925 Frontier Nursing Service using nurse-midwives established

1934 Pearl McIver becomes the irst nurse employed by USPHS

1935 Passage of the Social Security Act

1941 Beginning of World War II

1943 Passage of the Bolton-Bailey Act for nursing education; Cadet

Nurse Program established; Division of Nursing begun at

USPHS; Lucille Petry appointed chief of the Cadet Nurse Corps

1944 First basic program in nursing accredited as including suficient

public health content

TABLE 2.2 Milestones in the History of Community Health and Public Health Nursing: 1866–1944

FIG. 2.7 A nurse from the Visiting Nurse Association demon-

strates proper infant care and bathing techniques to the parents.

26 PART 1 Perspectives in Health Care Delivery and Nursing

Currently, associate degree nursing (ADN) programs edu-

cate the largest percentage of nurses. Both health care and ADN

education have changed; both have moved away from a heavy

focus on inpatient care to community-based care. Curricula in

ADN programs often include content and clinical experiences

in management, community health, home health, and gerontol-

ogy. These clinical areas have typically been key components

of baccalaureate education. The American Association of Col-

leges of Nursing (AACN) was founded in 1969 to respond to

the need for an organization that would further nursing educa-

tion in American universities and 4-year colleges, including

establishing essentials of nursing education for baccalaureate

and higher-degree programs.

New personnel also added to the lexibility of the public

health nurse to address the needs of communities. Beginning in

1965 at the University of Colorado, the nurse practitioner

movement opened a new era for nursing involvement in pri-

mary care that affected the delivery of services in community

health clinics. Initially, the nurse practitioner was often a public

health nurse with additional skills in the diagnosis and treat-

ment of common illnesses. Although some nurse practitioners

chose to practice in other clinical areas, those who continued in

public health settings made sustained contributions to improv-

ing access and providing primary care to people in rural areas,

inner cities, and other medically underserved areas (Roberts

and Heinrich, 1985). As evidence of the effectiveness of their

services grew, nurse practitioners became increasingly accepted

as cost-effective providers of a variety of primary care services.

PUBLIC HEALTH NURSING FROM THE 1970s TO THE PRESENT

During the 1970s, nurses made many contributions to improv-

ing the health care of communities, including participation in

the new hospice movement and through the development of

birthing centers, daycare for elderly and disabled persons, drug-

abuse treatment programs, and rehabilitation services in long-

term care. Adequate funding for population health remained

dificult to secure. Health care costs grew during the 1980s.

Growing costs of acute hospital care, medical procedures, and

institutional long-term care reduced funding for health promo-

tion and disease prevention programs. The use of ambulatory

services, including health maintenance organizations, was en-

couraged, and utilization of nurse practitioners (advanced-

practice nurses) increased. Despite unstable reimbursement,

home health care increased its role in the care of the sick at

home. By the 1980s, individuals and families assumed more

responsibility for their own health, and health education—

always a part of community health nursing—became more

popular. Consumer and professional advocacy groups urged

the passage of laws to prohibit unhealthy practices in public,

such as smoking and driving under the inluence of alcohol.

However, reduced federal and state funds led to decreases in the

number of nurses in oficial public health agencies.

The Division of Nursing of the US Public Health Service

conducted and sponsored nursing research beginning in the

late 1930s. This expanded in the late 1940s (Uhl, 1965).

EVIDENCE-BASED PRACTICE

Nursing has a long and rich past, yet this is rarely conveyed to undergraduate

nursing students; as a result, nurses devalue the achievements of earlier

nurses. This chapter argues that studying the history of nursing has beneits

for undergraduate students and the profession at large. It provides students

with a realistic understanding of nursing and what has inluenced past devel-

opments to bring us to the present situation. Thus it provides students with the

context of nursing practice and a irm foundation on which other nursing

courses can build. Introducing students to the history of nursing introduces

them to a heritage of working in the community and in institutions; of working

independently and interdependently; and of ongoing struggles to forge a pro-

fessional status based on philanthropy, ethics, and, later, education. Studying

the history of nursing, especially at the beginning of the undergraduate pro-

gram, allows students to understand the factors that have inluenced past

events and how these factors continue to have an impact on nursing today and

into the future.

In addition to the contextual beneits gleaned from the study of the history

of nursing, fundamental critical thinking skills can be developed by encourag-

ing students to question the evidence before them and seek inluencing fac-

tors or the “bigger picture.” Additional beneits include the ability to debunk

some well-known myths that have affected nursing over the years, the ability

to explore gender roles in nursing and discuss how gender affects today’s

practice, and the ability to understand the unwritten rules of the clinical

environment.

Nurse Use

The inluence of nursing should be valued and understood within the context

of the time it was being practiced. Students who have an appreciation of nurs-

ing’s past have a better understanding of nursing and who nurses are. With

knowledge of the history of nursing, students can better understand that they

are entering a profession with a rich and diverse past and that this can provide

a irm platform on which to base their other studies. By studying the history of

nursing, they also develop their critical thinking skills, which allows them to

question and evaluate information that is presented to them on a daily basis.

From Madsen W: Teaching history to nurses: will this make me a better

nurse? Nurs Educ Today 28:524-529, 2008.

distributed to the new National League for Nursing (NLN) in

1952. The American Nurses Association (ANA) continued as

the second national nursing organization, after merging with

the National Association for Colored Graduate Nurses in 1951.

In 1948 the NLN adopted the recommendations of Esther

Lucile Brown’s study of nursing education, Nursing for the Future,

and this considerably inluenced how nurses were prepared. She

recommended that basic nursing education take place in colleges

and universities. In the 1950s, public health nursing became a

required part of most baccalaureate nursing education programs.

In 1952 nursing education programs began in junior and com-

munity colleges. Louise McManus, a director of the Division of

Nursing Education at Teachers College, Columbia University,

wanted to see if bedside nurses could be prepared in a 2-year

program. The intent was to prepare nurses more quickly than

in the past to ease the prevailing nursing shortage (Kalisch and

Kalisch, 1995). This would also move more nursing education

into American higher education. Mildred Montag, an assistant

professor of nursing education at Teacher’s College, became the

project coordinator. In 1958, when the 5-year study was com-

pleted, this experiment was determined to be a success.

27CHAPTER 2 The History of Public Health and Public and Community Health Nursing

The National Center for Nursing Research (NCNR) was estab-

lished in 1985 within the federal National Institutes of Health.

The NCNR focused attention on the value of nursing research

and promoted the work of nurses. With the effort of many

nurses the NCNR attained institute (rather than center) status

in 1993 and became the National Institute of Nursing Research

(NINR), relecting the continued growth in nursing research.

By the late 1980s the public health initiative had declined in

its ability to implement its mission and inluence the health of

the public. The disarray resulting from reduced political support,

inancing, and effectiveness was clearly described by the Institute

of Medicine (IOM) in The Future of Public Health (IOM, 1988).

Although many people agreed about what the mission of public

health should be, there was much less agreement about how to

turn the mission of public health into action and effective pro-

grams. The IOM report emphasized the core functions of public

health as assessment, policy development, and assurance.

The Healthy People initiative has inluenced goals and prior-

ity setting in public health and in public health nursing. In 1979

Healthy People proposed a national strategy to improve the

health of Americans signiicantly by preventing or delaying the

onset of major chronic illnesses, injuries, and infectious dis-

eases. Speciic goals and objectives were established, and the

goals were to be evaluated at the end of each decade. Implemen-

tation of these strategies has considerably inluenced the work

of nurses, through their employment in health agencies and

through participation in state or local Healthy People coalitions

(Healthy People 2020 box). The most recent initiative, the devel-

opment of Healthy People 2020 (US Department of Health and

Human Services, 2010) objectives, has built on the work of

Healthy People 2010 (US Department of Health and Human

Services, 2000). Some objectives in Healthy People 2010 have

been met; others are being retained in Healthy People 2020, and

new ones have been added. Healthy People 2020 objectives and

intervention strategies are included in each chapter of this text.

Since the 1990s, public concerns about health have focused

on cost, quality, and access to services. Despite widespread in-

terest in universal health insurance coverage, neither individu-

als nor employers are willing to pay for this level of service. The

core debate of the economics of health care—who should pay

for what—has emphasized the need for reform of medical care

rather than comprehensive reform of health care. In 1993 a

blue-ribbon group assembled by President Clinton, with First

Lady Hillary Rodham Clinton serving as chair, proposed the

American Health Security Act. This proposal led to broad dis-

cussion of the key issues and concerns in health care, especially

the organization and delivery of medical care, with an emphasis

on managed care. When Congress failed to pass the American

Health Security Act, considerable change followed in health

care inancing, and the private sector assumed even greater

control. As managed care grew, costs were contained, but con-

straints increased in terms of how to access care and how much

and what kind of care would be reimbursed. Throughout these

debates, public health was generally ignored. Little attention

was given to ensuring that populations and the communities in

which they lived were healthy. This omission relected the large

gap between the proposal and actual comprehensive health care

reform.

In 1991 the ANA, AACN, NLN, and more than 60 other

specialty nursing organizations joined to support health care

reform. The coalitions of organizations emphasized the key

health care issues of access, quality, and cost. Improved pri-

mary care and public health efforts would help build a

healthy nation. Professional nursing continues to support

revisions in health care delivery and extension of public

health services to prevent illness, promote health, and protect

the public (Table 2.3). Chapters 3 (The Changing US Health

and Public Health Care Systems) and 8 (Economic Inlu-

ences) describe the current work to change the way health is

provided and who pays for the care.

Year Milestone

1946 Nurses classiied as professionals by US Civil Service Commission; Hill-Burton Act approved, providing funds for hospital construction in

underserved areas and requiring these hospitals to provide care to poor people; passage of National Mental Health Act

1950 25,091 nurses employed in public health

1951 National nursing organizations recommended that college-based nursing education programs include public health content

1952 National Organization for Public Health Nursing merged into the new National League for Nursing; Metropolitan Life Insurance Nursing Program closed

1964 Passage of the Economic Opportunity Act; public health nurse deined by the American Nurses Association (ANA) as a graduate of a bachelor of

science in nursing (BSN) program

1965 ANA position paper recommended that nursing education take place in institutions of higher learning; Congress amended the Social Security Act

to include Medicare and Medicaid

1977 Passage of the Rural Health Clinic Services Act, which provided indirect reimbursement for nurse practitioners in rural health clinics

1978 Association of Graduate Faculty in Community Health Nursing/Public Health Nursing (later renamed Association of Community Health Nursing

Educators)

1980 Medicaid amendment to the Social Security Act to provide direct reimbursement for nurse practitioners in rural health clinics; both ANA and the

American Public Health Association (APHA) developed statements on the role and conceptual foundations of community and public health

nursing, respectively

1983 Beginning of Medicare prospective payments

1985 National Center for Nursing Research (NCNR) established within the National Institutes of Health (NIH)

1988 Institute of Medicine published The Future of Public Health

TABLE 2.3 Milestones in the History of Community Health and Public Health Nursing: 1946–2013

Continued

28 PART 1 Perspectives in Health Care Delivery and Nursing

Year Milestone

1990 Association of Community Health Nursing Educators published Essentials of Baccalaureate Nursing Education

1991 More than 60 nursing organizations joined forces to support health care reform and published a document entitled Nursing’s Agenda for Health

Care Reform

1993 American Health Security Act of 1993 was published as a blueprint for national health care reform; the national effort, however, failed, leaving

states and the private sector to design their own programs

1993 NCNR became the National Institute for Nursing Research, as part of the National Institutes of Health

1993 Public Health Nursing section of the American Public Health Association updated the deinition and role of public health nursing

1996 Passage of the Health Insurance Portability and Accountability Act

2001 Signiicant interest in public health ensues from concerns about biological and other forms of terrorism in the wake of the intentional destruction

of buildings in New York City and Washington, D.C., on September 11

2002 Ofice of Homeland Security established to provide leadership to protect against intentional threats to the health of the public

2003–2005 Multiple natural disasters, including earthquakes, tsunamis, and hurricanes, demonstrated the weak infrastructure for managing disasters in the

United States and other countries and emphasized the need for strong public health programs that included disaster management

2007 An entirely new Public Health Nursing Scope and Standards of Practice released through the ANA, relecting the efforts of the Quad Council of

Public Health Nursing Organizations

2010 Patient Protection and Affordable Care Act signed by President Barack Obama; Healthy People 2020 realized by the US Department of Health and

Human Services

2011 The Quad Council of Public Health Nursing Organizations published Competencies for Public Health Nursing

2013 The American Nurses Association published the second edition of Public Health Nursing: Scope and Standards of Practice

2013 The Quad Council of Public Health Nursing Organizations updated Competencies for Public Health Nursing Practice

TABLE 2.3 Milestones in the History of Community Health and Public Health Nursing: 1946–2013—cont’d

HEALTHY PEOPLE 2020

History of the Development of Healthy People

In 1979 the groundbreaking Healthy People: The Surgeon General’s Report on

Health Promotion and Disease Prevention noted “the health of the American

people has never been better” (US Department of Health, Education and Wel-

fare, 1979, p 3). But this was only the prologue to deep criticism of the status of

American health care delivery. Between 1960 and 1978, health care spending

increased 700%—without striking improvements in mortality or morbidity. Dur-

ing the 1950s and 1960s, evidence accumulated about chronic disease risk fac-

tors, particularly cigarette smoking, alcohol and drug use, occupational risks, and

injuries. But these new research indings were not systematically applied to

health planning and to improving population health.

In 1974 the Canadian government published A New Perspective on the Health

of Canadians (Lalonde, 1974), which found death and disease to have four con-

tributing factors: inadequacies in the existing health care system, behavioral

factors, environmental hazards, and human biological factors. Applying the

Canadian approach, in 1976, US experts analyzed the 10 leading causes of

US mortality and found that 50% of American deaths were the result of unhealthy

behaviors, and only 10% were the result of inadequacies in health care. Rather

than just spending more to improve hospital care, clearly, prevention was the key

to saving lives, improving the quality of life, and saving health care dollars.

A multidisciplinary group of analysts conducted a comprehensive review of

prevention activities. These analysts veriied that the health of Americans could

be signiicantly improved through “actions individuals can take for themselves”

and through actions that public and private decision makers could take to

“promote a safer and healthier environment” (p 9). Like Canada’s New Perspec-

tives, in the United States Healthy People (1979) identiied priorities and measur-

able goals. Healthy People grouped 15 key priorities into three categories: key

preventive services that could be delivered to individuals by health providers,

such as timely prenatal care; measures that could be used by governmental

agencies, organizations, and industry to protect people from harm, such as re-

duced exposure to toxic agents; and activities that individuals and communities

could use to promote healthy lifestyles, such as improved nutrition.

In the late 1980s, success in addressing these priorities and goals was evaluated,

new scientiic indings were analyzed, and new goals and objectives were set for

the period from 1990 to 2000 through Healthy People 2000: National Health Promo-

tion and Disease Prevention Objectives (US Public Health Service, 1991). This pro-

cess was repeated 10 years later to develop goals and objectives for the period from

2000 to 2010 and for 2010 to 2020. Recognizing the continuing challenge of the use

of emerging scientiic research to encourage modiication of health behaviors and

practices, Healthy People 2020 (US Department of Health and Human Services,

2010) addresses health equity, elimination of disparities, and improved health for all

groups across the life span through disease prevention, improved social and physi-

cal environments, and healthy development and health behaviors.

Like the nurse in the early 20th century who spread the gospel of public health

to reduce communicable diseases, today’s population-centered nurse uses

Healthy People to reduce chronic and infectious diseases and injuries through

health education, environmental modiication, and policy development.

During the late 20th and early 21st centuries, challenges con-

tinued to trigger growth and change in nursing in the community.

Nurse-managed centers now provide a diversity of nursing ser-

vices, including health promotion and disease and injury preven-

tion, in areas where existing organizations have been unable to

meet community and neighborhood needs. These centers provide

valuable services but typically face many challenges in securing

adequate funding. As population needs also continue to grow and

change, schools of nursing, health departments, rural health clin-

ics, migrant health centers, and other community agencies are

challenged to provide the range of services necessary to meet spe-

ciic needs. Transfer of oficial health services to private control

has sometimes reduced professional lexibility and service deliv-

ery. A nursing shortage reduces stafing when community nurses

29CHAPTER 2 The History of Public Health and Public and Community Health Nursing

look to employment in acute-care facilities that often pay higher

salaries. The Association of Community Health Nurse Educators

recommends increased graduate programs to educate public

health nurse leaders, educators, and researchers. Natural disasters

(e.g., loods, hurricanes, and tornados) and human-made disas-

ters (including explosions, building collapses, airplane crashes,

and toxic ingredients added to food) have required rapid, inno-

vative, and time-consuming responses. Preparation for future

disasters and possible bioterrorism requires well-prepared nurses.

Some states hear new calls to deploy school nurses in every

school; a new recognition of the link between school success and

health is making the school nurse as essential as in Lillian Wald’s

era. Many of these topics are detailed in the chapters that follow.

The Affordable Care Act of 2010 has been controversial, and

many compromises have been made between the House of Rep-

resentatives and the Senate in the inal crafting of this health care

act. Much of the Affordable Care Act deals with changes in insur-

ance plans and coverage. See http://www.healthcare.gov/news/

factsheets/index.html for details about the Affordable Care Act.

Public health nursing, historically and at present, is charac-

terized by reaching out to care for the health of people in need

and providing safe and high-quality care where needed. Cur-

rently, many nurses work in the community. Some bring a pub-

lic health population-based approach and have as their goal

preventing illness and protecting health. Other nurses have

a community-oriented approach and deal primarily with the

health care of individuals, families, and groups in a community.

Still other nurses bring a community-based approach that fo-

cuses on “illness care” of individuals and families in the com-

munity. Each type of nurse is needed in today’s communities. It

is important that we learn from the past and use time and re-

sources carefully and effectively. Regardless of the level of educa-

tion of the nurse who provides care in the community, including

population-based care, all nurses need to provide care that is safe

and of high quality. The accompanying box below describes the

history of the Quality and Safety Education for Nurses (QSEN)

initiative, which aims to include quality and safety knowledge,

skills, and attitudes in all levels of nursing education.

FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES

Although the scope and responsibilities of public health nurses have changed over

time, the commitment to quality and safety has remained constant. Since the be-

ginning of population-centered nursing in the United States, the nurses involved in

this specialty have been committed to preserving health and preventing disease.

They have focused on environmental conditions such as sanitation and control of

communicable diseases, education for health, prevention of disease and disability,

and, at times, care of the sick and aged in their homes. This long-standing commit-

ment to quality and safety is consistent with the work of the QSEN, a national

initiative designed to transform nursing education by including in the curriculum

content and experiences related to building knowledge, skills, and attitudes for six

quality and safety initiatives (Cronenwett, Sherwood, and Gelmon, 2009). The

QSEN work, led by Drs. Linda Cronenwett and Gwen Sherwood at the University of

North Carolina, has made great progress in bridging the gap between quality and

safety in both practice and academic settings (Brown, Feller, and Benedict, 2010).

The six QSEN competencies for nursing are as follows:

1. Patient-centered care: Recognizes the client or designee as the source of

control and as a full partner in providing compassionate and coordinated care

that is based on the preferences, values, and needs of the client.

2. Teamwork and collaboration: Refers to the ability to function effectively

with nursing and interprofessional teams and to foster open communication,

mutual respect, and shared decision making to provide quality client care.

3. Evidence-based practice: Integrates the best current clinical evidence

with client and family preferences and values to provide optimal client care.

4. Quality improvement: Uses data to monitor the outcomes of the care pro-

cesses and uses improvement methods to design and test changes to con-

tinually improve the quality and safety of health care systems.

5. Safety: Minimizes the risk of harm to clients and providers through both

system effectiveness and individual performance.

6. Informatics: Uses information and technology to communicate, manage knowl-

edge, mitigate error, and support decision making (Brown et al, 2010, p 116).

Of the six QSEN competencies, all but safety were derived from the IOM report

Health Professions Education (2003). The QSEN team added safety because this

competency is central to the work of nurses. Articles have been published to

teach educators about QSEN, and national forums have been held. In addition,

the AACN has hosted faculty-development institutes for faculty and academic

administrators using a train-the-trainer model, and safety and quality objectives

have been built in the AACN essentials for nursing education. Similarly, the NLN

has incorporated the “NLN Educational Competencies Model” into its educa-

tional summits. The six QSEN competencies are integrated throughout the text

to emphasize the importance of quality and safety in public health nursing today.

Note: The terms patient and care will be changed to client and intervention to

relect a public health nursing approach.

Speciically related to the history of nursing, the following targeted compe-

tency can be applied:

Targeted Competency: Safety—Minimizes the risk of harm to clients and

providers through both system effectiveness and individual performance.

Important aspects of safety include the following:

• Knowledge: Discuss potential and actual impact of national client safety

resources initiatives and regulations

• Skills: Participate in analyzing errors and designing system improvements

• Attitudes: Value vigilance and monitoring by clients, families, and other

members of the health care team

Safety Question

Updated deinitions around client safety include addressing safety at the indi-

vidual level and at the systems level. The history of public health nursing dem-

onstrates the myriad ways that public health nurses have addressed client safety

in their evolving practice. Public health nurses support safety by caring for indi-

viduals and providing care for communities and groups. Historically, how have

public health nurses addressed safety at the individual client level? How

have public health nurses addressed client safety at the systems level?

How have public health nurses been involved in system improvements?

Answer: Individual level: A rich part of public health nursing’s history has

been the development of home visitation, in which clients are cared for in their

own environment. Similarly, public health nurses have improved client outcomes

by pioneering new models of interventions for maternal–child health and indi-

viduals in rural communities.

Systems level: Through their work with communities, public health nurses

were an integral part of reducing the incidence of communicable diseases by the

mid-20th century. More recently, public health nursing has contributed to health

care system improvements through the development of the hospice movement,

birthing centers, daycare for elderly and disabled persons, and drug-abuse and

rehabilitation services. These initiatives have updated the health care system to

provide targeted care for previously overlooked populations.

Prepared by Gail Armstrong, PhD, DNP, ACNS-BC, CNE, Associate Professor, University of Colorado College of Nursing.

http://www.healthcare.gov/news/factsheets/index.html

30 PART 1 Perspectives in Health Care Delivery and Nursing

Today, nurses look to their history for inspiration, explana-

tions, and predictions. Information and advocacy are used to

promote a comprehensive approach to addressing the multiple

needs of the diverse populations served. Nurses will seek to

learn from the past and to avoid known pitfalls, even as they

seek successful strategies to meet the complex needs of today’s

vulnerable populations. The How To box describes how to con-

duct an oral history interview. This is one effective way to learn

from the successes and failures of our predecessors.

HOW TO Conduct an Oral History Interview

1. Identify an issue or event of interest.

2. Gather information from written materials.

3. Find a person to interview.

4. Get permission from the person to do the interview, and make an appoint-

ment to do so.

5. Gather information about the person’s background and the period of

interest.

6. Write an outline of your questions. Use open-ended questions because

they usually give you more information.

7. Meet with the person being interviewed; use a recording device.

8. Conduct the interview by asking only one question at a time and allowing

adequate time for the reply.

9. Clarify points when needed; ask for examples; remember, most people

like to talk about themselves.

10. After the interview, write it up as soon as possible when your recall

is best.

11. Compare your written report with the audio recording. There may be

times when you can ask the person interviewed to read your report for

accuracy.

As plans for the future are made, as the public health chal-

lenges that remain unmet are acknowledged, it is the vision of

what nursing can accomplish that sustains these nurses. Nurses

continue to rely on both nursing and public health standards

and competency guides to help chart their practice.

The ANA’s (2013) Scope and Standards of Public Health Nurs-

ing Practice, the Council on Linkages’ (2010) Domains and Core

APPLYING CONTENT TO PRACTICE

Public Health Nursing, a major journal in the ield of public health nursing,

publishes articles that broadly relect contemporary research, practice, educa-

tion, and public policy for population-based nurses. Begun in 1984, Public

Health Nursing was published quarterly through 1993 and has been a bi-

monthly journal since 1994.

More than any other journal, Public Health Nursing has assumed responsibil-

ity for preserving the history of public health nursing and for publishing new

historical research on the ield. The contemporary Public Health Nursing shares

its name with the oficial journal of the NOPHN in the period 1931 to 1952

(earlier names were used for the oficial journal from 1913 to 1931, which built

on the Visiting Nurse Quarterly, published 1909 to 1913).

Public Health Nursing presents a wide variety of articles, including both new

historical research and reprints of classic journal articles that deserve to be

read and reapplied by modern public health nurses. For example, one historical

article reprinted in Public Health Nursing addressed a nurse’s 1931 work on

county drought relief that underscores continuing professional themes of case-

inding, collaboration, and partnership (Wharton, 1999). Original historical re-

search presented in Public Health Nursing is extremely varied, from public

health nursing education, to public health nurse practice in Alaska’s Yukon, to

excerpts from the oral histories of public health nurses. Contemporary nurses

ind inspiration and possibilities for modern innovations in reading the history

of public health nursing in the pages of Public Health Nursing.

Competencies, and the Quad Council’s (Swider et al, 2013)

Competencies of Public Health Nurses each include the processes

of assessment, analysis, and planning. Each also incorporates

the importance of communication, cultural competency, policy,

and public health skills in its recommendations for effective

public health nurse practice. Speciic to this chapter, the Coun-

cil on Linkages (2014, p. 17) features a core competency under

the domain of public health sciences skills: “Identiies promi-

nent events in the history of public health.” Moreover, the Quad

Council (Swider et al, 2013) builds on this competency with an

application to nursing under Domain 6 that a public health

nurse “Describes the historical foundation of public health and

public health nursing” (p 533).

P R A C T I C E A P P L I C A T I O N

Mary Lipsky has worked for a visiting nurse association in a

large urban area for 2 years. She is responsible for a wide variety

of services, including caring for older and chronically ill clients

recently discharged from hospitals, new mothers and babies,

mental health clients, and clients with long-term health prob-

lems, such as chronic wounds.

Daily when she leaves the ield to go home, she inds that she

continues to think about her clients. She keeps going over these

and other questions in her mind: Why is it so dificult for moth-

ers and new babies to qualify for and receive Special Supple-

mental Nutrition Program for Women, Infants, and Children

(WIC) services? Why must she limit the number of visits and

length of service for clients with chronic wounds? Why are so

few services available for clients with behavioral health prob-

lems? In particular, she thinks about the burdens and challenges

that families and friends face in caring for the sick at home.

A. Why might it be dificult to solve these problems at the indi-

vidual level, on a case-by-case basis?

B. What information would you need to build an understand-

ing of the policy background for each of these various popu-

lations?

Answers can be found on the Evolve website.

31CHAPTER 2 The History of Public Health and Public and Community Health Nursing

R E M E M B E R T H I S !

• A historical approach can be used to increase the under-

standing of public and community health nursing in the past

and its contemporary dilemmas and future challenges.

• Public health and community health nursing are products of

various social, economic, and political forces and incorpo-

rate public health science in addition to nursing science and

practice.

• Federal responsibility for health care was limited until the

1930s, when the economic challenges of the Depression

highlighted the need for and led to the expansion of federal

assistance for health care.

• Florence Nightingale designed and implemented the irst

program of trained nursing, and her contemporary, William

Rathbone, founded the irst district nursing association in

England.

• Urbanization, industrialization, and immigration in the

United States increased the need for trained nurses, espe-

cially in public and community health nursing.

• The increasing acceptance of public roles for women per-

mitted public and community health nursing employment

for nurses and public leadership roles for their wealthy

supporters.

• Frances Root was the irst trained nurse in the United States

who was salaried as a visiting nurse. She was hired in 1887 by

the Women’s Board of the New York City Mission to provide

care to sick persons at home.

• The irst visiting nurse associations were founded in 1885

and 1886 in Buffalo, Philadelphia, and Boston.

• Lillian Wald established the Henry Street Settlement, which

became the Visiting Nurse Service of New York City, in 1893.

She played a key role in innovations that shaped public and

community health nursing in its irst decades, including

school nursing, insurance payment for nursing, national

organizations for public health nurses, and the US Children’s

Bureau.

• Founded in 1902, with the vision and support of Lillian

Wald, school nursing tried to keep children in school so that

they could learn.

• The Metropolitan Life Insurance Company established the

irst insurance-based program in 1909 to support commu-

nity health nursing services.

• The National Organization for Public Health Nursing

(founded in 1912) provided essential leadership and coor-

dination of diverse public and community health nursing

efforts; the organization merged into the new National

League for Nursing in 1952.

• Oficial health agencies slowly grew in numbers between

1900 and 1940, accompanied by a steady increase in public

health nursing positions.

• The innovative Sheppard-Towner Act of 1921 expanded

community health nursing roles for maternal and child

health during the 1920s.

• Mary Breckinridge established the Frontier Nursing Service

in 1925 to provide rural health care.

• The tension between the nursing roles of caring for the sick

and of providing preventive care and the related tension

between intervening for individuals and for groups have

characterized the specialty since at least the 1910s.

• The challenges of World War II sometimes resulted in

extension of community health nursing care and some-

times in retrenchment and decreased public health nurs-

ing services.

• By the mid-20th century, the reduced incidence of com-

municable diseases and the increased prevalence of chronic

illness, accompanied by large increases in the population

older than 65 years of age, led to a reexamination of

the goals and organization of community health nursing

services.

• From the 1930s to 1965, organized nursing and community

health nursing agencies sought to establish health insurance

reimbursement for nursing care at home.

• Implementation of Medicare and Medicaid programs in 1966

established new possibilities for supporting community-

based nursing care but encouraged agencies to focus on

postacute-care services rather than prevention.

• Efforts to reform health care organization, pushed by in-

creased health care costs during the past 40 years, have fo-

cused on reforming acute medical care rather than on de-

signing a comprehensive preventive approach.

• The 1988 Future of Public Health report documented the

reduced political support, inancing, and impact of increas-

ingly limited public health services at the national, state, and

local levels.

• In the late 1990s federal policy changes dangerously reduced

inancial support for home health care services, threatening

the long-term survival of visiting nurse agencies.

• The Healthy People program has brought a renewed em-

phasis on prevention to public and community health

nursing.

• In 2011 the Quad Council, an alliance of four national nurs-

ing organizations that addresses public health nursing issues,

inalized its own set of public health nursing competencies.

These competencies were revised in 2013.

• The 2000, 2010, and 2020 versions of Healthy People; recent

disasters and acts of terrorism; and, most recently, the Pa-

tient Protection and Affordable Care Act of 2010 have

brought a renewed emphasis on the beneits of both public

health and nursing.

32 PART 1 Perspectives in Health Care Delivery and Nursing

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EVOLVE WEBSITE

http://evolve.elsevier.com/Stanhope/foundations

• NCLEX® Review Questions

• Practice Application Answers

https://familyhistory.hhs.gov/FHH/html/index.html

K E Y T E R M S

advanced-practice nursing

(APN), 36

Affordable Care Act, 38

community participation, 44

Declaration of Alma-Ata, 33

disease prevention, 33

electronic health record (EHR), 37

health, 33

health promotion, 33

managed care, 39

primary care, 39

primary health care (PHC), 44

public health, 39

US Department of Health and Human

Services (USDHHS), 39

C H A P T E R O U T L I N E

Health Care in the United States

Forces Stimulating Change in the Demand for Health Care

Demographic Trends

Social and Economic Trends

Health Workforce Trends

Technological Trends

Current Health Care System in the United States

Cost

Access

Quality

Organization of the Current Health Care System

Primary Care System

Public Health System

The Federal System

The State System

The Local System

Forces Inluencing Changes in the Health Care System

Integration of Public Health and the Primary Care

System

Potential Barriers to Integration

Primary Health Care

Promoting Health/Preventing Disease: Year 2020 Objectives

for the Nation

O B J E C T I V E S

After reading this chapter, the student should be able to do the

following:

1. Describe the events and trends that inluence the status of

the health care system.

2. Discuss key aspects of the private health care system.

3. Deine public health and the nurse’s role.

4. Compare and contrast the current public health system

with the model of primary health care.

5. Assess the effects of health care and insurance reform on

population health care.

3 The Changing U.S. Health and Public Health

Care Systems

Marcia Stanhope

C H A P T E R

In September 1978, an international conference was held in

the city of Alma-Ata, which at that time was the capital of the

Soviet Republic of Kazakhstan. During this conference, the

Declaration of Alma-Ata and a new concept in health care de-

livery emerged: the primary health care model. This declaration

states that health is a human right and that the health

of its people should be the primary goal of every government.

One of the main themes of this declaration was the

involvement of community health workers and traditional

healers in a new health system (World Health Organization

[WHO], 1978).

Primary health care (PHC) was introduced, deined, and

described. In 2008 WHO renewed its call for health care

improvements and reemphasized the need for public policy-

makers, public health oficials, primary care providers, and

leadership within countries to improve health care delivery.

WHO said, “Globalization is putting the social cohesion of

many countries under stress, and health systems . . . are clearly

not performing as well as they could and should” (WHO, 2008).

As deined by WHO, PHC, which is deined differently than

primary care or public health, promotes the integration of all

health care systems within a community to come together to

improve the health of the community, including primary care

and public health.

Therefore PHC provides for the integration of health pro-

motion, disease prevention, and curative and rehabilitative

34 PART 1 Perspectives in Health Care Delivery and Nursing

services (WHO, 1978). Because of the changing environment in

health care delivery in the United States, the work by WHO in

1978 is becoming increasingly important. Box 3.1 lists selected

deinitions that will help explain the concepts introduced in this

chapter.

HEALTH CARE IN THE UNITED STATES

Despite the fact that health care costs in the United States are

the highest in the world and comprise the greatest percent-

age of the gross domestic product, the indicators of what

constitutes good health do not document that Americans are

really getting their money’s worth. In the first decade of the

21st century there have been massive and unexpected

changes in health, economic, and social conditions as a re-

sult of terrorist attacks, hurricanes, fires, floods, infectious

diseases, and an economic turndown in 2008. New systems

have been developed to prevent and/or deal with the on-

slaught of these horrendous events. Not all of the systems

have worked, and many are regularly criticized for their inef-

ficiency and costliness. Simultaneously, new and nearly mi-

raculous advances have been made in treating health-related

conditions. Organs and joints are being replaced, and medi-

cines are keeping people alive who only a few years ago

would have suffered and died. These advances and “wonder

drugs” save and prolong lives, and a number of deadly and

debilitating diseases have been eliminated through effective

immunizations and treatments. In addition, sanitation, water

supplies, and nutrition have been improved, and animal

cloning has begun.

However, attention to all of these advances may overshadow

the lack of attention to public health and prevention. Several of

the most destructive health conditions can be prevented either

through changes in lifestyle or interventions such as immuniza-

tions. The increasing rates of obesity, especially among chil-

dren; substance use; lack of exercise; violence; and accidents

have alarming repercussions, particularly when they lead to

disruptions in health.

This chapter describes a health care system in transition

as it struggles to meet evolving global and domestic chal-

lenges. The overall health care and public health systems

in the United States are described and differentiated, and

the changing priorities are identified, with emphasis on

integrating public health and primary care. Nurses play a

pivotal role in meeting these needs, and the role of the nurse

is described.

FORCES STIMULATING CHANGE IN THE DEMAND FOR HEALTH CARE

In recent years, enormous changes have occurred in society,

both in the United States and most other countries of the

world. The extent of interaction among countries is stronger

than ever, and the economy of each country depends on the

stability of other countries. The United States has felt the ef-

fects of rising labor costs as many companies have shifted

their production to other countries with lower labor costs. It

is often less expensive to assemble clothes, automobile parts,

and appliances and to have call distribution centers and

call service centers in a less industrialized country and pay

the shipping and other charges involved than to have the

items fully assembled in the United States. In recent years

the vacillating cost of fuel has affected almost every area of

the economy, leading to both higher costs of products

and layoffs as some industries have struggled to stay solvent.

This has affected the employment rate in the United States.

The economic downturn of 2008 left many people unem-

ployed, and many lost their homes because they could not

pay their mortgages. When the unemployment rate is high,

more people lack comprehensive insurance coverage because

in the United States this has been typically provided by em-

ployers. In late November 2008, the US unemployment

rate was 6.7%. This represented an increase from 4.6% in

2007. In July 2012 the unemployment rate had increased to

8.2%, close to double the rate in 2007. In recent years the

economy has begun to recover. In 2014, for example, the un-

employment rate decreased to 6.1%—down 2.1 percentage

points from 2012 (Bureau of Labor Statistics [BLS], 2014a).

Also, health care services and the ways in which they are

inanced are changing with the continuing implementation

of the Patient Protection and Affordable Care Act (ACA),

enacted in 2010. Many of the planned changes were imple-

mented by 2016. However, in 2016, with the election of a new

president, there were many threats related to the future of

the ACA.

BOX 3.1 Deinitions of Selected Terms

• Disease prevention: Activities whose goal is to protect people from

becoming ill as a result of actual or potential health threats

• Disparities: Racial or ethnic differences in the quality of health care, not

based on access or clinical needs, preferences, or appropriateness of an

intervention

• Electronic medical record: A computer-based client medical record

• Globalization: A trend toward an increased low of goods, services,

money, and disease across national borders

• Health: A state of complete physical, mental, and social well-being, not

merely the absence of disease or inirmity (WHO, 1986a)

• Health promotion: Activities that have as their goal the development of

human attitudes and behaviors that maintain or enhance well-being

• Institute of Medicine: A part of the National Academy of Sciences and an

organization whose purpose is to provide national advice on issues relating

to biomedical science, medicine, and health

• Primary care: The providing of integrated, accessible health care services

by clinicians who are accountable for addressing a large majority of per-

sonal health care needs, developing a sustained partnership with clients,

and practicing in the context of family and community

• Primary health care: A combination of primary care and public health

care made universally accessible to individuals and families in a community,

with their full participation, and provided at a cost that the community and

country can afford (WHO, 1978)

• Public health: Organized community and multidisciplinary efforts, based

on epidemiology, aimed at preventing disease and promoting health (Insti-

tute of Medicine, 1988, p 4)

35CHAPTER 3 The Changing U.S. Health and Public Health Care Systems

It is often said that the states are the laboratories of democracy. One state,

Massachusetts, began an experiment in health reform in 2006. Two years after

health reform legislation became effective, only 2.6% of Massachusetts’s resi-

dents were uninsured, the lowest percentage ever recorded in any state (Dorn

et al, 2009). However, the program became one of the most successful and a

model for the Affordable Care Act. After 5 years approximately 98% to 99% of

all of the commonwealth’s citizens were covered by the plan.

Although other states have experimented with various programs to decrease

the number of uninsured individuals, the Massachusetts plan has had the most

success. The health reform plan rests on an individual mandate that requires

everyone who can afford insurance to purchase coverage. Those unable to afford

insurance receive subsidies that allow low-income individuals and families to

purchase coverage. A new state-run program, Commonwealth Care (CommCare),

provides beneits to adults who are not eligible for Medicaid but whose incomes

fall below 300% of the federal poverty level.

To understand how the state has achieved such success in this effort toward

universal coverage, a group of evaluators met with 15 key informants representing

hospitals, community health centers, insurance companies, Medicaid, and Com-

mCare. Several factors, it was found, have contributed to the historic level of cover-

age seen in the state. Rather than requiring consumers to complete separate ap-

plications for programs such as Medicaid, the Children’s Health Insurance Program

(CHIP), or CommCare, a single application system provides entry to all the state

programs. If an uninsured client is admitted to a hospital or visits a community

that Hispanic persons outnumbered African Americans, with

non-Hispanic whites being the largest single ethnic group in the

United States (ONS, 2014). The nation’s foreign-born popula-

tion is growing, and it is projected that from now until 2050 the

largest population growth will be attributable to immigrants

and their children. The states with the largest percentage of

foreign-born populations are California, New York, Texas, and

Florida (Migration Policy Institute, 2015).

The composition of the US household is also changing. From

1935 to 2010, mortality for both genders in all age groups and

races declined (Hoyert, 2012) as a result of progress in public

health initiatives, such as antismoking campaigns, AIDS preven-

tion programs, and cancer screening programs. The leading

causes of death have changed from infectious diseases to chronic

and degenerative diseases (National Center for Health Statistics

[NCHS], 2014). New infectious diseases are emerging, such as

the Ebola virus, which affected the United States in 2014,

with the irst case occurring in Dallas, Texas (CDC, 2014a), and

now the Zika virus, which is spread by infected mosquitoes. This

virus, which can result in birth defects and Guillain–Barré syn-

drome, has created a public health emergency throughout the

world. All but four states reported cases in 2016 (CDC, 2016).

New treatments for infectious diseases have resulted in steady

declines in mortality among children, but such declines depend on

parents’ participation in immunization programs. A recent measles

outbreak in Orange County, California, shows that continuous

focus on control of infectious diseases is essential (Orange County

Health Care Agency, 2014). The mortality for older Americans has

also declined. However, people 50 years of age and older have

EVIDENCE-BASED PRACTICE

DEMOGRAPHIC TRENDS

The population of the world is growing as a result of increased

fertility and decreased mortality rates. The greatest growth is

occurring in underdeveloped countries, and this is accompanied

by decreased growth in the United States and other developed

countries. The year 2000, however, marked the irst time in more

than 30 years that the total fertility rate in the United States was

above the replacement level. Replacement means that for every

person who dies, another is born (Hamilton et al, 2010). Both

the size and the characteristics of the population contribute to

the changing demography.

Seventy-seven million babies were born between the years of

1946 and 1963, giving rise to the often-discussed baby-boomer

generation (Ofice for National Statistics [ONS], 2014) The old-

est of these boomers reached 65 years of age in 2011, and they are

expected to live longer than people born in earlier times. The

impact on the federal government’s insurance program for peo-

ple 65 years of age and older, Medicare, is expected to be enor-

mous, and this population is predicted to double between the

years 2000 and 2030, representing 20% of the total population

(Centers for Disease Control and Prevention [CDC], 2013a).

In 2016, the US population totaled more than 322 million peo-

ple, representing the third most populated country in the world.

From 1990 to 2012, the US foreign-born immigrant population

grew from about 19 million to approximately 41 million, and it is

continuing to increase every year (US Census Bureau, 2016).

At the time of the 1990 census, African Americans were the

largest minority group in the United States (US Census Bureau,

1996). However, in 2014, the US Census Bureau announced

From Dorn S, Hill I, Hogan S: The secrets of Massachusetts’ success: why 97 percent of state residents have health coverage: state health

access reform evaluation, Romneycare-The truth about Massachusetts health care. 2014, accessed at mittromneycentral.com. 9/25/2014, Robert

Wood Johnson Foundation. Available at http://www.urban.org Accessed September 19, 2012.

health center, his or her eligibility is automatically evaluated; if eligible, the client is

automatically converted to CommCare coverage, even without completing an ap-

plication. A “Virtual Gateway” has been developed through which staff members of

community-based organizations have been trained to complete online applications

on behalf of consumers and to provide education and counseling about insurance

options to underserved communities. Because reimbursement is held back from

providers that do not offer staff to help consumers sign up for one of the available

insurance options, hospitals and health centers are motivated to dedicate staff to

provide education and counseling to the formerly uninsured. The result is that at

least half of the new enrollees in Medicaid and CommCare have been enrolled

without illing out any forms on their own. In addition to these efforts, shortly after

the reform legislation was enacted, the state inanced a massive public education

effort to inform consumers about their new options.

Nurse Use

As health reform is implemented on the national level, nurses can play a crucial

role in driving down the number of uninsured individuals. Nurses should educate

themselves so that they can encourage clients to apply and take advantage of all

available coverage options. Taking an active role in consumer educational pro-

grams is a natural extension of a nurse’s role as a client advocate. Nurses can

promote legislation to simplify enrollment processes and encourage the develop-

ment of shared databases for community health care providers, thus preventing

consumers from falling through the cracks in our fragmented health care system.

http://www.urban.org

36 PART 1 Perspectives in Health Care Delivery and Nursing

higher rates of chronic and degenerative illness than other age

groups, and they use a larger portion of health care services.

SOCIAL AND ECONOMIC TRENDS

In addition to the size and changing age distribution of the

population, other factors also affect the health care system. Sev-

eral social trends that inluence health care include changing

lifestyles, a growing appreciation for the quality of life, the chang-

ing composition of families and living patterns, changing house-

hold incomes, and a revised deinition of quality health care.

Americans spend considerable money on health care, nutri-

tion, and itness (BLS, 2012) because health is seen as an irre-

placeable commodity. To be healthy, people must take care of

themselves. Many people combine traditional medical and

health care practices with complementary and alternative ther-

apies to achieve the highest level of health. Complementary

therapies are those that are used in addition to traditional

health care, and alternative therapies are those that are used

instead of traditional care. Examples include acupuncture and

herbal medications, among others (National Center for Com-

plementary and Alternative Medicine [NCCAM], 2014). People

often spend a considerable amount of their own money for

these types of therapies because few are covered by insurance.

In recent years, some insurance plans have recognized the value

of complementary therapies and have reimbursed for them.

State ofices of insurance are good sources to determine whether

these services are covered and by which health insurance plans.

Approximately 65 years ago, income was distributed in such

a way that a relatively small portion of households earned high

incomes; families in the middle-income range made up a some-

what larger proportion, and households at the lower end of the

income scale made up the largest proportion. By the 1970s,

household income had risen, and income was more evenly dis-

tributed, largely as a result of dual-income families.

From 1970 through 2011, several trends in income distribution

emerged. The economic downturn now known as the Great Re-

cession, which began in 2008, resulted in layoffs, outsourcing, and

other economic changes, with many families seeing decreases in

wages. From 2011 through 2015, the average per-person income

in the United States increased. The income of households in the

top 1% of earners grew by 200%, compared with growth of 67%

for the next 18%, growth of 40% for 60% of middle-income

households, and 48% growth for the bottom 20% of households

(Congressional Budget Ofice [CBO], 2016). It is obvious that the

gap between the richest and the poorest is widening because of the

evident differences in the wage-increase percentages of the higher-

income levels. Chapter 8 provides a detailed discussion of the

economics of health care and how inancial constraints inluence

decisions about public health services.

HEALTH WORKFORCE TRENDS

The health care workforce ebbs and lows. The early years of the

21st century saw the beginning of what is expected to be a long-

term and sizable nursing shortage. Similarly, most other health

professionals are documenting current and anticipated future

shortages. Historically, nursing care has been provided in a variety

of settings, primarily in the hospital. Approximately 63% of all

registered nurses (RNs) continue to be employed in hospitals

(National Center for Health Workforce Analysis, 2013). A few

years ago hospitals began reducing their bed capacities as care

became more community based. Now they are expanding, includ-

ing the construction of new facilities for both acute and longer-

term chronic care. This growth is attributable to the factors previ-

ously discussed: the ability to treat and perhaps cure more

diseases, the complexity of the care and the need for inpatient

services, and the growth of the older age group.

The nursing shortage has been discussed in recent years, yet

new graduates often have dificulty inding positions when they

graduate (American Association of Colleges of Nursing [AACN],

2014a, 2014b, 2014c). Participating in a nurse internship pro-

gram and holding a bachelor of science in nursing (BSN) degree

or higher will provide more opportunities for the new graduate.

In 2014, the BLS predicted there would be 527,000 new nursing

positions by 2016 (BLS, 2014b). In addition, 55% of nurses re-

ported in a recent survey that they intended to retire between

2011 and 2020, which will open positions for others (National

Council of State Boards of Nursing [NCSBN], 2013).

Periodic shortages are especially common in the primary-

care workforce in the United States, and nurse practitioners

(NPs), clinical nurse specialists (CNSs), and certiied nurse-

midwives (CNMs), who are considered to be practitioners of

advanced-practice nursing (APN) specialties, are vital mem-

bers of primary-care teams. However, as the baby boomers age,

there are projections for increasing RN needs in the workforce

through 2022 (AACN, 2016)

In terms of the nursing workforce, increasing the number of

minority nurses remains a priority and a strategy for addressing

the current nursing shortage. In 2013 minority nurses represented

approximately 22% of the RN population. It is thought that

increasing the minority population will help close the health-

disparity gap for minority populations (AACN, 2014b). For ex-

ample, persons from minority groups, especially when language

is a barrier, often are more comfortable with and more likely to

access care from a provider from their own minority group.

TECHNOLOGICAL TRENDS

The development and reinement of new technologies such as

telehealth have opened up new clinical opportunities for nurses

and their clients, especially in the areas of managing chronic

conditions, assisting persons who live in rural areas, and provid-

ing home health care, rehabilitation, and long-term care. On the

positive side, technological advances promise improved health

care services, reduced costs, and more convenience in terms of

time and travel for consumers. Reduced costs result from a more

eficient means of delivering care and from replacement of

people with machines. Advanced technology also reduces paper-

work; enables providers, clients, and agencies to access accurate

information; facilitates care coordination and safety; and pro-

vides direct access to health records between agencies and to

clients (Health Information Technology, 2013). Contradictory as

it may seem, cost is also the most signiicant negative aspect of

advanced health care technology. The more high-technology

equipment and computer programs become available, the more

37CHAPTER 3 The Changing U.S. Health and Public Health Care Systems

Advances in health care technology will continue. One example

of an effective use of technology is the funding provided to health

centers by the Health Resources and Services Administration

(HRSA) of the US Department of Health and Human Services so

that they can adopt and implement electronic health records

(EHRs) and other health information technology (HIT) (HRSA,

2008). The HRSA’s Ofice of Health Information Technology was

created in 2005 to promote the effective use of HIT as a mechanism

for responding to the needs of the uninsured, underinsured, and

special-needs populations (HRSA, 2014). Speciically, in December

2012, an award of more than $18 million made available through

the Affordable Care Act was announced to expand HIT in 600

health centers (HRSA, 2012). One innovative use of the EHR in

public health is to embed reminders or guidelines into the system.

For example, the CDC published health guidelines that contain

clinical recommendations for screening, prevention, diagnosis, and

treatment. To ind and keep current on these guidelines, clinicians

must visit the CDC website. The availability of an EHR system

allows the embedding of reminders so that the clinician can have

access to practice guidelines at the point of care. Some additional

beneits in public health (and these are some of the uses health

centers make of such records) include the following:

• 24-hour availability of records, with downloadable labora-

tory results and up-to-date assessments

• Coordination of referrals and facilitation of interprofes-

sional care in chronic disease management

• Incorporation of protocol reminders for prevention, screening,

and management of chronic disease

• Improvement of quality measurement and monitoring

• Increased client safety and decline in medication errors

Two federal programs, Medicaid and the State Children’s

Health Insurance Program (SCHIP), have effectively used HIT in

several key functions, including outreach and enrollment, service

delivery, and care management, in addition to communications

with families and the broader goals of program planning

and improvement. In early 2009, the Surgeon General’s Ofice

reopened a website that had been tried irst in 2004 but then

closed: My Family Health Portrait, which helps the user to create

an electronic family tree (National Institutes of Health [NIH],

2010). This is described as an easy-to-use computer application

that allows the user to keep a personal record of family health

history (https://familyhistory.hhs.gov/FHH/html/index.html). In

addition, the CDC recently began a family history public health

initiative through the Ofice of Public Health Genomics to in-

crease awareness of family history as an important risk factor for

common chronic diseases. This initiative had four main activities:

1. Research to deine, measure, and assess family history in

populations and individuals

2. Development and evaluation of tools for collecting family

history

3. Evaluation of the effectiveness of strategies based on family

history

4. Promotion of evidence-based applications of family history

to health professionals and the public (CDC, 2013b)

CURRENT HEALTH CARE SYSTEM IN THE UNITED STATES

Despite the many advances and the sophistication of the US

health care system, the system has been plagued with problems

related to cost, access, and quality. These problems are different

for each person and are affected by the ability of individuals to

obtain health insurance. Most industrialized countries want the

same things from their health care system; several give their

government a greater role in health care delivery and eliminate

or reduce the use of market forces to control cost, access, and

quality. Seemingly, there is no one perfect health care system in

the world.

FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES

Targeted Competency: Informatics—Use information and technology to com-

municate, manage knowledge, mitigate error, and support decision making.

Important aspects of informatics include the following:

Knowledge: Identify essential information that must be available in a com-

mon database to support interventions in the health care system.

Skills: Use information management tools to monitor outcomes of interven-

tion processes.

Attitudes: Value technologies that support decision making, error prevention,

and case coordination.

Informatics Question: Updated informatics deinitions focus on having ac-

cess to the necessary client and system information at the right time, to make

the best clinical decision. In the Strategic Plan for 2010 to 2015 of the US Depart-

ment of Health and Human Services (USDHHS), there are ive overarching goals.

Goal 1, Objective C focuses on “Emphasizing primary and preventive care

linked with community prevention services.” Which community data would a

public health nurse assess to determine the work that needs to be done in a

community related to this USDHHS strategic goal?

Answer: To assess future work that could be done to effectively address

Goal 1, Objective C, public health nurses might gather data in the following areas:

• How informed are members of the community about existing community ser-

vices that support health promotion (e.g., exercise classes, educational

classes, self-management training, and nutrition counseling)?

• How relevant are the services offered by health centers to the needs of a

community?

• Do payment or insurance barriers exist for individuals to access preventive

health services?

• How accessible is entry to care for vulnerable populations such as pregnant

women and infants?

• What community-based prevention programs exist for individuals with and at

risk for chronic diseases and conditions?

• How available are substance-abuse screening and intervention programs?

• How linked are primary care and health promotions and wellness programs in

a community?

Prepared by Gail Armstrong, PhD(c), DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver College of Nursing.

they are used. High-technology equipment is expensive, quickly

becomes outdated when newer developments occur, and often

requires highly trained personnel. There are other drawbacks to

new technology, particularly in the area of home health care.

These include increased legal liability, the potential for decreased

privacy, too much reliance on technological advances, and the

inconsistent quality of resources available on the Internet and

other sources, like magazines and newspapers (Palma, 2014).

38 PART 1 Perspectives in Health Care Delivery and Nursing

COST

Beginning in 2008, a historic weakening of the national and global

economy—the Great Recession—led to the loss of 7 million jobs

in the United States (Economic Report, 2010). Even as the gross

domestic product (GDP), an indicator of the economic health of a

country, declined in 2009, health care spending continued to grow

and reached $2.5 trillion in the same year (Truffer et al, 2010). In

the years between 2010 and 2019, national health spending is

expected to grow at an average annual rate of 6.1%, reaching

$4.5 trillion by 2019, for a share of approximately 19.3% of the GDP.

This translates into a projected increase in per-capita spending.

In Chapter 8, additional discussion illustrates how health

care dollars are spent. The largest share of health care expendi-

tures goes to pay for hospital care, with physician services being

the next largest item. The amount of money that has gone to

pay for public health services is much lower than that for the

other categories of expenditures. Other signiicant drivers of

the increasingly high cost of health care include prescription

drugs, technology, and chronic and degenerative diseases.

The economic rebound following the Great Recession will likely

continue with the increasing Medicare enrollment of the aging

baby-boomer population. It is projected that these new Medicare

enrollees will increase Medicare expenditures for the foreseeable

future. The number of Medicaid recipients can be expected to de-

cline as jobs are added to the economy, and the percentage of work-

ers covered by employer-sponsored insurance rises to relect that

growth. For the irst time since 2008, unemployment rates in 2016

dropped to less than 5% of the working population (BLS, 2016).

Although workers’ salaries have not kept pace, employer-

sponsored insurance premiums have grown 119% since 1999

(Kaiser Family Foundation, 2015a), and the inability of workers to

pay this increased cost has led to a rise in the percentage of work-

ing families who are uninsured. It will be essential for nurses to

keep abreast of any changes in these facts as the Affordable Care

Act undergoes reevaluation in the years ahead (Cox et al, 2015).

ACCESS

Another signiicant problem is poor access to health care. The

American health care system is described as a two-class sys-

tem: private and public. People with insurance or those who

can personally pay for health care are viewed as receiving su-

perior care; those who receive lower-quality care are (1) those

whose only source of care depends on public funds or (2) the

working poor, who do not qualify for public funds either

because they make too much money to qualify or because

they are illegal immigrants. Employment-provided health

care is tied to both the economy and to changes in health in-

surance premiums. One study found that in 2009, 61% of the

nonelderly population obtained employer-sponsored health

insurance as a beneit; however, employment did not guarantee

insurance (Rowland et al, 2009). This became clear when con-

sidering that 9 in 10 (91%) of the middle-class uninsured came

from families with at least one full-time worker in jobs that did

not offer health insurance or where coverage was unaffordable

(Rowland et al, 2009).

In 2012, the total number of uninsured persons in the

United States was 48 million. As discussed, there is a strong re-

lationship between health insurance coverage and access to

health care services. Insurance status determines the amount

and kind of health care people are able to afford and where they

can receive care. As a result of the Affordable Care Act, by 2014,

the uninsured nonelderly population had dropped to 32 mil-

lion people, approximately 16% of the total population. During

this same time period, 58% of the total population was covered

by employer health insurance. Others, such as the elderly and

the Medicaid-eligible populations, were covered by government

insurance programs (Kaiser Family Foundation, 2015b).

The uninsured receive less preventive care and are diagnosed at

more advanced disease states; once diagnosed, they tend to receive

less therapeutic care in terms of surgery and treatment options.

There is a safety net for the uninsured or underinsured. As dis-

cussed later in this chapter, there are more than 1300 federally

funded community health centers throughout the country. Feder-

ally funded community health centers provide a broad range of

health and social services, which are delivered by NPs, RNs, physi-

cian assistants, physicians, social workers, and dentists. Commu-

nity health centers are primarily located in medically underserved

areas, which can be rural or urban. These centers serve people of

all ages, races, and ethnicities, with or without health insurance.

Public health nurses who worked with local Head Start programs noted that

many children had untreated dental caries. Although these children qualiied for

Medicaid, only two dentists in the area would accept appointments from Med-

icaid patients. Dentists asserted that Medicaid patients frequently did not show

up for their appointments and that reimbursement was too low compared with

that from other third-party payers. They also said the children’s behavior made

it dificult to work with them. So, the waiting list for local dental care was ap-

proximately 6 years long. Although some nurses found ways to transport clients

to dentists in a city 70 miles away, it was very time consuming and was feasible

for only a small fraction of the clients. When decayed teeth abscessed, it was

possible to get extractions from the local medical center. The health department

dentist also saw children, but he, too, was booked for years in advance.

CASE STUDY

Issues with Childhood Dental Caries

Created by Deborah C. Conway, Assistant Professor, University of

Virginia School of Nursing.

QUALITY

The quality of health care leaped to the forefront of concern

following the 1999 release of the Institute of Medicine (IOM)

report To Err Is Human: Building a Safer Health System (IOM,

2000). As indicated in this groundbreaking report, as many as

98,000 deaths a year could be attributed to preventable medical

errors. Some of the untoward events categorized in this report

included adverse drug events and improper transfusions, sur-

gical injuries and wrong-site surgery, suicides, restraint-related

injuries or death, falls, burns, pressure ulcers, and mistaken

client identities. It was further determined that high rates

of errors with serious consequences were most likely to occur

in intensive care units, operating rooms, and emergency

39CHAPTER 3 The Changing U.S. Health and Public Health Care Systems

ofices, hospitals, nursing homes, mental health facilities, ambu-

latory care centers, freestanding clinics and clinics inside stores

such as drugstores, free clinics, public health agencies, and home

health agencies. Providers include nurses, advanced-practice

nurses, physicians and physician assistants, dentists and dental

hygienists, pharmacists, and a wide array of essential allied health

providers, such as physical, occupational, and recreational thera-

pists; nutritionists; social workers; and a range of technicians. In

general, however, the American health care system is divided into

the following two, somewhat distinct, components: a private or

personal care component and a public health component. These

components have some overlap, as discussed in the following sec-

tions. It is important to discuss primary health care and examine

the interest in developing a primary-care system.

PRIMARY-CARE SYSTEM

Primary care, the irst level of the private health care system,

is delivered in a variety of community settings, such as physi-

cians’ ofices, urgent-care centers, in-store clinics, community

health centers, and community nursing centers. Near the end

of the past century, in an attempt to contain costs, the number

of managed-care organizations grew. Managed care is deined

as a system in which care is delivered by a speciic network of

providers that agree to comply with the care approaches estab-

lished through a case-management approach. The key factors

are a speciied network of providers and the use of a gatekeeper

to control access to providers and services. This form of care

has not become as prominent as the original concept outlined.

The government tried to reap the beneits of cost savings by

introducing the managed-care model into Medicare and Medic-

aid, with varying levels of success. The traditional Medicare plan

involves Parts A and B. Part C, the Medicare Advantage program,

incorporates private insurance plans into the Medicare program,

including health maintenance organization (HMO) and pre-

ferred provider organization (PPO) managed-care models and

private fee-for-service plans. In addition, Medicare Part D has

been added to cover prescriptions (see Chapter 8).

PUBLIC HEALTH SYSTEM

The public health system is mandated through laws that are

developed at the national, state, or local level. Examples of pub-

lic health laws instituted to protect the health of the community

include a law mandating immunizations for all children enter-

ing kindergarten and a law requiring constant monitoring of

the local water supply. The public health system is 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.

THE FEDERAL SYSTEM

The US Department of Health and Human Services (USDHHS,

or simply HHS) is the agency most heavily involved with the

health and welfare concerns of US citizens. The organizational

chart of the HHS (Fig. 3.1) shows the ofice of the secretary, 11

departments. Beyond the cost in human lives, preventable

medical errors result in the loss of several billions of dollars

annually in hospitals nationwide. Categories of error include

diagnostic, treatment, and prevention errors and communica-

tion, equipment, and other system failures. Signiicant to nurses,

the IOM estimated that the number of lives lost to preventable

errors in medication alone represented more than 7000 deaths

annually, with a cost of about $2 billion nationwide.

Although the IOM report made it clear that the majority of

medical errors were not produced by provider negligence, lack

of education, or lack of training, questions were raised about the

nurse’s role and workload and their effects on client safety. In a

follow-up report, Keeping Patients Safe: Transforming the Work

Environment of Nurses, the IOM (2003) stated that nurses’ long

work hours pose a serious threat to patient safety because fatigue

slows reaction time, saps energy, and diminishes attention to

detail. The group called for state regulators to pass laws barring

nurses from working more than 12 hours a day and 60 hours a

week—even if by choice (IOM, 2003). Although this informa-

tion is largely related to acute care, many of the patients who

survive medical errors are later cared for in the community.

The culture of quality improvement and safety has made

providers and consumers more conscious of safety, but medical

errors and untoward events continue to occur. As a means to

improve consumer awareness of hospital quality, the Centers for

Medicare and Medicaid Services (CMS) began publishing a da-

tabase of hospital quality measures, Hospital Compare, in 2005.

Hospital Compare, a consumer-oriented website that provides

information on how well hospitals provide recommended care

in such areas as heart attack, heart failure, and pneumonia, is

available through the CMS website (www.cms.gov). In a further

effort, the CMS announced in 2008 that it would no longer re-

imburse hospitals, under Medicare guidelines, for care provided

for “preventable complications,” such as hospital-acquired infec-

tions. This reimbursement policy was extended to Medicaid

reimbursement in 2011 (CMS, 2009; Galewitz, 2011).

The accreditation process for public health is new, and the

impact of quality and safety monitoring has not yet been deter-

mined. The ability of a public health agency or a community to

respond to community disasters is one event that will be moni-

tored in the accreditation process. In May 2016, 135 of 303

local, tribal, and state centralized integration systems and mul-

tijurisdictional health departments had received accreditation

in this new process. The accredited health departments served

167 million people, amounting to 54% of the total population

base. The aims of this process are as follows:

• To assist and identify quality health departments to improve

performance and quality and to develop leadership

• To improve management

• To improve community relationships (Public Health Ac-

creditation Board [PHAB], 2016)

ORGANIZATION OF THE CURRENT HEALTH CARE SYSTEM

An enormous number and range of facilities and providers make

up the health care system. These include physicians’ and dentists’

40 PART 1 Perspectives in Health Care Delivery and Nursing

Office of Intergovernmental

and External Affairs (IEA)

Office of the Assistant Secretary

for Legislation (ASL)

Office of the Assistant Secretary for Administration

(ASA)

Office of the Assistant Secretary

for Financial Resources (ASFR)

Office of The Assistant Secretary

for Public Affairs (ASPA)

Office of the Assistant Secretary for Planning

and Evaluation (ASPE)

Office of the Assistant Secretary for Preparedness

and Response∗

(ASPR)

Office of Minority Health (OMH)#

Office of Health Reform

(OHR)

The Executive Secretariat

Secretary Deputy Secretary

Chief of Staff

Program Support Center (PSC)

Office of the Assistant Secretary

for Health∗

(OASH)

Office of Inspector General (OIG)

Center for Faith-based & Neighborhood

Partnerships (CFBNP)

Departmental Appeals Board

(DAB)

Office of Medicare Hearings and

Appeals (OMHA)

Office of the National Coordinator for Health

Information Technology (ONC)

Office of Global Affairs∗

(OGA)

Office for Civil Rights (OCR)

Office of the General Counsel

(OGC)

Administration for Children and

Families (ACF)

Agency for Healthcare

Research and Quality∗

(AHRQ)

Centers for Disease Control and Prevention∗

(CDC)

Substance Abuse & Mental Health Services

Administration∗

(SAMHSA)

∗Designates a component of the U.S. Public Health Service.

#Administratively supported by the Office of the Assistant Secretary for Health

Administration for Community Living

(ACL)

Agency for Toxic Substances &

Disease Registry∗

(ATSDR)

Centers for Medicare &

Medicaid Services (CMS)

Health Resources and Services

Administration∗

(HRSA)

National Institutes of Health∗

(NIH)

Food and Drug Ddministration∗

(FDA)

Indian Health Services∗

(IHS)

FIG. 3.1 Organization of the US Department of Health and Human Services. (From US Depart-

ment of Health and Human Services, HHS Organizational Chart, http://www.hhs.gov/about/

orgchart/.)

http://www.hhs.gov/about/orgchart/

41CHAPTER 3 The Changing U.S. Health and Public Health Care Systems

BOX 3.2 USDHHS Strategic Plan Goals and Objectives—Fiscal Years 2010 to 2015*

GOAL 1: Strengthen Health Care

Objective A Make coverage more secure for those who have insurance, and extend affordable coverage to the uninsured.

Objective B Improve health care quality and patient safety.

Objective C Emphasize primary and preventive care linked with community prevention services.

Objective D Reduce the growth of health care costs while promoting high-value, effective care.

Objective E Ensure access to quality, culturally competent care for vulnerable populations.

Objective F Promote the adoption and meaningful use of health information technology.

GOAL 2: Advance Scientiic Knowledge and Innovation

Objective A Accelerate the process of scientiic discovery to improve patient care.

Objective B Foster innovation to create shared solutions.

Objective C Invest in the regulatory sciences to improve food and medical product safety.

Objective D Increase our understanding of what works in public health and human service practice.

GOAL 3: Advance the Health, Safety, and Well-Being of the American People

Objective A Promote the safety, well-being, resilience, and healthy development of children and youth.

Objective B Promote economic and social well-being for individuals, families, and communities.

Objective C Improve the accessibility and quality of supportive services for people with disabilities and older adults.

Objective D Promote prevention and wellness.

Objective E Reduce the occurrence of infectious diseases.

Objective F Protect Americans’ health and safety during emergencies, and foster resilience in response to emergencies.

GOAL 4: Increase Eficiency, Transparency, Accountability and Effectiveness of HHS Programs

Objective A Ensure program integrity and responsible stewardship of resources.

Objective B Fight fraud and work to eliminate improper payments.

Objective C Use HHS data to improve the health and well-being of the American people.

Objective D Improve HHS environmental, energy, and economic performance to promote sustainability.

GOAL 5: Strengthen the Nation’s Health and Human Service Infrastructure and Workforce

Objective A Invest in the HHS workforce to meet America’s health and human service needs today and tomorrow.

Objective B Ensure that the Nation’s health care workforce can meet increased demands.

Objective C Enhance the ability of the public health workforce to improve public health at home and abroad.

Objective D Strengthen the Nation’s human service workforce.

Objective E Improve national, state, local, and tribal surveillance and epidemiology capacity.

*In the process of being updated for 2014–2018.

From the US Department of Health and Human Services, 2014.USDHHS Strategic Plan Goals and Objectives—Fiscal Years

2010 to 2015. Retrieved July 2, 2014, from www.hhs.gov.

agencies, and a program support center (USDHHS, 2014a). Ten

regional ofices are maintained to provide more direct assistance

to the states. Their locations are shown in Table 3.1. The HHS is

charged with regulating health care and overseeing the health

status of Americans. See Box 3.2 for the goals and objectives of the

HHS strategic plan for iscal years 2010 to 2015. Newer areas in

the HHS are the Ofice of Public Health Preparedness, the Center

for Faith-Based and Neighborhood Partnerships, and the Ofice

of Global Affairs. The Ofice of Public Health Preparedness was

added to assist the nation and states to prepare for bioterrorism

after September 11, 2001. The Faith-Based Initiative Center was

developed by President George W. Bush to allow faith communi-

ties to compete for federal money to support their community

activities. The goal of the Ofice of Global Affairs is to promote

global health by coordinating HHS strategies and programs with

other governments and international organizations (USDHHS,

2014a). The activities of several key agencies include the following:

1. The US Public Health Service (USPHS, or simply PHS) is a

major component of the DHHS. The PHS consists of eight

agencies: Agency for Healthcare Research and Quality,

Agency for Toxic Substances and Diseases Registry, Centers

for Disease Control and Prevention, Food and Drug Admin-

istration, Health Resources and Services Administration,

Indian Health Service, National Institutes of Health, and

Substance Abuse and Mental Health Services Administra-

tion. Each has a speciic purpose (see Chapter 8 for a dis-

cussion of the relevancy of the agencies to policy and the

provision of health care). The PHS also has a Commis-

sioned Corps, the National Health Services Corp (NHSC),

which is a uniformed service of more than 6500 health

professionals who serve in many HHS and other federal

agencies. The surgeon general of the United States is the

head of the Commissioned Corps. The corps ills essential

services for public health clinics and provides leadership

within the federal government departments and agencies

to support the care of underserved and vulnerable popula-

tions (USPHS, 2014).

2. An important agency and a recent addition to the federal gov-

ernment, the US Department of Homeland Security (USDHS,

or simply DHS), was created in 2003 (USDHS, 2014). The

http://www.hhs.gov

42 PART 1 Perspectives in Health Care Delivery and Nursing

Region Location Territory

1 Boston Connecticut, Maine, Massachusetts, New

Hampshire, Rhode Island, Vermont

2 New York New Jersey, New York, Puerto Rico, Virgin

Islands

3 Philadelphia Delaware, District of Columbia, Maryland,

Pennsylvania, Virginia, West Virginia

4 Atlanta Alabama, Florida, Georgia, Kentucky, Mississippi,

North Carolina, South Carolina, Tennessee

5 Chicago Illinois, Indiana, Michigan, Minnesota, Ohio,

Wisconsin

6 Dallas Arkansas, Louisiana, New Mexico, Oklahoma,

Texas

7 Kansas City Iowa, Kansas, Missouri, Nebraska

8 Denver Colorado, Montana, North Dakota, South

Dakota, Utah, Wyoming

9 San

Francisco

Arizona, California, Hawaii, Nevada, American

Samoa, Commonwealth of the Northern

Mariana Islands, Federated States of

Micronesia, Guam, Republic of the Marshall

Islands, Republic of Palau

10 Seattle Alaska, Idaho, Oregon, Washington

TABLE 3.1 Regional Ofices of the U.S. Department of Health and Human Services

Data from US Department of Health and Human Services: HHS

Regional Offices, Retrieved December 2014 from http://www.hhs.gov/

about/regions/

mission of the DHS is to prevent and deter terrorist attacks

and protect against and respond to threats and hazards to the

nation. The goals for the department include awareness, pre-

vention, protection, response, and recovery. The DHS works

with irst responders throughout the United States, and

through the development of programs such as the Commu-

nity Emergency Response Team (CERT), it trains people to be

better prepared to respond to emergency situations in their

communities. Nurses working in state and local public health

departments and those employed in hospitals and other

health facilities may be called on to respond to acts of terror-

ism or natural disasters in the course of their careers, and the

DHS, along with the Food and Drug Administration (FDA)

and CDC, is developing programs to ready nurses and other

health care providers for an uncertain future (USDHS, 2014).

THE STATE SYSTEM

When the United States faced a pandemic H1N1 lu outbreak in

2009, the federal government and the public health community

quickly prepared to meet the challenge of educating the public

and health professionals about the lu and making vaccinations

available. In 2014 public health efforts within the states were

responding to an enterovirus affecting large numbers of chil-

dren with symptoms of upper respiratory disease and weakness

in the arms and legs. The virus was considered life-threatening

(CDC, 2014b). In addition to standing ready for disaster pre-

vention or response, state health departments have other equally

important functions, such as providing health care inancing

and administration for programs such as Medicaid, providing

mental health and professional education, establishing health

codes, licensing facilities and personnel, and regulating the in-

surance industry. State systems also have an important role in

direct assistance to local health departments, including ongoing

assessment of health needs.

LEVELS OF PREVENTION

Related to the Public Health Care System

Primary Prevention

Implement a community-level program, such as walking for exercise, to assist

citizens in improving health behaviors related to lifestyle.

Secondary Prevention

Implement a family-planning program to prevent unintended pregnancies

among young couples who attend the local community health center.

Tertiary Prevention

Provide a self-management asthma program for children with chronic asthma

to reduce their need for hospitalization.

Nurses serve in many capacities in state health departments;

they are consultants, direct-service providers, researchers, teachers,

and supervisors. They also participate in program development,

planning, and the evaluation of health programs.

THE LOCAL SYSTEM

The local health department has direct responsibility to the citi-

zens in its community or jurisdiction. Services and programs

offered by local health departments vary depending on the state

and local health codes that must be followed, the needs of the

community, and available funding and other resources. For ex-

ample, one health department might be more involved with

public health education programs and environmental issues,

whereas another health department might emphasize direct cli-

ent care. Local health departments vary in providing sick care or

even primary care. More often than at other levels of govern-

ment, public health nurses at the local level provide population

health and direct services. Some of these nurses deliver special or

selected services, such as following up on contacts in cases of

tuberculosis or venereal disease or providing child immuniza-

tion clinics. Others provide more general care, delivering ser-

vices to families in certain geographical areas. This method of

delivery of nursing services involves broader needs and a wider

variety of nursing interventions. The local level often provides

an opportunity for nurses to take on signiicant leadership roles,

with many nurses serving as directors or managers.

Since the tragedy of September 11, 2001, state and local

health departments have increasingly focused on emergency

preparedness and response. In case of an event, state and local

health departments in the affected area will be expected to col-

lect data and accurately report the situation, to respond appro-

priately to any type of emergency, and to ensure the safety of

the residents of the immediate area while protecting those just

http://www.hhs.gov/about/regions/

43CHAPTER 3 The Changing U.S. Health and Public Health Care Systems

outside the danger zone. This level of knowledge—to enable

public health agencies to anticipate, prepare for, recognize, and

respond to terrorist threats or natural disasters such as hurri-

canes or loods—has required a level of interstate and federal–

local planning and cooperation that is unprecedented for these

agencies. Whether participating in disaster drills or preparing a

local high school for use as a shelter, nurses play a major role in

meeting the challenge of an uncertain future.

FORCES INFLUENCING CHANGES IN THE HEALTH CARE SYSTEM

Although most people are personally satisied with their own

physicians or nurse practitioners, at present, few people are

satisied with the health care system in general. Costs have been

high and have continued to rise while quality and access have

been uneven across the country and within communities, de-

pending on the ability to pay. What, then, are some of the fac-

tors that might inluence health care to change? First, as a na-

tion, citizens must decide what has to be provided for all

people, who will be in charge of the system, and who will pay

for what. In recent years, federal and state services have been

reduced, and more responsibility for health care delivery has

been moved to the private sector. Health care has become big

business. Health care company stocks are now traded on major

stock exchanges, directors receive beneits when proits are

high, and the locus of control has shifted from the provider to

the payer. Many competing forces have inluenced the changing

design of the health care system, some of which are consumers,

employers (purchasers), care delivery systems, and state and

federal legislation.

First, consumers want lower costs and high-quality health care

without limits and with an improved ability to choose the pro-

viders of their choice. Second, employers (purchasers of health

care) want to be able to obtain basic health care plans at reason-

able costs for their employees. Many employers have seen their

proits diminish as they put more money into providing ade-

quate health care coverage for employees. Third, health care sys-

tems want a better balance between consumer and purchaser

demands. Thus they continually watch their own budgets and

expenses. To maintain a proit while providing quality care, many

health care delivery groups have downsized and created alliances,

mergers, and other joint ventures. Finally, legislation, especially

concerning access and quality, continues to be enacted, thus cre-

ating one more force helping to shape the health care system. The

goal of “evidence-based care” is to ensure quality.

Many have said that solving the health care crisis requires the

institution of a rational health care system that balances equity,

cost, and quality. The fact that millions of people have been

uninsured, that wide disparities have existed in access, and that

a large proportion of deaths each year seem attributable to pre-

ventable causes (e.g., errors, tobacco use, alcohol abuse, pre-

ventable injuries, and obesity), has indicated that the American

system is currently not serving the best interests of the Ameri-

can population. WHO has suggested that integrating primary

care and public health into a primary health care system will be

the basis for better health for all world citizens (WHO, 1986a).

INTEGRATION OF PUBLIC HEALTH AND THE PRIMARY-CARE SYSTEM

Although primary care and public health share the goal of pro-

moting the health and well-being of all people, these two disci-

plines historically have operated independently of each other.

Problems that stem from this separation have long been recog-

nized, but new opportunities are emerging for bringing these

systems together to promote lasting improvements in the health

of individuals, communities, and populations (IOM, 2012).

In recognition of this potential, the CDC and the HRSA,

both agencies of the DHHS, asked the IOM to convene a com-

mittee of experts, including input from nursing, to examine the

integration of primary care and public health (IOM, 2012).

To recognize the differences in these two systems, deinitions

were used to guide the work of the experts. Primary care was

deined as “the providing of integrated, accessible health care

services by clinicians who are accountable for addressing a large

majority of personal health care needs, while developing part-

nerships with patients and practicing in the context of family

and community” (IOM, 1996, p. 1). Public health was deined

as “fulilling society’s interest in assuring conditions in which

people can be healthy” (IOM, 1988, p. 140). The purpose of the

integration is to achieve the WHO goal of primary health care.

CHECK YOUR PRACTICE?

You are working in a community health center, which is designed to offer both

primary care and public health services to improve the health of the population

in the geographical location of the center. Identify barriers to your practice as

a nurse as you work to integrate these services in your practice.

POTENTIAL BARRIERS TO INTEGRATION

Contrasting the two systems, primary care, which can be either

a public or a private entity, is person focused, provides a point of

irst contact for individuals to address health problems, is con-

sidered comprehensive, and provides coordination of individual

care; public health can also be delivered through public and

private entities to contribute to the health of society, but govern-

ment plays a major role in public health. Health departments

are legally bound to provide essential public health services and

to work with the total community and multiple stakeholders to

address community-level health problems. Public health also

has speciic functions of assurance, assessment, and policy devel-

opment to address community-level health issues and has a

charge to create healthy communities (see Chapter 1).

In addition to differing roles and functions and issues related

to funding, different clients and different foci will need to be

addressed to form a solid foundation for a partnership. Primary

care is largely funded through individual client payments, health

insurance, and sometimes through federal grants. Public health

is largely funded through tax dollars, federal and state grants,

and sometimes health insurance payments through Medicare

and Medicaid. Primary care serves the individuals who present

to the practice, while public health serves to assess population

health problems. Both focus on meeting the most prevalent

health needs of the population. Primary care focuses more on

44 PART 1 Perspectives in Health Care Delivery and Nursing

the curative aspect of care, while public health focuses more on

the prevention of health problems (Levesque et al, 2013).

The common goal of both public health and primary care,

although these systems operate independently, is to ensure a

healthier population. The committee of experts convened by

the IOM (2012) noted that integration of these two systems has

the potential to produce a greater impact on the health of

populations than either could have when working alone.

The Healthy People initiatives, beginning with the US Sur-

geon General’s 1979 report, indicate the long-standing desire to

improve population health in the United States.

PRIMARY HEALTH CARE

Primary health care (PHC), the goal of the integration of public

health and primary care, includes a comprehensive range of ser-

vices, including public health and preventive, diagnostic, thera-

peutic, and rehabilitative services. This system is composed of

public health agencies, community-based agencies and primary-

care clinics, and health care providers. From a conceptual point of

view, PHC is essential care made universally accessible to indi-

viduals, families, and the community. Health care is made avail-

able to them with their full participation and is provided at a cost

that the community and country can afford. This care is not uni-

formly available and accessible to all people in many countries,

including the United States. Full community participation means

that individuals within the community help in deining health

problems and in developing approaches to address the problems.

The setting for primary health care is within all communities of a

country, and it involves all aspects of society (WHO, 1978).

The primary health care movement oficially began in 1977

when the 30th WHO Health Assembly adopted a resolution ac-

cepting the goal of attaining a level of health that permitted all

citizens of the world to live socially and economically productive

lives. At the international conference in 1978 in Alma-Ata, in the

former Soviet Union (currently Almaty, in Kazakhstan), it was

determined that this goal was to be met through PHC. This

resolution, the Declaration of Alma-Ata, became known by the

slogan “Health for All [HFA] by the Year 2000,” which captured

the oficial health target for all the member nations of WHO. In

1998 the program was adapted to meet the needs of the new

century and was deemed “Health for All in the 21st Century.”

In 1981 WHO established global indicators for monitoring

and evaluating the achievement of HFA. In the World Health

Statistics Annual (WHO, 1986b), these indicators are grouped

into the following four categories:

• Health policies

• Social and economic development

• Provision of health care

• Health status

The indicators suggest that health improvements are a result

of efforts in many areas, including agriculture, industry, education,

housing, communications, and health care. Because PHC is as

much a political statement as a system of care, each United Nations

member country interprets PHC according to its own culture, health

needs, resources, and system of government. Clearly, the goal of PHC

has not been met in most countries, including the United States.

PROMOTING HEALTH/PREVENTING DISEASE: YEAR 2020 OBJECTIVES FOR THE NATION

As a WHO member nation, the United States has endorsed pri-

mary health care as a strategy for achieving the goal of “Health for

All in the 21st Century.” However, the PHC emphasis on broad

strategies, community participation, self-reliance, and a multidis-

ciplinary health care delivery team is not the primary strategy for

improving the health of the American people. The national health

plan for the United States identiies disease prevention and health

promotion as the areas of most concern in the nation. Each de-

cade since the 1980s has been measured and tracked according to

health objectives set at the beginning of the decade. The PHS of

the DHHS publishes the objectives after gathering data from

health professionals and organizations throughout the country.

Healthy People 2020, which was oficially launched in Decem-

ber 2010 (USDHHS, 2010a), is composed of a large number of

objectives related to 42 topic areas. These objectives are designed

to serve as a road map for improving the health of all people in the

United States during the second decade of the 21st century. These

objectives are described by four main goals (USDHHS, 2010b):

• Attain high-quality, longer lives free of preventable disease,

disability, injury, and premature death.

• Achieve health equity, eliminate disparities, and improve the

health of all groups.

• Create social and physical environments that promote good

health for all.

• Promote quality of life, healthy development, and healthy

behaviors across all life stages.

These goals provide the framework with which measurable

health indicators can be tracked. The emphasis on the social and

physical environment moves Healthy People 2020 from the tradi-

tional disease-speciic focus to a more holistic view of health

consistent with a public health frame of reference (Healthy Peo-

ple 2020, 2012). This in turn will encourage public health nurses

to broaden their scope to all aspects of their clients’ lives that

may need assessment and intervention, including where they

live, the condition of their homes, and how the appropriateness

of the home environment may change as clients age. The

Healthy People 2020 box presents indicators of Healthy People

2020 related to the strengthening of the public health infrastruc-

ture. These objectives will assist nurses in having data to show

that their assessments and interventions are changing practice.

HEALTHY PEOPLE 2020

Selected Objectives That Pertain to Strengthening

the Public Health Infrastructure

• PHI-7 (Developmental): Increase the proportion of population-based

Healthy People 2020 objectives for which national data are available for all

major population groups.

• PHI-8: Increase the proportion of Healthy People 2020 objectives that are

tracked regularly at the national level.

From US Department of Health and Human Services. Healthy People

2020. Available at http://www.healthypeople.gov Accessed December

27, 2010.

http://www.hhs.gov/healthcare/facts/timeline/

45CHAPTER 3 The Changing U.S. Health and Public Health Care Systems

APPLYING CONTENT TO PRACTICE

Discussions and debates will continue about the impact of the ACA and the

IOM’s discussions of integrating public health and primary care, reducing

cost, and increasing quality and access for all Americans. It is important not

to lose sight of the goal: to protect and improve the health of all populations.

After spending 18 months in a public policy fellowship and working with the

Ways and Means Committee in Congress, Nancy Ridenour, PhD, RN, and dean

of the College of Nursing at the University of New Mexico, described

her opportunity to work with others as the ACA was being developed. At a

board of nursing celebration in Kentucky in the summer of 2014, Dr. Ridenour

explained to the audience that it would be important for nurses to be involved

in the implementation of the ACA to promote the success of the health care

changes proposed. It is all about the inluence of nurses and the nursing

profession (Kentucky Board of Nursing, 2014). Focus efforts on the implemen-

tation of the key features of the ACA (Table 3.2) in work with individual cli-

ents and populations in your community. An example of this application

would be working with families to encourage enrolling children in the state

child health insurance programs to assure that the family’s children will re-

ceive preventive and primary care as needed.

TABLE 3.2 Overview of Key Features of the Affordable Care Act by Year

2010

New Consumer Protections

• Putting information for consumers online

• Prohibiting denial of coverage of children based on preexisting conditions

• Prohibiting insurance companies from rescinding coverage

• Eliminating lifetime limits on insurance coverage

• Regulating annual limits on insurance coverage

• Establishing consumer assistance programs in the states

Improving Quality and Lowering Costs

• Providing small business health insurance tax credits

• Offering relief for 4 million seniors who hit the Medicare prescription drug

“donut hole”

• Providing free preventive care

• Preventing disease and illness

• Cracking down on health care fraud

Increasing Access to Affordable Care

• Providing access to insurance for uninsured Americans with preexisting

conditions

• Extending coverage for young adults

• Expanding coverage for early retirees

• Rebuilding the primary-care workforce

• Holding insurance companies accountable for unreasonable rate hikes

• Allowing states to cover more people on Medicaid

• Increasing payments for rural health care providers

• Strengthening community health centers

2011

Improving Quality and Lowering Costs

• Offering prescription drug discounts

• Providing free preventive care for seniors

• Improving health care quality and eficiency

• Improving care for seniors after they leave the hospital

• Introducing new innovations to bring down costs

Increasing Access to Affordable Care

• Increasing access to services at home and in the community

Holding Insurance Companies Accountable

• Bringing down health care premiums

• Addressing overpayments to big insurance companies and strengthening

Medicare Advantage

2012

Improving Quality and Lowering Costs

• Linking payment to quality outcomes

• Encouraging integrated health systems

• Reducing paperwork and administrative costs

• Understanding and ighting health disparities

Increasing Access to Affordable Care

• Providing new, voluntary options for long-term care insurance

2013

Improving Quality and Lowering Costs

• Improving preventive health coverage

• Expanding authority to bundle payments

Increasing Access to Affordable Care

• Increasing Medicaid payments for primary care doctors

• Open enrollment in the health insurance marketplace begins.

2014

New Consumer Protections

• Prohibiting discrimination due to preexisting conditions or gender

• Eliminating annual limits on insurance coverage

• Ensuring coverage for individuals participating in clinical trials

Improving Quality and Lowering Costs

• Making care more affordable

• Establishing the health insurance marketplace

• Increasing the small business tax credit

Increasing Access to Affordable Care

• Increasing access to Medicaid

• Promoting individual responsibility

2015

Improving Quality and Lowering Costs

• Paying physicians based on value, not volume

For more detail about each of the bulleted statements, please refer to HHS.gov/HealthCare (Key Features of the Affordable Care Act, 2014: http://

www.hhs.gov/healthcare/facts/timeline/).

46 PART 1 Perspectives in Health Care Delivery and Nursing

P R A C T I C E A P P L I C A T I O N

R E M E M B E R T H I S !

During a well-child clinic visit, Jenna Wells, RN, met Sandra Farr

and her 24-month-old daughter, Jessica. The Farrs had recently

moved to the community. Mrs. Farr stated that she knew that

Jessica needed the last in a series of immunizations, and because

they did not have health insurance, she brought her daughter to

the public health clinic. On initial assessment, Mrs. Farr told the

nurse that her husband would soon be employed, but the family

would have no health care coverage for the next 30 days. She also

said that they needed to decide which health care package they

wanted. Mr. Farr’s company offers a PPO, an HMO, and a com-

munity nursing clinic plan to all employees. Neither Mr. nor

Mrs. Farr has ever used an HMO or a community nursing clinic,

and they are not sure what services are provided.

Mrs. Farr asks Nurse Wells what she should do.

Nurse Wells should do which of the following?

A. Encourage Mrs. Farr to choose the HMO because it will pay

more attention to the family’s preventive needs, and direct

Mrs. Farr to other sources of health care should the family

need to see a provider while they are uninsured.

• Health care in the United States is made up of a personal

care system and a public health system, with overlap between

the two systems.

• Primary care is a personal health care system that provides

for irst contact and continuous, comprehensive, and coor-

dinated care.

• Primary health care is essential care made universally acces-

sible to individuals and families in a community. Health care

is made available to them through their full participation

and is provided at a cost that the community and country

can afford.

• Primary care and the public health systems are part of pri-

mary health care.

• Public health refers to organized community efforts de-

signed to prevent disease and promote health.

• Important trends that affect the health care system include

demographic, social, economic, political, and technological

trends.

• More than 48 million people in the United States were unin-

sured in 2012, and many more simply lacked access to ade-

quate health care.

• With the implementation of the Affordable Care Act (ACA), by

2014 the numbers of uninsured dropped to 32 million people.

B. Encourage Mrs. Farr to choose the PPO because it will have

a greater number of qualiied providers from which to

choose, and direct Mrs. Farr to other sources of health care

should the family need to see a provider while they are un-

insured.

C. Encourage Mrs. Farr to choose the local community nursing

center because it is staffed with nurse practitioners who are

well qualiied to provide comprehensive health care with an

emphasis on health education, and direct Mrs. Farr to other

sources of health care should the family need to see a pro-

vider while they are uninsured.

D. Explain the differences between a PPO, HMO, and commu-

nity nursing clinic; encourage Mrs. Farr to discuss the op-

tions with her husband about signing up for a health insur-

ance plan under the ACA plans; and direct Mrs. Farr to

other sources of health care should the family need to see a

provider while they are uninsured.

Answers can be found on the Evolve website.

• Many federal agencies are involved in government health

care functions. The agency most directly involved with the

health and welfare of Americans is the US Department of

Health and Human Services (USDHHS).

• Most state and local jurisdictions have government activities

that affect the health care ield.

• Health care and insurance reform measures seek to make

changes in the cost and quality of and access to the present

system, such as the ACA passed in 2010.

• To achieve the speciic health goals of programs such as

Healthy People 2020, primary care and public health must

work within the community for community-based care.

• The most sustainable individual and system changes come

when people who live in the community have actively par-

ticipated.

• Nurses are more than able to ill the gap between personal

care and public health because they have skills in assess-

ment, health promotion, and disease and injury preven-

tion; knowledge of community resources; and the ability

to develop relationships with community members and

leaders.

• Nurses are important to the success of the ACA.

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PART 2 Influences on Health Care Delivery and Nursing

After reading this chapter, the student should be able to do the

following:

1. Describe a brief history of the ethics of nursing in public

and community health.

2. Discuss ethical decision-making processes.

3. Compare and contrast ethical theories and principles, virtue

ethics, caring ethics, and feminist ethics.

O B J E C T I V E S

4. Describe how ethics is part of the core functions of nursing

in public health.

5. Analyze codes of ethics for nursing and for public health.

6. Apply the ethics of advocacy to nursing in public health.

4 Ethics in Public and Community

Health Nursing Practice

Sydney Axson and Connie M. Ulrich1

C H A P T E R

Introduction

Brief History of Ethics and Bioethics: Relationship

to Nursing and Public Health

Foundations of Nursing and Public Health’s Codes of

Ethics

Ethical Decision Making

Ethical Principles and Theories as Guides to Ethical

Decision Making

C H A P T E R O U T L I N E

Ethics and the Core Functions of Public Health

Nursing

Nursing Code of Ethics

Public Health Code of Ethics

Advocacy and Ethics

Deinitions, Codes, Standards

Advocacy and Health Care Reform

advocacy, 61

beneicence, 50

bioethics, 50

code of ethics, 51

consequentialism, 53

deontology, 54

distributive justice, 54

ethic of care, 56

ethical decision making, 52

ethical dilemmas, 51

ethical issues, 50

ethics, 50

feminist ethics, 56

feminists, 57

moral distress, 50

nonmaleicence, 50

principlism, 54

utilitarianism, 53

values, 52

virtue ethics, 56

virtues, 56

K E Y T E R M S

INTRODUCTION

Public health and community health nurses focus on preven-

tion, protecting, promoting, preserving, and maintaining health.

Working within public health settings, however, can challenge

nurses in many ways. First, public health nurses may be the irst

point of contact for patients and their families within the local

community. Therefore these nurses are in a unique position as

they work to establish trusting relationships not only with their

patients and families but also with a broad array of community

groups that represent local interests. As health care providers,

nurses navigate personal beliefs, patient and/or family wishes,

and community values. They must do so within the parameters

of community resources and organizational policy and within

the guidelines of their professional codes of conduct. This

1We acknowledge Mary Cipriano Silva, Jeanne Merkle Sorrell, and

James J. Fletcher for their previous work on this chapter. We have kept their

original thoughts in the majority of this chapter and added additional infor-

mation pertinent to thinking about ethics in public health nursing practice.

50 PART 2 Inluences on Health Care Delivery and Nursing

complex and challenging process has tangible ramiications.

One such possible effect is moral distress, that is, knowing (or

thinking one knows) the morally right course of action but not

being able to act accordingly (Corely et al, 2005; Jameton, 1984;

Epstein and Hamric, 2009; Raines, 2000; Ulrich, O’Donnell,

Taylor et al, 2007; Ulrich, Hamric, and Grady, 2010). In more

recent commentary, Hamric (2014) has deined moral distress as

a serious violation of one’s moral integrity based on a failure to

act or where attempted actions failed. Experiencing moral dis-

tress has negative consequences; it affects job satisfaction and

can lead to nurses leaving the profession altogether (Hamric and

Blackhall, 2007; Ulrich, O’Donnell, Taylor et al, 2007). Unsur-

prisingly, the supply of nurses able to appropriately engage

with the challenges of their jobs directly affects the health of any

community.

Second, public health or community nurses must also be

prepared for any emerging or reemerging infectious disease that

might arise within their communities. Here, they have to weigh

or balance the potential beneits and risks to individuals as well

as the risks and harms to the broader community. Most re-

cently, an outbreak of the Zika virus (a mosquito-borne virus)

is presenting a signiicant public health threat to communities

across the United States as well as globally. Lucey and Gostin

(2016) suggests that “training health workers to observe and

report Zika-related disease and robust systems for collecting

and analyzing surveillance data will complement public health

strategies” (p 865). This raises important questions about

the ethics preparedness of public health nurses and the ethical

issues that they might face. The lead levels in the water supply

in a largely minority and poor population in Flint, Michigan,

is another example of a public and community health crisis

and highlights ethical issues associated with concepts of inclu-

sion, diversity, participation, empowerment, social justice,

advocacy, and interdependence (Racher, 2007). This chapter

applies core knowledge of ethics to public health nursing

to help nurses develop effective coping strategies for ethical

issues, including moral distress and other issues of import.

Further, characteristics unique to community health practice

are explored.

BRIEF HISTORY OF ETHICS AND BIOETHICS: RELATIONSHIP TO NURSING AND PUBLIC HEALTH

Ethics is both a process for relection and a body of knowledge

that focuses on the study of morality or the moral life (Beau-

champ and Childress, 2013). Stated differently, Chaloner says

“Ethics is a branch of philosophy concerned with determining

right and wrong in relation to people’s decisions and actions”

(2007, p 42). Ethics-related questions often ask the following:

How should I behave? What actions should I perform? What

kind of person should I be? What are my obligations to myself

and to others? Ethics is important in all aspects of life and is

inherent in nursing; basing actions on ethical principles

supports clinical decision making and the practice of nursing.

For example, the ethical principles of beneicence (doing good)

and nonmaleicence (do no harm) can be traced back to the

Hippocratic Oath for health care professionals and provides a

framework for patient–clinician relationships (Racher, 2007).

Bioethics, a multidisciplinary subield of ethics, is the system-

atic study of ethical issues in research, clinical care, or other areas

in the life sciences, using both normative and empirical method-

ological approaches (Jonsen, 1998; Reich, 1995). Several sentinel

historical events have shaped the ield of bioethics, including the

well-known Nuremberg Tribunal that followed World War II.

The Nuremberg Tribunal reviewed the egregious human rights

abuses performed under the guise of scientiic experimentation

by Nazi leaders, including physicians (Easley and Allen, 2007).

These abuses, and the prosecution of their perpetrators, led to the

development of the Nuremberg Code of 1947, “which provides

the foundation for the protection of human subjects in research”

(Easley and Allen, 2007, p 367). Major social movements of the

1960s and 1970s in the United States facilitated further develop-

ment of the ield of bioethics. Examples include the campaign for

nuclear disarmament, the civil rights and peace movements, the

protests against the war in Vietnam, and new medical technolo-

gies that raised challenging ethical questions about life and death

(Easley and Allen, 2007). In addition, the irst institution in the

United States devoted to the study of bioethics was the Hastings

Center, founded by Daniel Callahan, PhD, and Willard Gaylin,

MD, in 1970. The Hastings Center (2017) addresses core ethical

issues that arise in all areas of the life sciences and that affect the

health and well-being of individuals, communities, and societies.

It remains an excellent resource for nurses and other health care

practitioners in the rapidly changing health care landscape.

Despite the atrocities of Nuremberg, violation of human

rights in the name of research continued, including the Tuskegee

syphilis study sanctioned by the US Public Service. From this,

the 1974 National Research Act established the National Com-

mission for the Protection of Human Subjects of Biomedical

and Behavioral Research; this commission created the seminal

Belmont Report (1979). A set of guidelines differentiating clini-

cal practice from research, the Belmont Report also outlines the

ethical principles of respect for persons (informed consent and

respecting autonomous decisions), beneicence (maximizing the

beneits and minimizing the harms), and justice (fair subject

selection in research) in the protection of human subjects who

participate in research (Belmont Report, 1979).

The ield of bioethics continues to evolve as ethical issues

remain prevalent in clinical practice and research and as new

questions arise in the care of the most vulnerable in our com-

munities. For example, questions abound on how to allocate

scarce resources in a just manner both at the micro and macro

levels and the beneits and harms of health technologies

and research, including renal dialysis, organs for transplants,

precision science, genetics and genomics, and emerging and

reemerging infectious diseases, among others.

FOUNDATIONS OF NURSING AND PUBLIC HEALTH’S CODES OF ETHICS

Modern nursing also has a rich heritage of ethics and morality.

Florence Nightingale (1820–1910) is often seen as nursing’s irst

moral leader and nurse in community health. Nightingale saw

51CHAPTER 4 Ethics in Public and Community Health Nursing Practice

nursing as a call to service and thought nurses should be people

of good moral character. She was a champion of primary

prevention, passionate about the need to provide care to

the disenfranchised, and committed to the importance of a

sanitary environment, as seen in her work with soldiers in the

Crimean War (1854–1856). The ethical foundations of clinical

practice that Nightingale contributed to nursing have endured.

Chapter 2 provides details about the many contributions of

Nightingale to the development of the nursing profession.

In the 1960s, two seminal events that changed the course of

nursing practice occurred. First, the American Nurses Associa-

tion (ANA) recommended all nursing education occur in insti-

tutions of higher education. Before this time, many of the

schools of nursing were offered by religious institutions and

had ethics included in their curricula. As the process of moving

nursing into higher education took place, ethics as a course was

removed from many schools of nursing. Often the decision to

omit ethics courses was inluenced by the need to include more

general education courses in the nursing curriculum. Second,

because of major advances in science and technology, the ield

of bioethics began to emerge and was also developing in nurs-

ing curricula. Today, although many nursing programs inte-

grate bioethical content into their courses or have separate

courses on this topic, research suggests that approximately 23%

of nurses still have no ethics education (Grady et al., 2008).

Nurses’ codes of ethics are important in the history of

nursing practice in the community. The Nightingale Pledge is

generally considered to be nursing’s irst code of ethics (ANA,

2001). After the Nightingale Pledge, a “suggested” code and

a “tentative” code were published in the American Journal

of Nursing but were not formally adopted. The Code for Profes-

sional Nurses was formally adopted by the ANA House of

Delegates in 1950. It was amended and revised ive more times,

until in 2001 the ANA House of Delegates adopted the Code of

Ethics for Nurses with Interpretive Statements. Most recently, the

Code of Ethics for Nurses underwent another signiicant revision

with approval in 2014. As stated by Marsha Fowler (2015), “the

Code of Ethics for Nurses with Interpretive Statements is remark-

able in its breadth and compass. It retains nursing’s historical

and ethical values, obligations, ideals, and commitments while

extending them into the ever-growing art, science, and practice

of nursing in 2015” (pp viii–ix).

The irst known international code of ethics was adopted by

the International Council of Nurses in 1953. Like the Code of

Ethics for Nurses with Interpretive Statements, it has undergone

various revisions and adoptions. The most recent revision of

the ICN Code of Ethics for Nurses was adopted in 2005, copy-

righted in 2006, and revised in 2012 (International Council of

Nurses, 2012).

As mentioned earlier in the chapter, the bioethics movement

of the late 1960s inluenced both nursing ethics and public

health ethics. The relationship between public health and ethics

has also been made explicit through the development of a

Code of Ethics (Public Health Leadership Society, 2002). After

input from many public health professionals and associations,

the Code of Ethics for Public Health was approved in 2002

(Olick, 2005). This code, entitled Principles of the Ethical

Practice of Public Health, deines public health in the following

way: “public health not only seeks to assure the health of whole

communities but also recognizes that the health of individuals

is tied to their life in the community” (Public Health Leadership

Society, 2002, p 1). It also identiies 12 guiding principles, in-

cluding, but not limited to, respect for individuals within their

communities, community engagement in policies and proce-

dures that affect the community’s overall health and well-being,

community consent, collaborative practices that support trust

within diverse communities, and upholding ethical principles

of conidentiality and justice. (For clarity in this chapter, this

document is referred to as the Code of Ethics for Public Health

unless the oficial title is used.)

Professional codes provide a foundation from which nurses

and other public health advocates can meet their professional

and moral obligations to their patients and communities. Nurses

in public health have to honor their professional duties in ways

that extend beyond one-on-one care, and this can present

unique ethical challenges. Indeed, in public health nursing, the

role of prevention is increasingly being informed by genomics as

well as other factors. Here, nurses must become more skilled in

learning how to reduce the potential inluence of genetic risk

factors by teaching clients how to live healthier lives, or address

the individual health effects of environmental risks within com-

munities, such as drinking water, lead levels, air pollutants, or

radiation exposure. Questions that arise in regard to genomics

and how this and other factors may affect public health nursing

include the following: Should people be held accountable for

making unhealthy life choices? To whom should you give infor-

mation about a genetic predisposition to an environmental

health problem? Should society’s resources be used for people

who knowingly engage in risky behavior given their genetic

makeup (Easley and Allen, 2007; Sharp et al, 2003)?

ETHICAL DECISION MAKING

Ethical issues are moral challenges facing all health care prac-

titioners, and are particularly common in community or

public health nursing. Ulrich, Taylor, Soeken, et al (2010) state

that “ethical issues can occur in any situation where profound

moral questions of ‘rightness’ or ‘wrongness’ underlie profes-

sional decision-making and the beneicent care of patients”

(p 251). A good example of an ethical issue in community or

public health nursing at both the individual and community

level is Ebola. One of the central ethical issues surrounding

Ebola was informed consent of health care providers as well as

the community regarding the risks of contracting the virus

and its implications for individual and community health and

well-being. From a public health perspective, other ethical

issues included concerns about surveillance and tracking mea-

sures, availability of personal protective equipment, and quar-

antine and isolation procedures for hospitalized patients as

well as American and foreign citizens who entered or reen-

tered the country. In contrast, ethical dilemmas are human

dilemmas and puzzling moral problems in which a person,

group, or community can envision morally justiied reasons

for both taking and not taking a certain course of action

52 PART 2 Inluences on Health Care Delivery and Nursing

(Purtilo and Doherty, 2016; Barrett, 2012). With Ebola,

arguments on who should receive the experimental drug

(ZMapp)—the American health care workers who became

infected or the African citizens who were dying on the front

lines of the virus outbreak in Africa—was a classic example of

an ethical dilemma. Here, various stakeholders presented

sound arguments regarding the allocation and testing of

ZMapp for each respective group.

Making ethical decisions on allocation priorities of a scarce

and untested resource such as ZMapp required a systematic

analysis and evaluation of the ethical issue or dilemma. Thus

ethical decision making is the part of ethics that focuses on

the process of how ethical decisions are made. Ethical theo-

ries, principles, and decision-making frameworks help nurses

and others think through these issues and dilemmas. Often,

ethical content is abstract, which makes decision making

more dificult.

Ethical decision-making frameworks use problem-solving

processes. They provide guides for making sound ethical deci-

sions that can be morally justiied. Some of these frameworks

are discussed in this chapter. It is important to remember that,

when all is said and done, we each make our own decisions.

Weston (2002) said, “Whether we admit it or not, we do make

our own decisions. We cannot pretend that we are simply obey-

ing some rules (or authorities) that settle matters—ours only to

obey. Choosing is inescapable” (p 28). Because we make our

own decisions, the following generic ethical decision-making

framework may be useful:

1. Identify the ethical issues and dilemmas.

2. Place the ethical issues and dilemmas within a meaningful

context.

3. Obtain all relevant facts.

4. Reformulate ethical issues and dilemmas, if needed.

5. Consider appropriate approaches to actions or options (i.e.,

utilitarianism, deontology, principlism, virtue ethics, care

ethics, feminist ethics).

6. Make the decision and take action.

7. Evaluate the decision and the action.

The steps of a generic ethics framework are often nonlinear,

and with the exception of the ethical approach, they do not

change substantially. Their rationales are presented in Table 4.1.

Step 5 (the one exception) lists six approaches to the ethical

decision-making process; these approaches are outlined through-

out the chapter in the How To boxes.

Several factors can affect the ethical decision-making pro-

cess. First, we live in a multicultural society in which nurses

might face ethical issues and dilemmas related to the diverse

cultures, values, and beliefs of their patients, families, and com-

munities. This, at times, can create conlict. Callahan (2000),

cofounder of the Hastings Center, helps explain these conlicts

and describes the following four situations for relection

and consideration when working with diverse individuals and

communities:

1. Situations that place persons at direct risk for harm, whether

psychological or physical

2. Situations in which cultural standards conlict with profes-

sional standards

3. Situations in which the greater community’s values are jeop-

ardized by values of a smaller culture within that community.

4. Situations in which community customs may cause mild of-

fense or annoyance to other communities, but no major

problems.

Chapter 5 further discusses cultural inluences on public health

nursing. Applying Callahan’s four standards to content in that

chapter will be helpful. Callahan (2000) discusses how to con-

sider diversity in the four situations. In situation 1, he says that

“we in America imposed some standards on ourselves for im-

portant moral reasons; and there is no good reason to exempt

subgroups from those standards” (p 43). Regarding situations

2 and 3, Callahan recognizes a challenge between cultural stan-

dards of individuals and communities and health care provid-

ers’ professional standards. Within this scenario, health care

providers have to recognize that some groups hold values dif-

ferent from those generally accepted as normative in society.

Callahan notes “in the absence of grievous harm, there is no

clear moral mandate to interfere with those values” (p 43).

However, sometimes there is some degree of moral pressure

(not coercion) to intervene with differing values for the sake of

community consensus. This often requires compromise and

negotiation between differing parties. Finally, regarding situa-

tion 4, he notes there is no moral mandate to intervene in non-

threatening cultural traditions and values even if they create

some degree of burden on others. Intervention only becomes

necessary when the imposed burdens cause harm or undue

hardship to other groups.

Because decision making is central to the practice of nurs-

ing, and many decisions are dificult to make, it is useful to

Steps Rationale

1. Identify the ethical

issues and dilemmas.

2. Place them within a

meaningful context.

3. Obtain all relevant facts.

4. Reformulate ethical

issues or dilemmas if

needed.

5. Consider appropriate

approaches to actions or

options.

6. Make decisions and take

action.

7. Evaluate decisions and

action.

Persons cannot make sound ethical decisions

if they cannot identify ethical issues and

dilemmas.

The historical, sociological, cultural, psycho-

logical, economic, political, communal,

environmental, and demographic contexts

affect the way ethical issues and dilemmas

are formulated and justiied.

Facts affect the way ethical issues and

dilemmas are formulated and justiied.

The initial ethical issues and dilemmas may

need to be modiied or changed on the

basis of context and facts.

The nature of the ethical issues and

dilemmas determines the speciic ethical

approaches used.

Professional persons cannot avoid choice

and action in applied ethics.

Evaluation determines whether the ethical

decision-making framework used resulted

in morally justiied actions related to the

ethical issues and dilemmas.

TABLE 4.1 Rationale for Steps of an Ethical Decision-Making Framework

53CHAPTER 4 Ethics in Public and Community Health Nursing Practice

Three cases will be presented in the following chapter sec-

tions. Each one should be examined using the ethical decision-

making processes outlined in the How To boxes and the differ-

ent codes of ethics provided in the chapter. These cases provide

an excellent opportunity to debate your personal beliefs about

the application of ethical processes with classmates and to as-

sess your own thoughts, feelings, and possible actions. The cases

deal with what the nursing response should be (1) when a client

will not assume responsibility for his or her health, (2) when

the question arises about whether a parent can adequately care

for a young child, and (3) when a client is not able or willing

to take personal responsibility and does not want the nurse to

report the situation.

ETHICAL PRINCIPLES AND THEORIES AS GUIDES TO ETHICAL DECISION MAKING

The remainder of this section of the chapter summarizes con-

tent about ethical theories and principles. As you read these

sections, remember that the ways ethical theories and princi-

ples are applied in the community may differ from how they

are applied with individuals. As Racher (2007, p 68) aptly says,

“Community practice is traditionally based on utilitarianism,

adheres to the axiom ‘the greatest good for the greatest num-

ber,’ and supports the position that maximizing beneits to

socially disadvantaged groups ultimately beneits society as a

whole.” Community practitioners work to increase participa-

tion in health promotion and manage chronic diseases; they

see these actions as beneiting the individual and the com-

munity. Public health is concerned with collective action

that beneits the greatest number of people, such as having

clean water, public safety, or the societal regulation of shared

risks, for example, reporting of some communicable diseases

(Easley and Allen, 2007). The public health perspective of care

may require that individuals forfeit some of their self-interests

for the beneits of a safe and healthy society. For example,

prohibiting people from smoking in restaurants, to beneit the

other people in the restaurant, may inconvenience the smoker

while providing a healthier environment for all people,

including the smoker. Similarly, at times a person’s right

to privacy and conidentiality may be usurped by the public

beneit of disclosure. This might take place during epidemics

or other national events when contact tracing and surveillance

epidemiological measures are warranted (Gostin, Bayer, and

Fairchild, 2003).

Utilitarianism and Deontology At times, decisions are based on outcomes or consequences. In

this approach, referred to as consequentialism, the right action

is the one that produces the greatest amount of good or the

least amount of harm in a given situation. Utilitarianism is a

well-known consequentialist ethical theory associated with out-

comes or consequences in determining which choice to make.

In utilitarianism, “the moral value of an action is determined by

its overall beneit” (Chaloner, 2007, p 43). Stated differently,

because the outcome is the key factor, the end justiies the

means.

#92202428.)

consider the experience of moral distress. As noted earlier,

moral distress occurs when one is unable to act in a way that he

or she thinks is right (consistent with their own personal

or professional values, cultural expectations, and/or religious

beliefs) due to internal or external constraints. Moral distress is

different from what we may consider emotional distress be-

cause there is not only an ethical component associated with

this phenomenon but also the threat to an individual’s moral

integrity (Epstein and Delgado, 2010; Hamric, 2014; Ulrich,

Hamric, and Grady, 2010; Varcoe et al, 2012). Nurses, as well as

other types of health care providers, have experienced moral

distress (Epstein and Delgado, 2010; Austin et al, 2008; Chen,

2009; Forde and Aasland, 2008; Hamric and Blackhall, 2007;

Lomis, Carpenter, and Miller, 2009). In a national survey, Ulrich

et al (2007) reported that nurses identiied feeling powerless,

overwhelmed, frustrated, and fatigued when they cannot re-

solve ethical issues experienced while working. These reported

feelings are psychosocial consequences of moral distress. When

this conlict occurs, it can lead to a sense of personal failure in

the kind of care nurses give and to subsequent performance is-

sues and may lead to work or career dissatisfaction. However,

moral distress may be addressed in some of the following ways:

1. Identifying the type(s) of situation that leads to distress

2. Communicating that concern to your manager and examin-

ing ways to work toward addressing the stressor

3. Seeking support from colleagues

4. Seeking support from ethics committees, social workers, and

pastoral care, among others

5. Being proactive and expressing one’s voice on matters that

are ethically concerning

It is often useful to talk with colleagues. You may learn that

they have similar concerns or that they have found ways to in-

terrupt the stressful situation(s) (Carlock and Spader, 2007).

Additionally, open dialogue with those in leadership positions

such as nurse managers can be helpful. Collaboration like this

can lead nurses to connect with other services such as ethics

committees and social work, both of which have important

roles in ethical practice.

http://www.Photos.com

54 PART 2 Inluences on Health Care Delivery and Nursing

Respect for autonomy: Based on human dignity and respect for individuals,

autonomy requires that individuals be permitted to choose those actions

and goals that fulill their life plans unless those choices result in harm to

another.

Nonmaleficence: According to Hippocrates, nonmaleficence requires

that we do no harm. It is impossible to avoid harm entirely, but this

principle requires that health care professionals act according to the

standards of due care, always seeking to produce the least amount of

harm possible.

Beneicence: This principle is complementary to nonmaleicence and re-

quires that we do good. We are limited by time, place, and talents in the

amount of good we can do. We have general obligations to perform

those actions that maintain or enhance the dignity of other persons

whenever those actions do not place an undue burden on health care

providers.

Distributive justice: Distributive justice requires that there be a fair distribu-

tion of the beneits and burdens in society based on the needs and contribu-

tions of its members. This principle requires that consistent with the dignity

and worth of its members and within the limits imposed by its resources,

a society must determine a minimal level of goods and services to be

available to its members.

HOW TO Apply the Utilitarian Ethics Decision Process

1. Determine moral rules that are important to society and that are derived

from the principle of utility.*

2. Identify the communities or populations that are affected or most affected

by the moral rules.

3. Analyze viable alternatives for each proposed action based on the moral

rules.

4. Determine the consequences or outcomes of each viable alternative on the

communities or populations most affected by the decision.

5. Select the actions on the basis of the rules that produce the greatest

amount of good or the least amount of harm for the communities or popula-

tions that are affected by the action.

NOTE: Remember that the utilitarian ethics decision process is one

of the approaches in step 5 of the generic ethical decision-making framework.

*Moral rules of action that produce the greatest good for the greatest

number of communities or populations affected by or most affected

by the rules.

In other situations, nurses may conclude that the action is

right or wrong in itself, regardless of the amount of good

that might come from it. This is the ethical theory known as

deontology, or adhering to moral rules or duty rather than to

the consequences of the actions (Munson, 2014). This view is

based on the premise that persons should always be treated as

ends in themselves and never as mere means to the ends of

others.

Each theory maintains that there is a universal irst principle,

the principle of utility for utilitarianism and the categorical

imperative for deontology, which serves as a rational norm for

behavior and allows us to calculate the rightness or wrongness

of each individual action. According to both utilitarianism and

deontology, the individual is the special center of moral con-

cern (Steinbock, Arras, and London, 2008). Deontology comes

from the Greek roots deon, meaning “duty,” and logos, meaning

“study of.” Giving priority to individual rights and needs refers

to the concept that a person’s rights and dignity should never

(or rarely) be sacriiced to the interests of society (Steinbock,

Arras, and London, 2008).

Health professionals have speciic obligations that exist

because of the practices and goals of the profession. These

health care obligations can be interpreted in terms of a set

of principles in bioethics as outlined by Beauchamp and

Childress (2009): respect for autonomy, nonmaleicence, be-

neicence, and justice (as shown in Box 4.1). Principlism

relies on these ethical principles to guide decision making. As

such, the principle of autonomy refers to self-governance.

Respecting autonomy requires health care providers to under-

stand a client’s ability to decide and act with his or her own

plan (Beauchamp and Childress, 2009). Nonmaleicence is the

noninliction of harm, and is often closely linked to the prin-

ciple of beneicence or the duty to act in ways that will beneit

others. Distributive justice or social justice refers to the allo-

cation of beneits and burdens to members of society. Beneit

refers to basic needs, including material and social goods, lib-

erties, rights, and entitlements. Some beneits of society are

wealth, education, and public services. Among the burdens to

BOX 4.1 Ethical Principles

be shared are items such as taxes, military service, and

the location of incinerators and power plants. Justice

requires that the distribution of beneits and burdens in a

society be fair. Although it is recognized that distribution

should be based on what one needs and deserves, considerable

disagreement exists when considering what these terms

mean in the context of fairness. The three primary theories of

distributive justice are egalitarian, libertarian, and liberal

democratic (see Box 4.2).

Although principlism has been used effectively to analyze

ethics-related situations in bioethics, it also has its critics

(Callahan, 2000, 2003; Walker, 2009). First, some argue that

the principles are too abstract and narrow to serve as guides

for action. Second, the principles themselves can conlict in a

given situation, and there is no independent basis for priori-

tizing them (Walker, 2009). Third, Walker (2009) contends

that there are more than four principles that relect the “com-

mon morality.” And, fourth, ethical judgments may depend

more on the judgment of sensitive persons than on the

application of abstract principles.

HOW TO Apply the Deontological Ethics Decision Process

1. Determine the moral rules (e.g., tell the truth) that serve as standards by

which individuals can perform their moral obligations.

2. Examine personal motives for proposed actions to ensure that they are

based on good intentions in accord with moral rules.

3. Determine whether the proposed actions can be generalized so that all

persons in similar situations are treated similarly.

4. Select the action that treats persons as ends in themselves and never as

mere means to the ends of others.

NOTE: Remember that the deontological ethics decision process is one of the

approaches in step 5 of the generic ethical decision-making framework.

55CHAPTER 4 Ethics in Public and Community Health Nursing Practice

Distributive Justice Theory Principles

Egalitarian This view advocates that everyone is entitled to equal rights and equal treatment in society. Ideally, each person has an

equal share of the goods of society, and it is the role of government to ensure that this happens. The government has

the authority to redistribute wealth if necessary to ensure equal treatment. Thus egalitarians support welfare rights—

that is, the right to receive certain social goods necessary to satisfy basic needs. These include adequate food, housing,

education, and police and ire protection. Both practical and theoretical weaknesses are inherent in egalitarianism

(Beauchamp and Childress, 2009).

Libertarian The libertarian view of justice advocates for social and economic liberty. Whereas egalitarianism lacks incentives for

individuals, libertarianism emphasizes the contribution and merit of the individual (Beauchamp and Childress, 2009).

Government has a limited role.

Liberal Democratic This view values both liberty and equality.

It is based on Rawls’s theory of justice and the “veil of ignorance.” Behind this veil, people (or their representatives) are

unaware of social position, race, culture, doctrine, sex, endowments, or any other distinguishing circumstances (Rawls,

2001). This is known as the original position and is an exercise to address the inequalities and bargaining advantages

that result from birth, natural endowments, and historical circumstances. Without these inequalities, all people are

free and equal and can work together as citizens to decide what is fair and therefore just. Once impartiality is guaran-

teed, Rawls suggests all rational people will choose a system of justice containing the following two basic principles

(Rawls, 2001, p 42):

Each person has the same claim to a fully adequate scheme of equal basic liberties, and this scheme is compatible with

the same scheme of liberties for all.

Social and economic inequalities are to satisfy two conditions: irst, they are to be attached to ofices and positions open

to all under conditions of fair equality of opportunity; and second, they are to be to the greatest beneit to the least-

advantaged members of society (the difference principle).

BOX 4.2 Three Primary Theories of Distributive Justice

Modiied from: Fry ST, Veatch RM, Taylor C: Case studies in nursing ethics, Boston, 2011, Jones and Bartlett Learning, pp 28-29.

Jeff Williams, team leader in Home Health Care Services at the county health

department, was preparing to visit Mr. Chisholm, a 59-year-old client recently

diagnosed as having emphysema. Mr. Chisholm, who was unemployed because

of a farming accident several years earlier, was well known to the health

department. Hypertensive and overweight, he was also a heavy, long-term

cigarette smoker despite his decreased lung function. Mr. Williams visited

Mr. Chisholm to ind out why the client had missed his latest chest clinic

appointment. He also wanted to determine whether the client was continuing

his medications as ordered.

As Mr. Williams parked his car in front of his client’s house, he could

see Mr. Chisholm sitting on the front porch smoking a cigarette. A flash

of anger made him wonder why he continued trying to encourage

Mr. Chisholm to stop smoking and why he took the time from his busy

home-care schedule to follow up on Mr. Chisholm’s missed clinic appoint-

ments. This client certainly did not seem to care enough about his own

health to give up smoking.

During the home visit, Mr. Williams determined that Mr. Chisholm had

discontinued the use of his prophylactic antibiotic and was not taking his

expectorant and bronchodilator medication on a regular basis. Mr. Chisholm’s

blood pressure was 210/114 mm Hg, and he coughed almost continuously.

Although he listened politely to Mr. Williams’s concerns about his respira-

tory function and the continued use of his medications, Mr. Chisholm simply

made no effort to take responsibility for his health care. Even so, another

clinic appointment was made, and Mr. Williams encouraged the client to

attend.

CASE STUDY 1

Applying the Principlism Ethics Decision Process

As he drove to his next home visit, Mr. Williams wondered to what extent he was

obligated as a nurse to spend time on clients who took no personal responsibility for

their health. He also wondered if there was a limit to the amount of nursing care a

noncooperative client could expect from a service provided in the community.

Consider this case using the principlism ethics decision process:

1. If the nurse wants to respect Mr. Chisholm’s right to autonomy, should he try

to explain the need for compliance with the treatment plan and urge the client

to comply? Or should the nurse tell Mr. Chisholm that he will be given a clinic

appointment when he begins to follow the treatment plan? Or should the

nurse schedule the next appointment and hope Mr. Chisholm will soon under-

stand why he should follow the care plan? Or is there an action you would

choose that is not listed here?

2. What are Mr. Williams’s professional responsibilities for Mr. Chisholm’s rights

to health care?

3. Is there a limit to the amount of care nurses should be expected to give to

clients?

4. What authority deines the moral requirements and moral limits of nursing

care to clients?

5. Using content in at least one of the How To boxes, apply one of the ethical

processes to this case. For example, debate with a classmate whether the

deontological ethics decision process is useful in determining the nursing

action with Mr. Chisholm. Speciically, examine your motives for being reluc-

tant to continue providing care to this client who seemingly has no desire to

promote his own health.

6. What ethical principles are causing distress for the nurse?

56 PART 2 Inluences on Health Care Delivery and Nursing

Virtue, Feminist, and Care Ethic Theories Several other ethical theories are important to consider in rela-

tionship to public health. For example, virtue ethics, one of the

oldest ethical theories, dates back to the ancient Greek philoso-

phers Plato and Aristotle. Rather than being concerned with

actions as seen in utilitarianism and deontology, virtue ethics

asks: What kind of person should I be? Virtue ethics seeks to

enable persons to lourish as human beings. Not to be confused

with principles, Aristotle deines virtues as acquired, excellent

traits of character that dispose humans to act in accord with

their natural good. Examples of virtues include benevolence,

compassion, discernment, trustworthiness, integrity, and con-

scientiousness (Beauchamp and Childress, 2009). Virtue ethics

emphasizes practical reasoning applied to character develop-

ment rather than focusing on moral justiication by relying on

theories and principles. In practice, virtues in nursing shape job

responsibilities and patient care. For example, the virtues listed

previously contribute to a nurse’s role as one of the most

trusted health professions.

Care Ethics

Caring in nursing, the ethic of care, and feminist ethics are in-

terrelated and converged between the mid-1980s and early

1990s. Nurses have written about caring as the essence of, or the

moral ideal, of nursing for many years (Leininger, 1984;

Watson, 2007). Caring and the ethic of care are core values of

public health nursing and address the importance of the idu-

ciary relationship between the patient and the care provider.

Carol Gilligan (1982) and Nel Noddings (1984) are often

associated with the ethic of care. Gilligan’s study of the psycho-

logical and moral development of women was novel. Her work

emerged at a time when abilities associated with autonomous

and effective decision making were considered masculine. This

perpetuated a devaluing of the stereotypical feminine charac-

teristics. Through her work, Gilligan was able to accentuate the

feminine experience as distinctive rather than less valuable. She

formulated basic premises of responsibility, care, and relation-

ships. In doing so, the link between caring and relationships

continued to grow more explicit. From this, it was posited that

women not only judge themselves within the context of their

relationships, but they also accept and are deined by the re-

sponsibility to care for others. Noddings echoed this sentiment

and stated an obligation to enhance caring. The commitment

that is inherent with caring facilitates ethical ideals. Gilligan

and Noddings have in common a feminine ethic because they

believe in the morality of responsibility in relationships that

emphasize connection and caring. To them, caring is a moral

imperative.

Feminist Ethics

Like virtue ethics and other communitarian views (i.e., the

relationship and responsibility between the individual and the

community), feminist ethics rejects abstract rules and princi-

ples. According to Rogers (2006), feminist ethics is pertinent to

public health because it recognizes the role of political and

social structures in health. Issues of equity present major chal-

lenges in public health. Inequalities in gender, historically af-

fecting females, gave rise to the feminist stance that devaluing

and systematic oppression of women are morally wrong. To-

day, feminism encompasses more than just issues unique to

women. Rogers says that the feminist perspective leads people

HOW TO Apply the Virtue Ethics Decision Process

1. Identify communities that are relevant to the ethical dilemmas or issues.

2. Identify moral considerations that arise from a communal perspective, and

apply the consideration to speciic communities.

3. Identify and apply virtues that facilitate a communal perspective.

4. Modify moral considerations as needed to apply to the speciic ethical

dilemmas or issues.

5. Seek ethical community support to enhance character development.

6. Evaluate and modify the individuals or community character traits that

impede communal living.

NOTE: Remember that the virtue ethics decision process is one of the

approaches in step 5 of the generic ethical decision-making framework.

EVIDENCE-BASED PRACTICE

Smoking, drinking, and poor nutrition are costly habits. They are costly to the

health of the person, to the family, and to society. As nations look at ways to

contain their health care costs and pay for their many obligations, many are

looking at taxing items considered to not be essential to health and well-

being of their citizens. Sin taxes are taxes on commodities and activities that

society thinks are nonessential and potentially harmful. Ethical questions

arise in the consideration of the use of sin taxes—for example, the question

of whose good will beneit: the good of the person or the good of the com-

munity? Green (2011) uses a public health nursing model based on the Public

Health Code of Ethics, the American Nurses Association Code of Ethics, and

other relevant ethical theories to examine the arguments for and against the

use of sin taxes. She determines that a position advocating the limited use of

sin taxes can be supported as a reasonable approach for a public health

professional to take.

Nurse Use

Two of the core functions of public health are considered to be advocacy and

policy development; therefore, it is important for nurses to understand the

pros and cons of issues such as sin taxes. Understanding the issues involved

will help nurses determine their own personal stance and provide them with

information to both be an advocate for a position and take part in policy

development.

Green R: The ethics of sin taxes, Public Health Nurs 28:68-77, 2011.

Modiied from Volbrecht RM: Nursing ethics: communities in dialogue,

Upper Saddle River, NJ, 2002, Prentice Hall, p 138.

HOW TO Apply the Principlism Ethics Decision Process

1. Determine the ethical principles (i.e., respect for autonomy, nonmalei-

cence, beneicence, justice) that are relevant to an ethical issue or dilemma.

2. Analyze the relevant principles within a meaningful context of accurate

facts and other pertinent circumstances.

3. Act on the principle that provides, within the meaningful context, the stron-

gest guide to action that can be morally justiied by the tenets foundational

to the principle.

NOTE: Remember that using principlism in the ethics decision process is one

of the approaches in step 5 of the general ethical decision-making framework.

57CHAPTER 4 Ethics in Public and Community Health Nursing Practice

to think critically about the connections among gender, disad-

vantage, and health, as well as the distribution of power in

public health processes. Feminists advocate economic, social,

and political equity. They pay attention to power relations that

constitute a community, the rules that regulate it, and who

pays and who beneits from membership in the community

(Rogers, 2006).

ETHICS AND THE CORE FUNCTIONS OF PUBLIC HEALTH NURSING

In Chapter 1, the three core functions of public health nursing

(i.e., assessment, policy development, and assurance) were

discussed. The following discussion links these three core

functions to ethics.

Assessment “Assessment refers to systematically collecting data on the popu-

lation, monitoring the population’s health status, and making

information available about the health of the community”

(Williams, 2012, p 7). Two ethical tenets support these core

functions: beneicence and nonmaleicence. The irst is benei-

cence. “Doing good” or maximizing the beneits and minimiz-

ing the harms requires clinicians’ competency related to knowl-

edge development, analysis, and dissemination. Here one can

ask the following: Are the persons assigned to develop commu-

nity knowledge adequately prepared to collect data on groups

and populations? This question is important because the re-

search, measurement, and analysis techniques used to gather

information about groups and populations usually differ from

the techniques used to assess individuals. Wrong research tech-

niques can lead to wrong assessments, which in turn may hurt

rather than help the intended group or population.

Additionally, do the persons selected to develop, assess, and

disseminate community knowledge possess integrity? Beau-

champ and Childress (2009) deine integrity as the holistic in-

tegration of moral character. It requires conscientious thought

during which people relect on the rightness or wrongness of

actions. The previous discussion of virtue ethics is helpful in

exploring this tenet. The importance of integrity is clear: with-

out integrity, the core function of assessment is endangered.

Providers lacking integrity pose a risk for misconduct and are a

HOW TO Apply the Care Ethics Decision Process

1. Recognize that caring is a moral imperative.

2. Identify personally lived caring experiences as a basis for relating to self

and others.

3. Assume responsibility and obligation to promote and enhance caring in

relationships.

NOTE: Remember that the care ethics decision process is one of the approaches

in step 5 of the generic ethical decision-making framework.

HOW TO Apply the Feminist Ethics Decision Process

1. Identify the social, cultural, political, economic, environmental, and profes-

sional contexts that contribute to the identiied problem (e.g., underrepre-

sentation of women in clinical trials).

2. Evaluate how the preceding contexts contribute to the oppression of

women.

3. Consider how women’s lives are deined by their status in subordinate

social groups.

4. Analyze how social practices marginalize women.

5. Plan ways to restructure those social practices that oppress women.

6. Implement the plan.

7. Evaluate the plan, and restructure it as needed.

NOTE: Remember that the feminist ethics decision process is one of the

approaches in step 5 of the generic ethical decision-making framework.

FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES

One of the six tenets of Quality and Safety Education for Nurses (QSEN) is

client-centered intervention (Sherwood and Drenkard, 2007). This chapter

discusses many ways in which an understanding of basic principles of ethics

can guide safe and effective nursing practice. Some key aspects of client-

centered interventions in public health nursing include being certain that the

information provided to individuals, families, and communities is accurate

and reflects the most current evidence and that it is presented in a timely

fashion. Community health education should take into account the age,

gender, and cultural and religious backgrounds of those who receive the in-

formation. Giving health information that does not meet these criteria can be

unsafe and clearly does not reflect attention to quality nursing care. One of

the QSEN competencies related to client-centered care states: Recognize

the client or designee as the source of control and full partner in providing

compassionate and coordinated care (intervention) based on respect for

client preferences, values, and needs. Specific aspects of client-centered

care related to communication are as follows:

• Knowledge: Integrate understanding of multiple dimensions of client-

centered intervention: information, communication, and education.

• Skills: Communicate client values, preferences, and expressed needs to

other members of the health care team.

• Attitudes: Respect and encourage individual expression of client values,

preferences, and expressed needs.

A second set of knowledge, skills, and attitudes included in this competency

helps us understand the public health dilemma of serving the good of the popula-

tion versus the good of the individual.

Consider this:

• Knowledge: Explore ethical and legal implications of client-centered inter-

ventions.

• Skills: Recognize the boundaries of therapeutic relationships.

• Attitudes: Acknowledge the tension that may exist between client rights

and the organizational responsibility for professional, ethical interventions.

(Cronenwett et al, 2007)

Client-centered ethical activity: Public health is more concerned about the

good of the collective group than of the individual. Debate with a classmate

whether children should be required to have all of the Centers for Disease Control

and Prevention vaccines before they can enter school or remain in school. Some

parents are choosing not to give their children all the recommended immunizations

because of fear of side effects of the vaccine. To support your argument, see http://

www.cdc.gov/vaccines/schedules/index.html for what is required. See web

articles, such as those at http://www.responsibility-project.libertymutual.com.

Modiied from Volbrecht RM: Nursing ethics: communities in dialogue,

Upper Saddle River, NJ, 2002, Prentice Hall, p 219.

http://www.cdc.gov/vaccines/schedules/index.html

http://www.responsibility-project.libertymutual.com

58 PART 2 Inluences on Health Care Delivery and Nursing

threat to public health. The role of assessment is to provide in-

formation to the beneit of public health; any action that deters

from this mission is troubling. The second ethical tenet relates

to “do no harm.” In any public health situation, balancing the

beneits and risks is essential. As discussed in the Ebola case,

minimizing harm to both individuals and communities re-

quired thoughtful dialogue on personal protective equipment

as well as community surveillance and monitoring measures.

Policy Development Public health nurses are critical to the development of policies

that relect the preferences and goals of their constituents. They

are in key positions to provide leadership on the ethical issues

that might arise within their communities and can use their

unique training and skills to make policy decisions (Williams,

2012). In fact, an important goal of both policy and ethics is to

achieve the public good (Silva, 2002), which is a part of the

concept of citizenship (Denhardt and Denhardt, 2000; Rogers,

2006; Ruger, 2008). To be an effective citizen, people must be

both informed about policy and able and willing to do what is

in the best interests of the community (Denhardt and Den-

hardt, 2000). Here, the voice of the community is the founda-

tion on which policy is developed. Silva (2002) also argues that

service to others over self is a necessary condition of what is

“good” or “right” policy (Silva, 2002). Denhardt and Denhardt

(2000) provide three perspectives on this belief:

1. Serve rather than steer. An increasingly important role

of the public servant (e.g., nurses and administrators) is to

help citizens articulate and meet their shared interests rather

than to attempt to control or steer society in new directions

(p 553).

2. Serve citizens, not customers. The public interest results

from a dialogue about shared values rather than the aggrega-

tion of individual self-interests. Therefore public servants do

not merely respond to the demands of “customers” but focus

on building relationships of trust and collaboration with

and among citizens (p 555).

3. Value citizenship and public service above entrepreneur-

ship. The public interest is better advanced by public ser-

vants and citizens committed to making meaningful contri-

butions to society rather than by entrepreneurial managers

acting as if public money were their own (p 556).

Service, an enduring nursing value, is at the core of these

three perspectives. Service requires ethical action and what is

ethical is also good policy (Silva, 2002). Therefore moral leader-

ship from nurses is critical to the development of ethical health

care policies.

Assurance “Assurance refers to the role of public health in making sure that

essential community health services are available including es-

sential personal health services for those who would otherwise

not receive them, and that there is a competent public health

and personal health care workforce.” (Williams, 2012, p 7). The

ethical principle of justice can apply to this core function as

follows:

1. All persons should receive essential personal health services.

Put in terms of justice, “to each person a fair share” or, “to all

groups or populations a fair share.” This does not necessarily

mean that all persons in a society should share all of society’s

beneits equally but that they should share at least essential

beneits. Many people think that basic health care for all is

essential for social justice.

2. Providers of public health services should be competent

and available. Although the Code of Ethics for Public

Health does not speak directly to workforce availability, it

does speak directly to ensuring professional competency of

public health employees. Healthy People 2020 discusses both

competencies and workforce, as seen in the Healthy People

2020 box.

Amelia Lewis, a 31-year-old African American woman with multiple diagnoses,

has been followed by the local mental health system for over 10 years. Four

years ago, while a client at the local day hospital, she met and married another

client, James Wood. She became pregnant and now has Tyesha, who is 3 years

old. Multiple agencies have followed Ms. Lewis and her little girl, who live in a

sparsely furnished apartment in subsidized housing. Mr. Wood lives separately,

and he and his family welcome contact with Tyesha, but the relationship

between Ms. Lewis and Mr. Wood has deteriorated. A guardian handles all of

Ms. Lewis’s inancial affairs.

Ms. Lewis has issues of trust, and she is often suspicious of the care providers

who come to her home. She does rely on some of the professionals with whom

she interacts on a weekly or biweekly basis. Her developmental level places her

at a stage at which her own needs are her primary focus, and this is not expected

to change; her interaction with Tyesha is perfunctory, involving little outward

affection. She is unable to understand that Tyesha is not capable of self-care and

that her 3-year-old child will not always obey when Ms. Lewis instructs her to

do something. Tyesha’s needs, level of functioning, and cognitive development

are quickly surpassing her mother’s ability to cope. Frustration and misunder-

standing ensue when Ms. Lewis thinks that Tyesha does not listen to her, and

CASE STUDY 2

Autonomy and Distributive Justice

encouragement and parent education have done little to improve the situation as

Tyesha gets older and more assertive. This has made toilet training, provision of

an appropriate diet, and other aspects of normal child care problematic.

Many services besides those for mental health are involved to help this family

of two cope. There is concern about abuse or neglect because of Ms. Lewis’s

lack of understanding of how to be a parent. Supplemental Security Income

provides monetary support because of her mental disability, and they have Med-

icaid coverage for their health care needs, as well as food stamps and modest

inancial assistance through Temporary Assistance for Needy Families (TANF).

Ms. Lewis cannot currently work and take care of her child because of her men-

tal disability. Before Tyesha’s birth, Ms. Lewis held a job and maintained self-

care, but the care of Tyesha has precluded her managing employment at this

time. Child Protective Services are also monitoring Ms. Lewis’s situation.

Ms. Lewis attends a local program to complete her General Education Develop-

ment (GED), which provides child care during the day. Although Ms. Lewis is not

expected to complete her GED, this program provides structured time for Tyesha

three times per week. The child is considered developmentally normal at this

time. Tyesha is being followed by an infant development program that monitors

her progress on developmental issues. The Child Health Partnership, an agency

59CHAPTER 4 Ethics in Public and Community Health Nursing Practice

NURSING CODE OF ETHICS

As noted in the discussion of history earlier in this chapter,

the Code of Ethics for Nurses with Interpretive Statements was

adopted by the ANA House of Delegates in 2001 and most

recently revised in 2015. This code serves three broad purposes,

as follows (ANA, 2015):

1. “It is a succinct statement of the ethical values, obligations,

duties, and professional ideals of nurses individually and

collectively” (p viii).

2. “It is the profession’s nonnegotiable ethical standard” (p viii).

3. “It is an expression of nursing’s own understanding of its

commitment to society” (p viii).

These purposes are relected in nine provisional statements of

the code. The Code of Ethics for Nurses and its interpretive

statements apply to nurses in community health, although the

emphasis for each type of nursing sometimes varies. For ex-

ample, provision 1 and its interpretive statement primarily

address the individual when discussing how the nurse prac-

tices with compassion and respect for the person being cared

for regardless of the person’s status, the person’s attributes, or

the nature of the health problem. However, it is also recog-

nized under provision 1 that there are times when individual

rights may be limited because of public health concerns (p 3).

The interpretive statements of provisions 2 and 8 are perti-

nent to public health nurses, including those who identify as

community health nurses. Provision 2 states “the nurse’s pri-

mary commitment is to the patient whether an individual,

family, group, community, or population” (p 5). Provision

8 highlights the need for collaborative practice with other

disciplines as well as the public to mitigate health disparities

and promote human rights. All nurses have a responsibility

to meet the obligations highlighting professional standards,

active involvement in nursing, and the integrity of the profes-

sion as outlined in the Code (see the Code of Ethics for Nurses

with Interpretative Statements for all provisions at http://www.

nursingworld.org).

that addresses the needs of challenged families, provides regular visits, family

support, and parenting education, and the GED teachers make regular home

visits to check on Ms. Lewis and Tyesha. Ms. Lewis thinks things are going just

ine.

The Child Health Partnership nurse is concerned about this family and thinks

that some permanent resolution of the situation is inevitable. There is minimal

coordination of services and no “lead agency” in the family’s care. Choose one

of the ethical decision processes or one set of code of ethics discussed in the

chapter and discuss and debate these questions:

1. Should the nurse involved in the Child Health Partnership program initiate any

action to try to coordinate the work of the many agencies involved with this

family?

2. Who has a professional responsibility to determine when the mother can no

longer cope with the developing child?

CASE STUDY 2—cont’d

Autonomy and Distributive Justice

3. Whose needs, Ms. Lewis’s or Tyesha’s, should take precedence?

4. Using one of the ethics decision processes, analyze the role of the nurse in

this situation. For example, considering the utilitarian ethics decision process,

decide if it is morally right for you to take the child away from the mother. If

you do this, what are the implications for the mother, the child, and the com-

munity? What would be the possible consequences of removing the child? Of

not removing the child? What principles can best guide your decision making?

What possible moral dilemmas will you experience?

5. Safety is a core concept of public health nursing. Using two of the six quality

and safety competencies (client-centered care and safety) for nurses identi-

ied in the Quality and Safety Education for Nurses (QSEN) work, develop a

plan of action for the nurse who is caring for this family (Sherwood and

Drenkard, 2007).

Created by Mary E. Gibson, PhD, RN Assistant Professor, School of Nursing, University of Virginia.

• AHS-2: Increase the proportion of insured persons with coverage for clinical

preventive services.

• AHS-4: Increase the proportion of practicing primary care providers.

Both of these areas that relate to access to care relect important ethical

considerations for nurses.

From U.S. Department of Health and Human Services: Healthy People

2020, 2010. Retrieved October 15, 2016. http://www.healthypeople.gov

Because inding affordable housing was dificult, 26-year-old Terry White lived

with her 6-month-old son, Tommy, and his father, Billy Smith, in one room of the

landlord’s own house. Ms. White was morbidly obese and was diagnosed with

bipolar disease. Mr. Smith had served time for drug dealing and was out on pa-

role and staying straight. Neither had inished high school. Mr. Smith’s past drug

use had rendered him unable to do much manual labor because of heart damage,

but on occasion, he would work in construction to support the family.

Public health nurse Jim Lewis had received a referral on Tommy when he was

diagnosed with failure to thrive (FTT) 2 months earlier. Ms. White (who had had

two children removed from her custody by Child Protective Services [CPS] in the

past) and Mr. Smith seemed to adore their baby, so much so that Ms. White

CASE STUDY 3

Using the Deontological Decision-Making Process

would hold the baby all day long. In the past 2 months, the nurse had taught

Ms. White about infant nutrition and gotten her enrolled in the Women, Infants,

and Children (WIC) nutrition program; as a result, Tommy had increased his rate

of physical growth and was above the 5% level of his growth percentile. Yet he

was not meeting his gross motor milestones per Denver Developmental Screen-

ing Test II (DDST II) testing. Mr. Lewis thought that Tommy was not allowed to

play on the loor enough to progress in sitting, pushing his shoulders up, or

crawling. Most of their small room was taken up with the bed and the boxes that

stored their belongings. There wasn’t really space for “tummy time” or play.

When not in the room, the family would take the bus to a discount store and

spend the day walking around to get a change of scene.

HEALTHY PEOPLE 2020

Objectives Related to Access to Health Services

Continued

60 PART 2 Inluences on Health Care Delivery and Nursing

absence of disease” (WHO, 2006). Similar to other Codes of

Ethics, the 12 value statements incorporate the ethical tenets

of preventing harm; doing no harm; promoting good; respect-

ing both individual and community rights; respecting auton-

omy, diversity, and conidentiality when possible; ensuring

professional competency; trustworthiness; and promoting ad-

vocacy for disenfranchised persons within a community. The

Code also lists values and beliefs regarding community and

public health. These include the belief that collaboration is a

key element of public health, that each person should have

opportunities to contribute to public discourse, and that iden-

tifying and promoting requirements for health is a primary

public health concern.

PUBLIC HEALTH CODE OF ETHICS

The Code of Ethics for Public Health (Public Health Leader-

ship Society, 2002) was noted in the discussion of history

earlier in this chapter. Created with the assumption that all

humans have the right to adequate health resources, this code

consists of 12 principles related to the ethical practice of pub-

lic health (Box 4.3); this includes those values and beliefs that

focus on health, community, and action and a commentary on

each of the 12 principles. The preamble describes the collec-

tive and societal nature of public health to keep people

healthy. In doing so, it reafirms the World Health Organiza-

tion’s (WHO) deinition of health as “a state of complete

physical, mental, and social well-being, and not merely the

One week Ms. White told the nurse she was not taking her medications for

bipolar disease anymore because they caused her to gain weight. The next week

she conided that Mr. Smith had had a “dirty” urine specimen check and would

have to return to prison in the near future. The following week Mr. Lewis found

the family living in a run-down motel because they were evicted after a disagree-

ment with the landlord. Ms. White was agitated, and she told the nurse that they

had only $100, Mr. Smith was going to have to return to prison that week, and

the motel bill was already $240. Ms. White knew she would be homeless soon

without Mr. Smith’s support but refused to talk with her social worker about her

needs. She asked the nurse not to tell anyone about her situation because she

was afraid CPS would take Tommy from her. It was clear to Mr. Lewis that he

might not know where Tommy was after they left this motel.

1. Considering the principle of telling the truth, what are Mr. Lewis’s profes-

sional responsibilities to Ms. White, to Tommy, and to the social worker

assigned to this family?

CASE STUDY 3—cont’d

Using the Deontological Decision-Making Process

2. Using the generic ethical decision-making framework discussed earlier in the

chapter and considering the deontological ethical decision-making process,

how should Mr. Lewis respond to Ms. White’s request to not tell anyone

about their situation? What communication, if any, should the nurse initiate

with the social worker? With others?

3. Using virtue ethics, what actions would you take to resolve any moral dilem-

mas you have about the safety of Tommy in this family situation? If you do

not tell anyone about the possible dangers to the child, what moral princi-

ples come into play? If you do tell the social worker about the situation and

the child is removed from the mother, what moral principles come into play

for you?

4. What ethical dilemmas may you experience if you are the nurse in this case?

How can you deal effectively with these potential dilemmas?

From the Public Health Leadership Society (PHLS): Code of ethics for public health,* New Orleans, La, 2002, Louisiana Public Health Institute. The

ethics project was funded in part by the Centers for Disease Control and Prevention.

*Oficially titled Principles of the Ethical Practice of Public Health, as noted by Thomas (2002).

BOX 4.3 Principles of the Ethical Practice of Public Health

1. Public health should principally address the fundamental causes of

disease and requirements for health, aiming to prevent adverse health

outcomes.

2. Public health should achieve community health in a way that respects the

rights of individuals in the community.

3. Public health policies, programs, and priorities should be developed and

evaluated through processes that ensure an opportunity for input from com-

munity members.

4. Public health should advocate and work for the empowerment of disenfran-

chised community members, aiming to ensure that the basic resources and

conditions necessary for health are accessible to all.

5. Public health should seek the information needed to implement effective

policies and programs that protect and promote health.

6. Public health institutions should provide communities with the information

they have that is needed for decisions on policies or programs and should

obtain the community’s consent for their implementation.

7. Public health institutions should act in a timely manner on the information

they have within the resources and the mandate given to them by the public.

8. Public health programs and policies should incorporate a variety of

approaches that anticipate and respect diverse values, beliefs, and cultures

in the community.

9. Public health programs and policies should be implemented in a manner

that most enhances the physical and social environment.

10. Public health institutions should protect the conidentiality of information

that can bring harm to an individual or community if made public. Excep-

tions must be justiied on the basis of the high likelihood of signiicant harm

to the individual or others.

11. Public health institutions should ensure the professional competencies of

their employees.

12. Public health institutions and their employees should engage in collabora-

tions and afiliations in ways that build the public’s trust and the institution’s

effectiveness.

Created by Deborah C. Conway, Assistant Professor of Nursing, School of Nursing, University of Virginia.

61CHAPTER 4 Ethics in Public and Community Health Nursing Practice

Commonalities exist between the Code of Ethics for Nurses

with Interpretative Statements and the Code of Ethics for

Public Health. Both Codes provide general ethical principles

and approaches that are enduring and dynamic. They require

nurses to think and act in accordance with the underlying

ethics of their profession. Of note, they each encourage

evidence-based and collaborative approaches for the better-

ment of health. Although the two codes do not specify (nor

should they specify) details for every ethical issue, other

mechanisms such as standards of practice, ethical decision-

making frameworks, and ethics committees provide further

guidance. Nevertheless, these two codes address most ap-

proaches to ethical justiication, including traditional and

emerging ethical theories and principles, humanist and femi-

nist ethics, virtue ethics, professional–individual or commu-

nity relationships, and advocacy.

ADVOCACY AND ETHICS

DEFINITIONS, CODES, STANDARDS

Advocacy is a powerful ethical concept in nursing. But what

does advocacy mean? “Advocacy is the application of informa-

tion and resources (including inances, effort, and votes) to

effect systemic changes that shape the way people in a com-

munity live” (Christoffel, 2000, p 722). Bateman (2000) sug-

gests that advocacy includes acting in the client’s best interest,

maintaining conidentiality, addressing informational needs,

acting impartially, and carrying out the preferences and goals

of the patient with diligence and competence. Public health

advocacy is intended “to reduce death or disability in groups

of people and that is not conined to clinical settings” (p 722).

As mentioned, public health includes aggregates or popula-

tions. It also encompasses both preventative and reactionary

measures. Thus the problems addressed with public health

advocacy affect, or have the potential to affect, a sizeable por-

tion of a community. Several codes and standards of practice

address advocacy and the various roles of nursing. Three are

noted here. Advocacy is addressed in the ANA and the Public

Health Leadership Society’s codes of ethics, as well as the

ANA’s Public Health Nursing: Scope and Standards of Practice

(ANA, 2013).

According to the ANA’s Code of Ethics for Nurses with Inter-

pretive Statements, “The nurse promotes, advocates for, and

protects the rights, health, and safety of the patient” (ANA,

2015, p 9). The focus of the interpretive statements regarding

advocacy is the nurse’s responsibility to take action when the

client’s best interests are jeopardized by questionable practice

on the part of any member of the health team, the health care

system, or others. However, Shannon argues that nursing does

not bear the “advocacy” label alone. Working with communities

as a public health nurse requires collaborative leadership and a

team-based approach to address the needs of vulnerable pa-

tients (Shannon, 2016).

According to the Public Health Leadership Society’s Code of

Ethics for Public Health, “Public health should advocate and

work for the empowerment of disenfranchised community

members, aiming to ensure that the basic resources and condi-

tions necessary for health are accessible to all” (Public Health

Leadership Society, 2002, p. 1). The Public Health Leadership

Society’s code elaborates on the preceding principle by address-

ing the following two issues: that the voice of the community

should be heard and that the marginalized or underserved in a

community should receive “a decent minimum” (p 4) of health

resources.

According to the ANA’s Public Health Nursing: Scope and

Standards of Practice (ANA, 2013), public health nurses have a

moral mandate to establish ethical standards when advocating

for health care policy. The preceding standards extend the

prior two concepts of advocacy by moving advocacy into the

policy arena, particularly health and social policy as applied to

populations.

ADVOCACY AND HEALTH CARE REFORM

The signing of the 2010 Affordable Care Act by President

Obama, after many years of controversial attempts at health

care reform, provides an excellent opportunity for nurses to

advocate for tying health care for all to ethics and social jus-

tice. Dr. Mary Wakeield, at that time acting deputy secretary

of the Department of Health and Human Services (HHS),

noted that not only should nurses participate in implement-

ing new directions for health care, but that it is important

that they help to envision these new directions (Wakeield,

2008). Nurses can advocate for access to consistent, effective,

eficient health care for all people. Wakeield notes that edu-

cating the public can be a unique challenge because clever

sound bites and attack ads in the media can lure consumers

into thinking the status quo is the best option. Nurses are an

important part of the health care industry and are respected

by the public; they can make meaningful contributions to-

ward health care reform through advocating for clients and

families.

LEVELS OF PREVENTION

Related to Ethics

Primary Prevention

Use the Code of Ethics for Nurses to guide your nursing practice.

Secondary Prevention

If you are unable to behave in accordance with the Code of Ethics for Nurses

(e.g., you speak in a way that does not communicate respect for a client), take

steps to correct your behavior. You could explain to the client your error and

apologize.

Tertiary Prevention

If you have treated a client or staff member in a way that is inconsistent with

ethics practices, seek guidance on other choices you could have made.

62 PART 2 Inluences on Health Care Delivery and Nursing

APPLYING CONTENT TO PRACTICE

Throughout this chapter, there has been application of the content related to

ethics in public health nursing and the many documents that inluence the role

of public health nurses. These include the ANA’s Scope and Standards of Public

Health Nursing, the ANA’s Code of Ethics, the core functions of public health as

outlined by the Institute of Medicine, and the Healthy People 2020 objectives.

Ethics is also an integral part of the Core Competencies for Public Health

Professionals. Skill 8 in the section on analytic and assessment skills states that

a public health professional uses “ethical principles in the collection, mainte-

nance, use, and dissemination of data and information,” and skill 2 under leader-

ship and systems thinking says a professional “incorporates ethical standards

of practice as the basis of all interactions with organization, communities, and

individuals.”

Council on Linkages Between Academia and Public Health Practice: Core competencies for public health professionals, Washington, DC, 2010, Public Health

Foundation, Health Resources and Services Administration.

P R A C T I C E A P P L I C A T I O N

R E M E M B E R T H I S !

The retiring director of the division of primary care in a state

health department had recently hired Ann Jones, a 34-year-old

nurse with a master’s degree in public health, to be director of

the division. Ms. Jones was responsible for monitoring of mil-

lions of dollars of state and federal money and supervising the

funded programs within her division.

She received many requests for funding from a particular

state agency that served a large, poor district. The poor people

of the district consisted primarily of young families with chil-

dren and homebound older adults with chronic illnesses. Over

the past 3 years, the federal government had allocated consider-

able money to the state agency to subsidize pediatric primary-

care programs, but no formal evaluation of these programs had

occurred.

The director of the state agency was a physician who had

been in this position for more than 20 years. He was good at

obtaining funding for primary-care needs in his district, but

the statistics related to the pediatric primary-care program

• Nursing has a rich heritage of ethics and morality.

• The ield of bioethics began to emerge and inluence nursing

in the late 1960s.

• Ethical decision making is the component of ethics that

focuses on the process of how ethical decisions are made.

• Many different ethical decision-making frameworks exist;

however, the problem-solving process underlies each of

them.

• Ethical decision making applies to all approaches to ethics—

utilitarianism, deontology, principlism, virtue ethics, the

ethic of care, and feminist ethics.

• Cultural diversity and moral distress make ethical decision

making more challenging.

• Classic ethical theories are utilitarianism and deontology.

• Principlism consists of respect for autonomy, nonmalei-

cence, beneicence, and justice.

• The core functions of nursing in public health (i.e., assess-

ment, policy development, assurance) are all grounded in

ethics.

seemed implausible—that is, few physical examinations

were performed on the children, which had resulted in extra

money in the budget. This unspent federal money was

being used to supplement home health care services for the

indigent homebound older adults in his district. The think-

ing of the physician was that he was doing good by providing

some needed services to both indigent groups in his district.

Ms. Jones experienced moral discomfort because she did

not have either the money or the personnel to provide both

services.

What should she do?

A. What facts are the most relevant in this scenario?

B. What are the ethical issues?

C. How can Ms. Jones resolve the issues?

NOTE: The preceding case and answers are adapted and

paraphrased from a real practice application shared by J. L.

Chapin (Chapin, 1990).

Answers can be found on the Evolve website.

• Healthy People 2020 discusses access to care.

• The 2015 Code of Ethics for Nurses contains nine statements

that address the moral standards that delineate nursing’s

values, goals, and obligations.

• The 2002 Code of Ethics for Public Health contains 12 state-

ments that address the moral standards that delineate public

health’s values, goals, and obligations.

• Advocacy is the act of pleading for or supporting a course of

action on behalf of a person, group, or community.

• The Code of Ethics for Nurses with Interpretive Statements, the

Principles of the Ethical Practice of Public Health, and Public

Health Nursing: Scope and Standards of Practice all address

advocacy.

• The processes of public health advocacy include, but are not

limited to, identifying problems, collecting data, developing

and endorsing regulations and legislation, enforcing policies,

and assessing the policy process.

63CHAPTER 4 Ethics in Public and Community Health Nursing Practice

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Cultural Inluences in Nursing in Community Health

Cynthia E. Degazon and Bobbie J. Perdue

5C H A P T E R

After reading this chapter, the student should be able to:

1. Discuss ways in which culture can affect nursing practice.

2. Describe methods for developing cultural competence to

meet the health needs of culturally diverse individuals,

communities, and organizations.

3. Evaluate the effects of cultural organizational factors on

health and illness.

O B J E C T I V E S

4. Conduct a cultural assessment of a person from a cultural

group other than yours.

5. Develop culturally competent nursing interventions to pro-

mote positive health outcomes for clients.

biological variations, 72

cultural accommodation, 77

cultural awareness, 75

cultural blindness, 79

cultural brokering, 78

cultural competence, 74

cultural conlict, 79

cultural desire, 77

cultural diversity, 70

cultural encounter, 76

cultural imposition, 79

cultural knowledge, 75

cultural nursing assessment, 80

cultural preservation, 77

cultural relativism, 79

cultural repatterning, 78

cultural shock, 80

cultural skill, 76

cultural variations, 70

culture, 68

environmental control, 72

ethnicity, 70

ethnocentrism, 79

immigrants, 66

nonverbal communication, 71

prejudice, 79

race, 69

racism, 79

social organization, 71

space, 71

stereotyping, 78

time, 71

verbal communication, 70

K E Y T E R M S

Immigrant Health Issues

Culture, Race, and Ethnicity

Culture

Race

Ethnicity

Cultural Diversity

Communication

Space

Social Organization

Time Perception

Environmental Control

Biological Variations

Nutrition

C H A P T E R O U T L I N E

Culture, Diversity, and Social Determinants of Health

Cultural Competence

Culturally Competent Nursing Interventions

Cultural Preservation

Cultural Accommodation

Cultural Repatterning

Cultural Brokering

Inhibitors to Developing Cultural Competence

Cultural Nursing Assessment

Building Culturally Competent Organizations

Nurses have cared for culturally diverse groups since the be-

ginning of the discipline. As early as 1893, nurses in New York

City started public health nursing under the leadership

of Lillian Wald and provided home care to people who lived

in the inner city, particularly immigrants who were recent

arrivals (Anderson and McFarlane, 2011). When nurses were

not from the same cultural background as the immigrants,

they had to deal with the cultural differences between them-

selves and the persons in their care. Often the same situation

still exists; that is, the nurse and client come from different

66 PART 2 Inluences on Health Care Delivery and Nursing

cultural groups and may not recognize or understand their

differences.

These irst migrants were largely English-speaking white

Protestants who thought of themselves as founders and set-

tlers in a new country rather than as immigrants. The irst

blacks to arrive in America were free men who brought their

own slaves with them. Another early group of people who

came to America were Africans brought on slave ships. These

Africans were instrumental in developing much of early

America with their skills, including farming. They also

brought their unique culture with them, and much of that

culture has lasted over time.

The next wave was from the 1820s to the 1920s and was

made up of immigrants who were different in color, lan-

guage, place of origin, and religion. This group brought their

own foreign cultures. At present, another increase in immi-

gration is occurring. There were an estimated 13.1 million

lawful permanent residents, often called “green card” holders,

living in the United States in 2013, and 8.8 million were

thought to be eligible to become naturalized citizens (Baker

and Rytina, 2014). Data from the US Census Bureau (2010,

2011) showed that (72.4%) of the US population deined

themselves as a member of a non-Hispanic white ethnic

group followed by African Americans (12.6%), Asian Ameri-

cans (4.8%), American Indians/Alaskan Natives (0.9%), Native

Hawaiian and other Paciic Islanders (0.2%), some other race

(6.2%), and two or more races (2.9%). Hispanic origin was

considered to be a separate concept from race but accounted

for 16.4% of the population with those predominantly identi-

ied as white or as some other race. These changes relect a

society that is becoming more diverse with regard to racial

and ethnic groups. As a result, signiicant differences in be-

liefs about health and illness are becoming apparent among

the various groups. Nurses who provide care to clients of

diverse cultures face many challenges, and this is especially true

when the nurse comes from a different cultural group than the

clients.

This chapter discusses strategies to assist nurses in provid-

ing culturally competent care. The special concerns of immi-

grants are discussed, and the following four groups are

emphasized: African Americans, Asian Americans, Latinos

and Hispanics, and Native Americans. There is also discussion

of selected religious beliefs of people who practice Islam and

how these beliefs need to be taken into account in providing

nursing care.

IMMIGRANT HEALTH ISSUES

Immigration has a large effect on many aspects of life in the

United States from the workplace to the classroom and

throughout communities. Immigration and the laws that

pertain to it have become increasingly controversial in recent

years. Ambivalence among people in the United States about

immigrants and the policies pertaining to them has grown

due to the turmoil in the world with the relocation of people

from any different countries. Some misunderstanding also

exists about what distinguishes an immigrant. Some states

are passing laws to reduce the number of illegal immigrants

who work in their state. The Refugee Act of 1980 provided a

uniform procedure for refugees (based on the United Nations

deinition) to be admitted to the United States (US Census

Bureau, 2001). People come to the United States for religious

and political freedom and for economic opportunities.

The 1986 Immigration Reform and Control Act permitted

illegal aliens already living in the United States to apply for

legal status if they met certain requirements. In 2014, about

41.2 million people in the United States were immigrants,

making this an all-time high for the country (Artiga et al,

2016). Foreign-born residents are those who are not US

citizens at birth, regardless of their current legal or citizen

status. About one-half of the noncitizens were people

without authorization to live or work in the United States

(Congress of the United States, 2012). Immigrants in the

United States and their US-born children represent one-quarter

of the population or approximately 80 million people. In

2013 Mexican-born immigrants made up nearly 28% of the

41.3 million foreign-born persons. India accounted for the

second largest with 5%, closely trailed by China (including

Hong Kong but not Taiwan) (Zong and Batalova, 2015). Ap-

proximately 51% of the immigrant population was female,

and the immigrant population had a median age of 43.1

compared with 35.9 for native-born citizens. In 2013 the fol-

lowing ive states had the largest number of immigrants:

California (10.3 million), New York and Texas (4.3 million

each), Florida (3.8 million), and New Jersey (1.9 million). An

especially dificult problem in public health nursing is that

in 2013 there were 25.1 million individuals ages 5 and older

who were limited English proicient (LEP), accounting for

more than 8% of the population. The complex issues involved

with immigrants and their health are beyond the scope of this

discussion, but several are discussed, and suggestions are made

for nursing actions.

There are four categories of foreign-born persons. First are

the legal immigrants, who are also known as lawful permanent

residents or green-card holders. These people are not citizens,

but they are by law allowed to both live and work in the

United States, often because they have useful job skills or fam-

ily ties. Nonelderly noncitizens are as likely as citizens to have

a full-time worker in the family; however, they are more likely

to be a low-income worker who works in low-wage, blue-

collar jobs and industries (Artiga et al, 2016). In regard to

health care, noncitizens are signiicantly more likely than citi-

zens to be uninsured. Noncitizens can obtain private coverage

as an individual, through an employer, or as a dependent.

Noncitizens are lawfully in the United States can enroll in

Medicaid and the Children’s Health Insurance Program

(CHIP), but they are subject to eligibility restrictions. Since

1966, most lawfully present immigrants must wait 5 years

after being considered “qualiied” before they can enroll in

Medicaid and CHIP. The Children’s Health Program Reautho-

rization Act of 2009 gave states the option of eliminating

the 5-year waiting period for “lawfully residing children and

67CHAPTER 5 Cultural Inluences in Nursing in Community Health

pregnant women who are otherwise eligible for Medicaid or

CHIP” (Artiga et al, 2016, p. 5).

The second category of foreign-born immigrants consists

of refugees and people seeking asylum. Refugees are admitted

outside the usual quota restrictions based on fear of persecu-

tion in their homeland. The grounds for seeking asylum or

refugee status must be at least one of ive that include the per-

son’s race, religion, nationality, social group, political opinion,

or national origin (National Immigration Forum, 2010). These

are people seeking protection because they fear harm if they

return to their home country. A person who receives refugee

status is considered to be in the country lawfully and can receive

the beneits described for lawful immigrants. The Centers for

Disease Control and Prevention (CDC) provides “Refugee

Health Guidelines” designed to promote and improve the

health of the refugee, prevent disease, and familiarize refuges

with the US health care system (CDC, 2012). The third category

of foreign-born people, nonimmigrants, includes those who are

admitted to the United States for a limited time and for a spe-

ciic purpose. Examples include students, tourists, temporary

workers, business executives, diplomats, artists, entertainers,

and reporters. The fourth category consists of unauthorized

immigrants, or undocumented or illegal aliens. They may have

crossed a border into the United States illegally, or their legal

permission to stay may have expired. They are eligible only for

emergency medical services, immunizations, treatment for the

symptoms of communicable diseases, and access to school

lunches. Undocumented immigrants are ineligible for coverage

under the Affordable Care Act (ACA), and they may not pur-

chase coverage through the marketplace or receive tax credits

(Artiga et al, 2016). Some states have state-funded health pro-

grams to provide coverage to some groups of immigrants

regardless of their immigration status.

Although these numbers may change as changes occur in

health care coverage, approximately one-third of immigrants

are uninsured. Noncitizens are more likely to be uninsured

than citizens because of lower rates of both public and

private coverage. Similarly, noncitizen children and citizen

children in families with mixed citizenship status are more

likely to be uninsured than are children of citizens (Artiga

et al, 2016).

Several misperceptions exist about the economic value of

allowing immigrants to enter or to stay in the United States.

In 2013 immigrants made up nearly 17% (26.2 million) of the

158.6 million workers in the civilian workforce. The 24.2 mil-

lion employed foreign-born workers were engaged in the fol-

lowing types of work: management, professional, and related

(29.8); service (25.1); sales and ofice (17.1); production,

transportation, and material moving (15.2); and natural re-

sources, construction, and maintenance (12.9) (the numbers

may not total to 100% due to rounding) (Zong and Batalova,

2015). Even though noncitizens are as likely as citizens to

work, they may be in jobs that do not provide health coverage

to employees.

The opinions about immigrants and the national debate

about them have changed since the events of September 11,

2001, and subsequent acts of terrorism around the world. Since

these attacks began, various immigration laws have been en-

acted that relect more dificulty for people seeking visas, and

there is more scrutiny of both visa and entry documents

(Changes in Immigration Law, 2008).

Carlock (2007) has compiled useful material on how to ind

and access information that is culturally suited to the nation’s

increasingly diverse population, including culturally and lin-

guistically appropriate client education. In addition to inancial

constraints on providing health care for immigrants, the fol-

lowing factors need to be considered:

• Language barriers

• Differences in social, religious, and cultural backgrounds

between the immigrant and the health care provider

• Providers’ lack of knowledge about high-risk diseases in the

speciic immigrant groups for whom they care

• The fact that many immigrants rely on traditional healing or

folk health care practices that may be unfamiliar to their US

health care providers

When working with immigrant populations, consider

how your own background, beliefs, and knowledge may be

significantly different from those of the people receiving

care. Language barriers may interfere with efforts to provide

assistance. Community members may be excellent resources

as translators, not only of the actual words but also of

the cultural beliefs, expectations, and use of nontraditional

health practices.

The inability to speak English interferes with an immigrant’s

ability to access health care or even to seek health care (Douglas

et al, 2014). Nurses need to know whether there are speciic risk

factors for a given immigrant population. For example, South-

east Asians are often at risk for hepatitis B (with its attendant

effects on the liver), tuberculosis, intestinal parasites, and visual,

hearing, and dental problems. Most of these conditions are

either preventable or treatable if managed correctly (Ofice of

Minority Health, 2008).

Nurses need to understand the nontraditional healing

practices that their clients use. Many of these treatments have

proved effective and can be blended with traditional Western

medicine. The key is to know what practices are being used

so the blending can be knowledgeably done. Community

members are excellent sources for this information, and

nurses working with immigrant populations should use the

community assessment, group work, and family techniques

described in other chapters. They can help clients and pro-

viders with communication, explanation, crisis intervention,

emotional and other forms of support and housing. It is

important to learn the strengths of the community and its

members.

Often children and adolescents adjust to the new culture

more easily than their elders. This can lead to family conlict

and, at times, violence. Be alert for warning signs of family

stress and tension. On the other hand, family members can

help translate their culture, religion, beliefs, practices, support

systems, and risk factors for the health care provider. They

also can assist with decision making and provide support to

68 PART 2 Inluences on Health Care Delivery and Nursing

enable the person or group seeking care to change behaviors

to become more health conscious. Nurses need to understand

the role of the family in immigrant populations and to treat

individuals in the context of the families from which the im-

migrants come.

The following skills are useful when working with immi-

grant populations:

• Know yourself and how culture inluences you.

• Get to know the families and their health-seeking behaviors.

Ask who the family members are, where they live, and who

is missing or dead. Ask about holidays and who attends and

who does not attend.

• Get to know the communities that you serve. Read about

them, volunteer, take a course, hold a forum with two-way

communication, attend festivals and other key event such as

religious meetings, and identify both formal and informal

resources and leaders.

• Learn how the community deals with common illnesses or

events.

• Try to see things from the viewpoint of the client, family, or

community.

Special note should be made about refugees. Unlike many of

immigrants, refugees may have left their homes as a result of a

disaster, and this might have led to physical or psychological

consequences. Some may have been tortured; others may have

lost family members in horrible ways. Still others may have lived

in camps and lost all or most of their possessions. Some will have

come from poor countries, and much of American culture will

be alien to them. Nurses need to be sensitive and be skilled in

inding resources to both help understand clients and their

needs and then meet those needs (Plumb, 2003). Non-English-

speaking refugees face challenges and barriers in accessing

health care. Some of the barriers, in addition to those related

to language, may include lack of transportation and not

understanding how to use any public transportation in their

area. Applying for Medicaid may be a barrier because of the

complexity of the process. A nurse-led clinical program in Boise,

Idaho, provides a useful exemplar of how nurses in the commu-

nity can help refugees. This program, Culturally Appropriate

Resources and Education Clinic (C.A.R.E.), provides a “conve-

nient, one-stop access to a seamless continuum of health care

services and education provided in a group setting” (Reavy et al,

2012). The clinic is located at the Family Center, an outpatient

resource at the regional medical center. Two-hour group sessions

are held at the clinic for about 10 clients. Peer health advisors and

certiied medical interpreters provide the teaching.

CULTURE, RACE, AND ETHNICITY

The concepts of culture, race, and ethnicity inluence our un-

derstanding of human behavior. These three terms are often

used incorrectly. Nurses need to understand the meaning of

each when providing culturally competent health care to clients

of diverse cultures.

CULTURE

Culture is a set of beliefs, values, and assumptions about life

that is widely held among a group of people and that is trans-

mitted across generations (Leininger, 2002a). Culture is an in-

dividual concept, a group phenomenon, and an organizational

reality. It develops over time and is resistant to change. It takes

many years for individuals to become familiar enough with a

new value for it to become part of their culture. In response to

the needs of its members and their environment, culture pro-

vides tested solutions to life’s problems.

Individuals learn about their culture during the processes of

learning language and becoming socialized, usually as children.

Parents and family, the most important sources for the transfer

of traditions, teach both explicit and implicit behaviors of the

culture. The explicit behaviors, such as language, interpersonal

distance, and kissing in public, can be observed and allow the

individual to identify with other persons of the culture. In this

way, people share traditions, customs, and lifestyles with others.

The implicit behaviors are less visible and include the way indi-

viduals perceive health and illness, body language, difference in

language expressions, and the use of titles. These behaviors are

subtle and may be dificult for persons to describe, yet they are

HOW TO Guidelines for Selecting and Using an Interpreter

1. The interpreter must interpret everything that is said by all the people in

the interaction and inform the public health nurse if the content might be

perceived as insensitive or harmful to the dignity of the client.

2. The interpreter conveys the content and the spirit of what is said without

omitting or adding.

3. The educational level and the socioeconomic status of the interpreter

are important. The nurse should know that the interpreter under-

stands the community’s interpretation of the disease, and the nurse

should understand the community’s health care practices regarding

the disease.

4. The nurse needs to evaluate the interpreter’s style, approach to clients,

and ability to develop a relationship of trust and respect.

5. The gender and/or age of the interpreter may be of concern; in some

cultures, women may prefer a female interpreter and men may prefer a

male, and older clients may want a more mature interpreter. Avoid using

children as interpreters, particularly when the client is an adult. If possi-

ble, avoid family members as interpreters.

6. Identify the client’s country of origin and language or dialect spoken

before selecting the interpreter. For example, Chinese clients speak

different dialects depending on the region in which they were born.

7. Observe the client for nonverbal messages such as facial expressions,

gestures, and other forms of body language. If the client’s responses

do not it with the question, the nurse should check to be sure that the

interpreter understood the question.

8. Make phrase charts and picture cards available.

9. Increase accuracy in the transmission of information by asking the inter-

preter to translate the client’s own words, and ask the client to repeat the

information that was communicated.

10. The interpreter must maintain the conidentiality of all information and

interactions. At the end of the interview, review the material with the

client and the interpreter to ensure that nothing has been missed or

misunderstood.

Data from Giger JN: Transcultural nursing: assessment and intervention,

ed 7, St. Louis, 2016, Mosby; and Randall-David E: Culturally competent

HIV counseling and education, McLean, Va, 1994, Maternal and Child

Health Clearinghouse

69CHAPTER 5 Cultural Inluences in Nursing in Community Health

a part of the culture. For example, deferring to older adults,

standing when they enter the room, or offering them a seat sug-

gests a cultural value related to older adults.

Another example of an implicit aspect of culture is the use

of language to communicate. For instance, in one culture a

sign might read “No smoking is permitted.” In another culture

the sign might read “Thank you for not smoking.” The former

statement represents a culture that values directness, whereas

the latter values indirectness. Each culture has an organiza-

tional structure that distinguishes it from others and provides

the structure for what members of the cultural group deter-

mine to be appropriate or inappropriate behavior (Figs. 5.1

and 5.2).

Andrews and Boyle (2012), Giger (2017), Leininger (2002b),

Purnell and Paulanka (2008), and Spector (2008) describe the

organizational elements of culture. These elements include

childrearing practices, religious practices, family structure,

space, and communication. In the case of language, each

language has unique characteristic expressions. Nurses need to

know these organizational elements to provide appropriate

care to persons of diverse cultures. This does not mean, how-

ever, that you should overlook or fail to incorporate the indi-

viduality of any person within any culture when developing a

plan of care. Just as all cultures are not alike, all individuals

within a culture are not alike. Within a culture, often people

speak different dialects, have different religions and religious

practices, represent widely divergent ages, and have different

socioeconomic and educational status. Also, in many coun-

tries, people who live there may be native to that country or

may have immigrated there. If an immigrant, the person may

continue to adhere to customs, language, and religion from

the native country. Each person should be viewed as a unique

human being with differences that are respected. People in

some cultures consider diseases such as cancer, mental illness,

and HIV to carry a stigma.

RACE

Race is a biological variation within population groups based

on physical markers derived from genetic ancestry such as skin

color, physical features, and hair texture. Individuals may be of

the same race but of different cultures. For example, African

Americans, who may have been born in Africa, the Caribbean,

North America, or elsewhere, are a heterogeneous group, but

they are often viewed as culturally and racially homogeneous.

This perception can cause providers to be unaware of cultural

differences among individuals who come from different coun-

tries but who share similar racial characteristics. This often

blurs an understanding of this culturally diverse group.

It is important to understand the growing numbers of inter-

racial families. Physical changes in biracial and multiracial

generations lead to changes in the physical appearance of indi-

viduals and make race less important in ethnic identity. Before

1989, biracial babies who had one white parent were assigned

the race of the nonwhite parent. Currently the US Census

Bureau allows people to choose more than one race (Fig. 5.3).

FIG. 5.1 This sign is from a culture that values directness

FIG. 5.2 This sign is from a culture that values an indirect

FIG. 5.3 In countries around the world, there are distinct differ-

ences in people who represent the same cultural group. (Copyright

http://www.Photos.com

70 PART 2 Inluences on Health Care Delivery and Nursing

ETHNICITY

Ethnicity is the shared feeling of peoplehood among a group of

individuals and relates to cultural factors such as nationality,

geographical region, culture, ancestry, language, beliefs, and

traditions (Giger, 2017). It relects cultural membership and

is based on individuals sharing similar cultural patterns (e.g.,

beliefs, values, customs, behaviors, traditions) that, over time,

create a common history that is resistant to change. Ethnicity

represents the identifying characteristics of culture (e.g., race,

religion, national origin) and is inluenced by education, in-

come level, geographical location, and association with people

from other ethnic groups. Therefore a reciprocal relationship

exists between the individual and society. Members of an ethnic

group give up aspects of their identity and society when they

adopt characteristics of the group’s identity. However, when the

ethnic identity is strong, the group maintains its values, beliefs,

behaviors, practices, and ways of thinking.

CULTURAL DIVERSITY

Cultural diversity refers to the degree of variation that is rep-

resented among populations based on lifestyle, ethnicity, race,

and interest across place and place of origin across time. It also

includes social class, gender identity, sexual orientation, and

physical abilities/disabilities as well as the changing populations

of the world. Although all cultures are not the same, all cultures

have the same basic organizing factors (Giger, 2017). These fac-

tors should be explored in a cultural assessment because of the

potential for differences among groups. Some of these differ-

ences among cultural groups are presented in Table 5.1. See the

Levels of Prevention box for preventions related to cultural dif-

ferences. Cultural diversity also includes the awareness of the

presence of differences among the members of a social group or

unit (Darnell and Hickson, 2015).

COMMUNICATION

Effective cross-cultural communication is a core competency

for public health professionals (Swider et al, 2013), and is the

fourth domain of the Guidelines for Implementing Culturally

Competent Nursing Care (Douglas et al, 2014). Communica-

tion with the client or family is required for a cultural assess-

ment. It is important to understand variations in patterns of

verbal communication and nonverbal communication and to

use words that a layperson can understand. Verbal communi-

cation is words used to express ideas and feelings; cultural

variations are found, for example, in pronunciation, word

meaning, voice quality, use of humor, and speed of talking. For

example, many people from the United States and the United

Kingdom have English as their irst language. However, the

word boot has different meanings for them. In the United States

African Americans Asian-Americans Hispanics Native Americans

Verbal communication Asking personal questions of

someone you have met

is seen as improper and

intrusive

High level of respect is shown

for others, especially those

in positions of authority

Expression of negative feelings

is considered impolite

Low tone of voice is used, and

the listener is expected to

be attentive

Nonverbal

communication

Direct eye contact in conver-

sation is often considered

rude

Direct eye contact with superi-

ors may be considered

disrespectful

Avoidance of eye contact is

usually a sign of attentive-

ness and respect

Direct eye contact is often

considered disrespectful

Touch Touching someone else’s

hair is often considered

offensive

It is not customary to shake

hands with persons of the

opposite sex

Touching is often observed

between two persons in

conversation

A light touch of the person’s

hand instead of a irm hand-

shake is often used as a

greeting

Family organization Usually have close extended

family networks; women

play key roles in health care

decisions

Usually have close extended

family ties; emphasis may be

on family needs rather than

individual needs

Usually have close extended

family ties; all members of

the family may be involved in

health care decisions

Usually have a close extended

family; emphasis tends to be

on the needs of the family

rather than on individual

needs

Time Often present oriented Often present oriented Often present oriented Often past oriented

Perception of health Harmony of mind, health,

body, and spirit with nature

When the “yin” and “yang”

energy forces are balanced

Balance and harmony among

mind, body, spirit, and nature

Harmony of mind, body, spirit,

and emotions with nature

Alternative healers “Granny,” “root doctor,”

voodoo priest, spiritualist

Acupuncturist, acupressurist,

herbalist

Curandero, espiritualista,

yerbero

Medicine man, shaman

Self-care practices Poultices, herbs, oils, roots “Hot” and “cold” foods, herbs,

teas, soups, cupping, burn-

ing, rubbing, pinching

“Hot” and “cold” foods, herbs Herbs, cornmeal, medicine

bundle

Biological variations Sickle cell anemia, mongolian

spots, keloid formation,

inverted “T” waves, lactose

intolerance, skin color

Thalassemia, drug interactions,

mongolian spots, lactose

intolerance, skin color

Mongolian spots, lactose

intolerance, skin color

Cleft uvula, lactose intoler-

ance, skin color

TABLE 5.1 Cultural Variations Among Selected Groups

71CHAPTER 5 Cultural Inluences in Nursing in Community Health

a boot typically refers to something one puts on one’s feet; in

the United Kingdom the boot may refer to what Americans call

the trunk of the car. Just as understanding verbal communica-

tion is important, so is the understanding of nonverbal com-

munication. Nonverbal communication is the use of body

language or gestures to convey a message. Aspects of nonverbal

language include eye contact, gestures, body posture, facial ex-

pressions, and silence. For example, some Hispanic women are

reluctant to make direct eye contact or answer questions, and

this behavior should not be seen as rudeness. Also, different

cultures have their own perspective of how close they should

stand to another person. In the United States, for many people,

standing close when talking to someone other than a friend or

family member may be seen as threatening or as invading one’s

personal space. In some cultures, standing close when speaking

to another person is a usual way to communicate, whereas in

other cultures, standing close seems intrusive and people may

be uncomfortable. Culturally appropriate verbal and nonverbal

communication helps nurses identify client’s values, beliefs,

practices, perceptions, and unique health care needs (Douglas

et al, 2014).

SPACE

Personal space is the physical area individuals need between

themselves and others to feel comfortable. When this space is

violated, the client may become uncomfortable. Nurses should

take cues from clients to place themselves in the appropriate

spatial zone and avoid misinterpretation of clients’ behavior as

they handle their spatial needs. Most cultural groups have spa-

tial preferences. Some groups typically stand close to one an-

other. However, one group may be comfortable with only a

9-inch distance between faces, whereas another group might

ind that small distance threatening and overly aggressive. It is

important to understand the space preferences of the groups

with whom you work because you may offend the client by

placing yourself at a distance when his or her culture values

close proximity to those with whom they speak and vice versa.

SOCIAL ORGANIZATION

Social organization refers to the way in which a cultural group

structures itself around the family to carry out role functions.

In some cultures, family may include people who are not actu-

ally related to one another. Find out who is considered to be in

the family, who the key decision makers are, and if the needs of

the family supersede those of an individual in the family. Nurses

should be aware that some Hispanic and Asian cultures place

the needs of the family above those of the individual. In the

American Indian/Alaskan Native family, members honor and

respect their elders. Nurses should advocate for the individual,

so that when families make decisions, the individual’s needs are

also considered. However, members of the family may need to

be included in the decision making.

TIME PERCEPTION

Regarding time, cultures are considered to be future, past, or

present oriented. Historically, the American middle-class cul-

ture has tended to be future oriented, and individuals were

willing to delay immediate gratiication until future goals are

accomplished. Recently this has changed as some people have

become less future oriented and more focused on the present.

In contrast, African American and Hispanic families may place

greater value on quality of life and view present time as being

more important than future time. The future is unknown, but

the present is known. When nurses discuss health promotion

and disease prevention strategies with persons from a present

orientation, they should focus on the immediate beneits these

clients would gain rather than emphasizing future outcomes.

In cultures that focus on a past orientation (e.g., the

Vietnamese culture), individuals may focus on wishes and

memories of their ancestors and look to them to provide direction

for current situations (Giger, 2017). In a past-oriented culture,

time is viewed as being more lexible than in a present-oriented

culture. Nurses socialized in the Western culture may view

time as money and equate punctuality with goodness and being

responsible. Working with clients who have a different percep-

tion of time than the nurse can be problematic. Nurses should

LEVELS OF PREVENTION

Related to Cultural Differences (Hypertension,

Stroke, and Heart Disease)

Primary Prevention

Provide health teaching about a balanced diet and exercise.

Secondary Prevention

Teach clients and/or family to monitor blood pressure. Teach about diet, keep-

ing in mind the client’s cultural preferences. Talk about health beliefs and

cultural implications, such as the use of alternative therapies; make sure alter-

native therapies are compatible with any medications that may be prescribed.

Tertiary Prevention

If blood pressure cannot be controlled by diet, refer the client to a physician or

nurse practitioner for medication; advise the client to engage in a cardiac

program that will oversee diet and exercise.

An example of misunderstood nonverbal communication

occurred when a nurse gave instructions to Asian American

clients about taking antituberculin drugs. The clients smilingly

responded with “yes, yes.” The nurse interpreted this response

to mean that the clients understood the instructions and ac-

cepted the treatment protocol. A week later, when the clients

returned for a follow-up visit, the nurse discovered that the

medications had not been taken. The nurse knew that accep-

tance by and avoidance of confrontation or disagreement with

those in authority are important behaviors in the Asian Ameri-

can culture; interventions were therefore adjusted accordingly.

The nurse repeated the medication instructions and gave the

clients an opportunity to raise questions and concerns and to

repeat the instructions that were given. The nurse also discussed

the cultural meaning and treatment of tuberculosis. It is impor-

tant to respect all information that a client shares with you,

even when the information is in conlict with your own value

system.

72 PART 2 Inluences on Health Care Delivery and Nursing

• What is the social signiicance of food in the family?

• What foods are most frequently bought for family consumption?

• What foods, if any, are taboo (prohibited) for the family?

• Does religion play a signiicant role in food selection?

• Who prepares the food? How is it prepared?

• How much food is eaten? When is it eaten, and with whom?

• Where does the client live, and what types of restaurants does he or she

frequent?

• Has the family adopted foods of other cultural groups?

• What are the family’s favorite recipes?

clarify the clients’ perception to avoid misunderstanding. It is

not realistic to expect clients to change their behavior and adopt

the nurse’s schedule.

ENVIRONMENTAL CONTROL

Environmental control refers to the relationships between hu-

mans and nature. Cultural groups might perceive humans as

having mastery over nature, being dominated by nature, or hav-

ing a harmonious relationship with nature. Those who view

nature as dominant (e.g., African Americans and Hispanics)

believe they have little or no control over what happens to them.

They may not adhere to a cancer treatment protocol because of

the belief that nothing will change the outcome because it is

their destiny. These individuals are less likely to engage in illness

prevention activities than those who have other worldviews.

Persons who view a human harmony with nature (e.g., African

Americans, Asians, and Native Americans) may perceive that

illness such as cancer is disharmony with other forces and that

medicine can relieve the symptoms but cannot cure the disease.

They would seek treatment for the malignancy from the mind,

body, and spirit connection because they believe that healing

comes from within. These groups are likely to look to naturalis-

tic solutions, such as herbs, acupuncture, and hot and cold treat-

ments, to resolve or cure a cancerous condition. Some clients

may view their illness as punishment for misdeeds and may have

dificulty accepting care from nurses who do not share their

belief. Individuals from cultures that view the environment as

being dominant over nature (e.g., Hispanics) may believe that

they have little or no control over a serious illness for which they

have been diagnosed. These individuals are less likely to engage

in illness management interventions that are harsh and that they

cannot trust to lead to a positive health outcome.

BIOLOGICAL VARIATIONS

Biological variations are the physical, biological, and physio-

logical differences that distinguish one racial group from

another. They occur in areas of growth and development,

skin color, enzymatic differences, and susceptibility to disease

(Andrews and Boyle, 2012; Giger, 2017). Other common and

obvious variations include eye shape, hair texture, adipose tis-

sue deposits, shape of earlobes, thickness of lips, and body

coniguration. There are also genetic differences that differen-

tially affect some groups. Lactose intolerance is much more

common in African blacks and African Americans than in the

general population. Also, Western-born neonates are slightly

heavier at birth than those born in non-Western cultures.

Mongolian spots are bluish discolorations that are sometimes

present on the skin of African American, Asian, Hispanic, and

Native American/Alaskan Native babies. These discolorations

may be mistaken for bruises. When nurses are exposed to

situations involving biological variations of which they are

unfamiliar, they may create embarrassing situations. Consider

the following scenario: The school nurse observes a bluish

discoloration on the thigh of a Filipino child that she mistook

for a bruise. The nurse reported her observation to the child

protective agency in her state. When the child’s mother arrived

to pick her child up at the end of the school day, she was ac-

cused of child abuse. The mother had to disprove the allegation

before her child could be released into her care.

NUTRITION

Nutritional practices are an integral part of the assessment process

for all families, especially because they play a prominent role in the

health problems of some groups. For many cultures, the prepara-

tion and eating of food are a social activity, and members of the

group come together to celebrate life events and family rituals with

food as a focus of the event. Efforts to understand dietary patterns

of clients should go beyond relying on membership in a deined

group. Knowing clients’ nutrition practices makes it possible to

develop treatment regimens that will not conlict with their cul-

tural food practices. Box 5.1 identiies several questions that nurses

should ask when conducting a nutritional assessment. Table 5.2

BOX 5.1 Assessment of Dietary Practices and Food Consumption Patterns

Cultural

Group

Food

Preferences

Nutritional

Excess

Risk

Factors

African

Americans

Fried foods, greens,

bread, lard, pork,

rice, foods with

high sodium and

starch content

Cholesterol, fat,

sodium, car-

bohydrates,

calories

Coronary artery

disease,

obesity

Asians Soy sauce, rice,

pickled dishes,

raw ish, teas, bal-

ance between yin

(cold) and yang

(hot) concepts

Cholesterol, fat,

sodium, car-

bohydrates,

calories

Heart disease,

liver disease,

cancer of the

stomach,

ulcers

Hispanics Fried foods, beans

and rice, chili,

carbonated bever-

ages, high-fat and

high-sodium foods

Cholesterol, fat,

sodium, car-

bohydrates,

calories

Heart disease,

obesity

TABLE 5.2 Food Preferences and Associated Risk Factors in Selected Cultural Groups

Data from Andrews MM, Boyle JS: Transcultural concepts in nursing

care, ed 6, Philadelphia, 2012, Lippincott Williams and Wilkins; and

Giger JN: Transcultural nursing: assessment and intervention, ed 7,

St. Louis, 2017, Mosby.

73CHAPTER 5 Cultural Inluences in Nursing in Community Health

identiies the nutritional disadvantages to health of selected food

preferences associated with four cultural groups. In working with

clients of different cultures, the nurse might need to consult cul-

turally oriented magazines. For example, some popular maga-

zines such as Essence, Ebony, and Latina have altered old family

recipes using healthier ingredients. These dishes taste good and

allow those who use them to continue their old traditions related

to food. As another example, many people who subscribe to the

Buddhist religion are vegetarian. Their faith teaches self-control

as a means to search for happiness. The Buddhist code of moral-

ity is in their Five Moral Precepts, and eating meat would conlict

with both the irst and the ifth (i.e., meat is seen as an intoxi-

cant). These precepts are as follows: Do not harm or kill living

things, steal, engage in sexual misconduct, lie, or consume

intoxicants, such as alcohol, tobacco, or mind-altering drugs

(ElGindy, 2013). Also, Muslims avoid pork and foods cooked

with alcohol.

nurses and clients come from the same social class, it is more

likely that they operate from the same health belief model and

consequently there is less opportunity for misinterpretation

and problems in communication.

Social determinants of health are thought to have a major

impact on health. These are the determinants and conditions in

which people are born, live, work, and age and include such

factors as education, racial segregation, social supports, and

poverty. For example, “children born to parents who have not

completed high school are more likely to live in an environment

that poses barriers to health” (Heiman and Artiga, 2015, p 1).

The neighborhoods of these children are less likely to have

parks in which they can play, sidewalks, recreation centers, or a

library. They are more likely to be unsafe, have exposed garbage

or litter, have poor or run-down housing, and be plagued by

vandalism (Heiman and Artiga, 2015). As will be discussed in

Chapter 23, Poverty, Homelessness, Mental Illness, and Teen

Pregnancy, more minority families than white families live be-

low the poverty level. Poor economic achievement is also a

common characteristic among at-risk populations, such as

those in poverty, the homeless, migrant workers, and refugees.

Data suggest that when nurses and clients come from the same

social class, it is more likely that they operate from the same

health belief model, and consequently, there is less opportunity

for misinterpretation and problems in communication.

A danger also exists in believing that certain cultural behav-

iors, such as folk practices, are restricted to lower socioeco-

nomic classes. For example, health professionals, such as nurses

and physicians, may also use folk systems in conjunction with

the biomedical system to promote their health and prevent

disease. Therefore nurses must conduct a cultural assessment

for all individuals when they irst come in contact with them.

Nurses should be able to distinguish between issues of culture

and socioeconomic class and not misinterpret behavior as having

a cultural origin when, in fact, it should be attributed to socioeco-

nomic class.

CULTURAL COMPETENCE

Many people are taught by and have knowledge of a dominant

culture. As long as the person operates within that culture, re-

sponses occur without thought to a variety of situations and do

not require examination of the cultural context. However, as

multiculturalism grows, it becomes increasingly important for

health care providers, including nurses and organizations, to

provide quality and effective care. For example, consider the

situation of a recent Mexican immigrant who speaks little

English and goes to a community health center because of a

urinary tract infection. The nurse understands that she must

use strategies that will allow her to effectively communicate

with the client; the client has the right to receive effective care,

to judge whether she received the care she wanted, and to follow

up with appropriate action if she did not receive the expected

care. Culturally competent care is provided not only to indi-

viduals of racial or ethnic minority groups but also to individu-

als belonging to groups held together by factors such as age,

religion, sexual orientation, and socioeconomic status. Nurses

APPLYING CONTENT TO PRACTICE

As has been discussed throughout the chapter, culturally competent nursing

care uses many of the standards, guidelines, and competencies from key nurs-

ing and public health documents. For example, the Council on Linkages (2010)

has a set of skills related to cultural competency and a set related to commu-

nication that is consistent with the information in this chapter. Likewise, the

Quad Council further develops and applies the skills of the Council on Linkages

related to both cultural competency and communication to public health nurs-

ing practice. As an example, the Council on Linkages states that a necessary

skill in public health is to consider “the role of cultural, social, and behavioral

factors in the accessibility, availability, acceptability and delivery of public

health services.” The Quad Council says that “public health nurses should

consider the role of cultural, social, and behavioral factors in the accessibility,

availability, acceptability and delivery of public health nursing services.”

Swider et al (2013) apply each of the Council on Linkages core competencies

to public health nursing practice.

CULTURE, DIVERSITY, AND SOCIAL DETERMINANTS OF HEALTH

Socioeconomic factors contribute greatly to understanding per-

ceptions of health and illness among minority groups. These

groups may not have opportunities for education, occupation,

income earning, and property ownership similar to those of the

dominant group. Socioeconomic status, which is a measure

often based on income, education, or occupation, is a critical

factor in determining access to health care and the development

of some chronic health problems and in health outcomes

(Mohammed, 2011; Sims, Sims, and Bruce, 2008). According to

the US Census Bureau (2011), in 2010 more white families than

minorities lived below the poverty level. However, the propor-

tion of poor families in a minority group is greater. For exam-

ple, white families represent 9.3% of those in poverty, whereas

African Americans represent 22.7% and Hispanics represent

22.7%. Consequently, minority families are disproportionately

represented on the lower tiers of the socioeconomic ladder.

Poor economic achievement is also a common characteristic

among at-risk populations, such as those in poverty, the home-

less, migrant workers, and refugees. Data suggest that when

74 PART 2 Inluences on Health Care Delivery and Nursing

must be culturally competent to provide nursing care that

meets the needs of these persons. Such nursing actions can de-

crease racial and health disparities and improve health out-

comes (Brondolo, Gallo, and Myers, 2009).

Cultural competence in nurses is a combination of cultur-

ally congruent behaviors, practice attitudes, and policies that

allow nurses to work effectively in cross-cultural situations.

The term competence refers to performance that is suficient

and adequate. Culturally competent nurses function effectively

when caring for clients of other cultures. Culturally competent

nurses learn about the cultures of the clients whom they serve

and they respect people from other cultures and value diversity;

this helps them provide more responsive care. Cultural compe-

tence includes acknowledging the fundamental differences in

the ways clients and families respond to illness and treatment

from what might be your response or a more typical Western

health care response. It is important for nurses to continuously

engage in critical relection to examine their own values, beliefs,

and cultural heritage in order to increase their awareness of

how these qualities can inluence their care (Douglas et al,

2014). This can include paying attention to dietary practices,

pain, death and dying, modesty, eye contact, closeness, and

touching others. YouTube offers many videos that address cul-

tural competence. Use key words such as “cultural competence

in nursing” and see what you can ind.

Ten guidelines, formerly referred to as standards, have been

developed by a collaborative task force of members of the

American Academy of Nursing (AAN) Expert Panel on Global

Nursing and Health and the Transcultural Nursing society.

These standards were developed to serve as a guide for provid-

ing culturally competent care. The authors of the standards say

that due to the migration of both nurses and clients, it is impor-

tant to have a set of universally applicable guidelines for provid-

ing culturally competent care. The recipient of the nursing care

can be an individual, a family, a community, or a population.

The standards are based on the principles of social justice and

human rights. These concepts are discussed in Chapter 4, Ethics

in Community Health Nursing Practice. The 10 standards are

(1) knowledge of cultures, (2) education and training in cultur-

ally competent care, (3) critical relection, (4) cross-cultural

communication, (5) culturally competent practice, (6) cultural

competence in health care systems and organizations, (7) pa-

tient advocacy and empowerment, (8) multicultural workforce,

(9) cross-cultural leadership, and (10) evidence-based practice

and research (Douglas et al, 2014). These guidelines are im-

portant because both health care professionals and organiza-

tions are responsible for providing the infrastructure needed

to deliver safe, culturally congruent, and compassionate care

(Douglas et al, 2014).

delay seeking care or may withhold key information. For ex-

ample, if a person is afraid of disapproval, he may not tell the

nurse that he is using both folk medicine and Western medi-

cine. The two medicines may have cumulative or contradic-

tory effects that could be dangerous to the client.

• Third, to meet some of the objectives for persons of different

cultures as outlined in Healthy People 2020 (see the Healthy

People 2020 box) (US Department of Health and Human

Services, 2010), lifestyle, background, traditions, values,

practices, and personal choices must be considered.

• Fourth, legal regulations and accreditation mandates specify

that culturally competent health care must be provided so that

health disparities can be reduced and ultimately eliminated. A

goal of Healthy People 2020 deals with eliminating health dis-

parities among people that occur as a result of gender, race or

ethnicity, education or income, disability, geographical loca-

tion, or sexual orientation. Diabetes is discussed in this context

because its prevalence is associated with disparities of income

and education, and it is more prevalent among Hispanics liv-

ing in the United States than among non-Hispanic whites.

Diabetes is more prevalent among American Indians and

Alaska Natives than among whites, demonstrating the need to

look at culture when working with these populations.

Developing Cultural Competence Developing cultural competence is one of the core competen-

cies for public health nurses (Swider et al, 2013). It is an ongo-

ing life process that involves every aspect of client care. It is

challenging and at times painful as nurses struggle to adopt new

ways of thinking and performing. Leininger (2002a) suggests

that the following two principles are useful in developing cul-

tural competence:

1. Maintain a broad, objective, and open attitude toward indi-

viduals and their cultures.

2. Avoid seeing all individuals as alike.

Nurses develop cultural competence in different ways, but

the key elements are experience with clients of other cultures,

an awareness of this experience, and the promotion of mutual

respect for differences. Because degrees of cultural competence

vary, not all nurses may reach the same level of development.

Also, developing cultural competence is a life-long process.

Goal

To eliminate health disparities among different segments of the population as

deined by gender, race or ethnicity, education, income, disability, geographic

location, and sexual orientation.

Selected Objectives

• AHS-3: Increase the proportion of persons with a usual primary-care

provider.

• AHS-7: Reduce the proportion of individuals who are unable to obtain or

delay in obtaining necessary care, dental care, or prescription medicine.

From U.S. Department of Health and Human Services: Healthy People

2020: understanding and improving health, Washington, DC, 2010, US

Government Printing Ofice.

HEALTHY PEOPLE 2020

Objectives Related to Cultural Issues

Nurses must be culturally competent for several key reasons,

including the following:

• First, the nurse’s culture often differs from that of the client,

leading to different understandings of communication, be-

haviors, and plans for care.

• Second, care that is not culturally competent may increase

the cost of health care and decrease the opportunity for posi-

tive client outcomes. Clients who do not feel understood may

75CHAPTER 5 Cultural Inluences in Nursing in Community Health

• Think about the irst time you had contact with someone you realized was

culturally different from you.

• Briely describe the situation or event. How old were you? What were your

feelings? What were your thoughts?

• What did your parents and other signiicant adults say about those who

were culturally different from your family? What adjectives were used?

What attitudes were conveyed?

• As you got older, what messages did you get about minority groups from the

larger community or culture?

• As an adult, how do you see others in the community talk about culturally

different people? What adjectives are used? What attitudes are conveyed?

How does this reinforce or contradict your earlier experience?

• What parts of this cultural baggage make it dificult to work with clients

from different cultural groups?

• What parts of this cultural baggage facilitate your work with clients?

Orlandi (1992) suggests that there are three stages in the

development of cultural competence: culturally incompetent,

culturally sensitive, and culturally competent (Table 5.3). Each

stage has three dimensions—cognitive (thinking), affective

(feeling), and psychomotor (doing)—that together have an

overall effect on nursing care.

A widely used model to explain the process of cultural com-

petence is that of Campinha-Bacote (2011). This model has the

following ive elements of cultural competence: (1) cultural

awareness, (2) cultural knowledge, (3) cultural skill, (4) cultural

encounter, and (5) cultural desire.

Cultural Awareness

Cultural awareness is the self-examination and in-depth explo-

ration of one’s own biases, stereotypes, and prejudices that in-

luence behavior (Campinha-Bacote, 2011). Nurses who have

developed cultural awareness are able to do the following:

• Learn about the cultural dimensions of clients.

• Understand their own behavior and how it helps or hinders

the delivery of competent care to persons from cultures

other than their own.

• Recognize that health is expressed differently across cultures

and that culture inluences an individual’s responses to

health, illness, disease, and death.

For example, at a community outreach program, a nurse was

teaching a racially mixed group the screening protocol for the

detection of breast and cervical cancer. An African American

woman in the group refused to give the return demonstration

for breast self-examination. When encouraged to do so, she

said, “My breasts are much larger than those on the model.

Besides, the models are not like me. They are all white.” After

hearing the client’s comments, the nurse realized that she had

made no reference in her talk to the inluence of culture or race

on screening for breast and cervical cancer.

The nurse talked with the client, asked for her recommenda-

tions, and encouraged her to return to the demonstration. The

nurse coached the client through the self-examination process

while pointing out that regardless of breast size, shape, and

color, the technique is the same for feeling the tissue and

squeezing the nipple to make certain that there is no discharge.

Because this nurse was culturally aware, she neither became

angry with herself or the client nor imposed her own values on

the client. Rather, the client talked about her beliefs, attitudes,

and feelings about screening for cancer that may be inluenced

by her culture. Subsequently, the nurse purchased a model of an

African American woman’s breast to use in future health educa-

tion programs with African American women. A nurse who was

not culturally aware may have misunderstood the client’s con-

cerns and acted in a defensive manner. This might have led to

lack of information being provided or a confrontation between

the nurse and client. Cultural awareness is consistent with

guideline 3, critical relection, of the Guidelines for Implement-

ing Culturally Competent Nursing Care (Douglas et al, 2014).

Critical relection implies that nurses examine their own values,

beliefs, and cultural heritage in order to provide effective care to

patients of different cultures. See Box 5.2 for questions to ask

yourself about your development of cultural awareness.

Cultural Knowledge

Cultural knowledge is information about organizational ele-

ments of diverse cultures and ethnic groups. Emphasis is on

learning about the client’s worldview from an emic (native)

perspective. An understanding of the client’s culture decreases

misinterpretations and misapplication of scientiic knowledge

and facilitates the client’s cooperation with the health care regi-

men (Campinha-Bacote, 2011). For example, cultural knowl-

edge informs us that Middle Eastern women may not attend

prenatal classes without encouragement and support from the

nurse (Meleis, 2005). The reason for this is that attending the

classes is about the future of the baby, whereas the mother’s

main concern may be on the present and what is happening

now. If nurses understand the cultural difference in this exam-

ple, they can select strategies to help the mother understand the

value of the classes. In contrast, knowledge about Nigerian cul-

ture would allow the nurse to understand that the mother

might begin prenatal classes but not continue because Nigerian

women view birth as a natural process and not a process they

need to attend a class to understand (Ogbu, 2005). Nurses who

lack cultural knowledge may develop feelings of inadequacy

Culturally

Incompetent

Culturally

Sensitive

Culturally

Competent

Cognitive

dimension

Oblivious Aware Knowledgeable

Affective

dimension

Apathetic Sympathetic Committed to

change

Skills dimension Unskilled Lacking some

skills

Highly skilled

TABLE 5.3 The Cultural Competence Framework: Stages of Competence Development

From Orlandi MA: Deining cultural competence: an organizing

framework. In Orlandi MA, editor: Cultural competence for evaluators,

Washington, DC, 1992, US Department of Health and Human Services.

BOX 5.2 Early Cultural Awareness

From Randall-David E: Culturally competent HIV counseling and educa-

tion, McLean, VA, 1994, Maternal and Child Health Clearinghouse.

76 PART 2 Inluences on Health Care Delivery and Nursing

and helplessness when they cannot effectively help their clients.

Studies have shown that when students are not exposed to a

variety of cultures, they may have gaps in their cultural knowl-

edge and ability to care for diverse clients (Jones, Cason, and

Bond, 2004). Although it is unrealistic to expect that nurses will

have knowledge of all cultures, they should be aware of and

know how to obtain knowledge of cultural inluences that affect

groups with whom they most frequently interact. Cultural

knowledge is consistent with guideline 1, knowledge of cul-

tures, in the Guidelines for Implementing Culturally Compe-

tent Nursing Care (Douglas et al, 2014).

The Evidence-Based Practice box provides an example of

learning how to meet the needs of a cultural group that is dif-

ferent from that of the nurse.

modify the physical distance between themselves and others,

and use strategies to avoid cultural misunderstandings while

meeting mutually agreed-upon goals. Cultural skill is consistent

with guideline 5, culturally competent practice, of the Guide-

lines for Implementing Culturally Competent Nursing Care

(Douglas et al, 2014) (Fig. 5.4).

Cultural Encounter

A cultural encounter is the fourth construct essential to becom-

ing culturally competent. Cultural encounter is the process that

permits nurses to seek opportunities to engage in cross-cultural

interactions with clients of diverse cultures to modify existing

beliefs about a speciic cultural group and possibly avoid stereo-

typing (Campinha-Bacote, 2011). Culture encounters are part of

the interpersonal nurse–patient relationship and focus on caring,

compassion, presence, caring consciousness, and empathy. There

are both direct (face-to-face) and indirect types of cultural en-

counters. Aspects of cultural encounter include effective com-

munication, use of appropriate language and literacy level, and

learning directly from clients about their life experiences and the

signiicance of these experiences for health (Leininger, 2002a).

An example of a direct cultural encounter is when nurses

learn directly from their Puerto Rican American clients about

spicy food they avoid when breastfeeding. Indirect cultural en-

counters occur when nurses share this information about the

effect of spicy food on breastfeeding with other nurses. When

nurses come into contact with persons who are culturally differ-

ent from themselves, they should adapt general cultural con-

cepts to the situation until they are able to learn directly from

the clients about their culture (Fig. 5.5). Nurses can develop

cultural competence by reading about, taking courses on, and

discussing different cultures within multicultural settings.

EVIDENCE-BASED PRACTICE

The purpose of this descriptive correlation study was to assess personal be-

liefs about the causes and meaning of having diabetes among members of the

Lumbee Indian tribe living in rural southeastern North Carolina. The sample

consisted of 40 adult men and women. A mixed-method approach using quali-

tative and quantitative data was used to conduct this study.

The participant responses indicated a moderate belief in the eficacy of dia-

betes treatment, a moderate belief in their ability to understand a coherent

model of diabetes, and a low level of emotional distress related to having dia-

betes. Two major themes emerged from the open-ended questions about the

causes of diabetes: (1) genetic predetermination and (2) lifestyle practices.

Although participants believed that their prescribed diabetes medications

were a necessary part of controlling their illness, several expressed fatigue

and “felt worn out” with having to persist with their treatment expectations.

Limitations were that the sample only included persons who were seeking

health care treatment for diabetes and did not include those who were not

scheduled for an appointment at the clinic during the data-collection period or

those who did not have access to health care.

Nurse Use

Nurses should be aware that their Lumbee Indian clients may not always have a

high degree of conidence in conventional treatment regimens or an understand-

ing of the unpredictable course of diabetes. Nurses should work with these cli-

ents to provide culturally congruent education using appropriate communication

to increase clients’ knowledge about current treatment regimens. Nurses should

incorporate culturally speciic strategies that will assist clients to take a more

active role in their illness management, dispel the attitude that a diagnosis of

diabetes is genetically predetermined, link concrete behaviors to disease pro-

gression and outcomes, and demonstrate to clients how attainable decreases in

blood sugar can reduce the risk of long-term consequences. Such strategies

would help eliminate negative perceptions that may interfere with the health

care delivery process. The researchers suggested that by using a broad systems

approach, nurses will increase the availability of Native American health care

providers who can serve as role models for the community as well as become

activists for developing community infrastructure to support healthy lifestyles.

From Jacobs A, Kemppainen JK, Taylor JS, et al: Beliefs about diabe-

tes and medication adherence among Lumbee Indians living in rural

southeastern North Carolina. J Transcult Nurs 25:167–175, 2014.

FIG. 5.4 An Asian American nurse interacts with an African

Cultural Skill

Cultural skill refers to the effective integration of cultural

awareness and cultural knowledge to obtain relevant cultural

data and meet the needs of culturally diverse clients. Culturally

skillful nurses use appropriate touch during conversation,

http://www.Photos.com

77CHAPTER 5 Cultural Inluences in Nursing in Community Health

• Culture is applicable to groups of whites, such as Italians or Irish

Americans, as well as to racial and ethnic minorities.

• During each interaction with clients, be sensitive to the cultural implications

of the encounter.

• Ask questions to stimulate learning about how clients identify and express

their cultural background.

• Much diversity exists within groups, and not all persons of the same racial or

ethnic group may share the same culture. Assess both cultural group patterns

and individual variations within a cultural group to avoid stereotyping.

• When misunderstandings arise, acknowledge the problem, and take respon-

sibility for your own errors.

• Be knowledgeable about your own cultural heritage, biases, beliefs, values,

and practices when providing care.

• Avoid making assumptions about nonverbal cues when interacting with

clients from unfamiliar cultures.

• Use a variety of sources, including clients, to develop cultural knowledge.

• Understand that developing cultural competence is an ongoing journey and

an evolving process.

Cultural Desire

Cultural desire is the ifth construct in the development of

cultural competence. It refers to the nurse’s intrinsic motivation

to provide culturally competent care (Campinha-Bacote, 2012).

Nurses who desire to become culturally competent do so

because they want to rather than because they are directed to do

so. They are energetic, enthusiastic, and goal directed in provid-

ing culturally competent care. Unlike the other constructs, cul-

tural desire cannot be directly taught in the classroom or other

educational settings. However, nurses are more likely to dem-

onstrate cultural desire when their work environment relects a

philosophy that values cultural competence at all levels of the

organization and for all its clients. Campinha-Bacote (2011)

encourages nurses not to be afraid of making mistakes but to

enthusiastically try to learn about other people. Box 5.3 lists

several important points to remember when trying to increase

your cultural competence.

CULTURALLY COMPETENT NURSING INTERVENTIONS

Nurses integrate their professional knowledge with the client’s

knowledge and practices to negotiate and promote culturally

relevant care. Leininger (2002a) suggests that the following

three modes of action, based on negotiation between the client

and nurse, can guide the nurse in providing culturally com-

petent care: cultural preservation, cultural accommodation,

and cultural repatterning. When these decisions and actions

are used with cultural brokering, the nurse is able to fulill

the various roles vital to providing holistic care for culturally

diverse clients.

CULTURAL PRESERVATION

Cultural preservation means that the nurse supports and facili-

tates the use of scientiically supported cultural practices from a

person’s culture along with those from the biomedical health

care system. Examples are acupressure and acupuncture. Acu-

puncture is an ancient Chinese practice of inserting needles at

speciic points in the skin to cure disease or relieve pain. These

practices are being accepted by increasing numbers of Western

practitioners as a legitimate method of health care. It is impor-

tant to know when clients are blending traditional health prac-

tices with those prescribed by the health care provider to make

certain they support rather than interfere with one another.

BOX 5.3 Developing Cultural Competency: Points to Remember

FIG. 5.5 A Hispanic nursing student interacting with African

American men at a nutrition center. To interact in a culturally compe-

tent manner, the nurse needs to have an awareness of and knowl-

edge about the differences between her culture and the men’s

culture and the skill to portray this in her behavior toward them.

CHECK YOUR PRACTICE?

Ms. Lin, a 73-year-old Chinese American woman, is discharged to home care

after surgery for cancer of the large intestine. The nurse found her at home

alone with her 76-year-old husband. After the physical assessment, the nurse

discussed making a referral for Ms. Lin to have a home health aide to assist

her with physical care and light housekeeping chores. The family was gracious

but seemed hesitant to accept the referral. The nurse knew that Chinese

people often value the extended family network and family decision making.

She asked the couple if they would like to discuss the situation with their

daughters. Both the client and her husband seemed pleased with the idea, and

the nurse promised to return the next day. When the nurse returned for her

visit, one of Ms. Lin’s daughters was present and told the nurse that the family

could manage without additional help. The three daughters had made a sched-

ule to take turns caring for their parents.

Which of the following should the nurse do? (1) Try to persuade Ms. Lin’s

daughters to accept help. (2) Accept and support the family’s decision and tell

them that if they decide at a later time to have the home health aide, they

should call the agency, and give them the telephone number. (3) Schedule the

next follow-up visit with them.

CULTURAL ACCOMMODATION

Cultural accommodation means that the nurse supports and

facilitates clients in their use of cultural practices when

such cultural practices are not harmful to clients. For example,

consider the practice of home burial of the placenta. In this

78 PART 2 Inluences on Health Care Delivery and Nursing

example, the delivery room nurse was helpful when Ms. Sanchez

asked her not to discard a piece of the amniotic sac that was

present on her grandbaby’s face immediately after birth.

Ms. Sanchez asked the nurse to give it to her instead. The

grandmother believed that being born with a piece of the am-

niotic sac on the face was a visible sign that something special

was going to happen in the person’s life. The grandmother

explained that after she dried the piece of the amniotic sac, she

would keep it in a safe place. She would also spend extra time

protecting the baby to prevent her from being harmed.

Although the delivery room nurse did not know about this

practice, she gave the grandmother the piece of the sac as she

requested. As another example, using cultural accommoda-

tion, a nurse can assist older Chinese American clients to

more effectively manage their hypertension by modifying

their use of high-sodium soy sauce by substituting low-

sodium soy sauce in their cooking. Similarly, African Americans

can be guided to use more broiled and boiled foods and eat

fewer fried foods.

In providing care to clients who practice the Islamic faith,

it is important to understand some of the key tenets of

their faith. The Five Pillars of Islam define the duties that

each Muslim should practice to be consistent with their

faith. The second pillar, Salat, can have implications for

nurses caring for these patients. Salat says that a Muslim

must pray five times a day while facing Mecca, which is

in an easterly direction in the United States (Charles and

Daroszewski, 2012). The prayers are given in a kneeling posi-

tion on a prayer mat or carpet. It is important for the agency

and the health care professionals to make it possible for

these clients to pray at the appointed times. The Qur’an also

dictates various health care choices related to contraception

and birth, sanitary practices, dietary practices, and medical

care concerns, to name a few (Charles and Daroszewski,

2012). In providing culturally appropriate care to Muslim

clients, it is important to take into account the tenets of their

religion. Cultural accommodation is consistent with guide-

line 4, cross-cultural communication, of the Guidelines for

Implementing Culturally Competent Nursing Care (Douglas

et al, 2014).

CULTURAL REPATTERNING

Cultural repatterning means that the nurse works with clients

to help them reorder, change, or modify their cultural practices

when these practices are harmful to them. For example, a cul-

turally competent nurse knows of the high incidence of obesity

among Mexican American women 20 years of age and older. A

school nurse was invited to develop a health education program

for Mexican teenagers in the local high school. While respecting

their cultural traditions, the nurse discussed weight manage-

ment strategies with the teenagers. The nurse understood the

teenagers’ cultural issues pertaining to food and knew how to

negotiate with them. She discouraged the use of fried foods

(such as tortillas), sour cream, and regular cheese and encour-

aged and demonstrated the use of baked tortillas and of salsa as

dip and topping.

In another example, a nurse who was giving prenatal in-

structions to pregnant Haitian women discovered that many of

them were visiting an herbalist to obtain teas that would help

them have a “strong baby.” The nurse asked for the names of

the herbs in the teas they were drinking and scheduled a con-

ference with the pharmacist to discuss the speciic ingredients

in the herbs and ways they might help the client meet her cul-

tural needs. The nurse found that one of the herbs contributed

to high blood pressure, a problem that many of the women

were experiencing. She explained to the women why they

should not drink the tea with the speciic herb. The nurse

enlisted the aid of the herbalist because she understood the

importance of supernatural causes of illness in the Haitian

culture (Miller, 2000).

CULTURAL BROKERING

Cultural brokering is advocating, mediating, negotiating,

and intervening between the client’s culture and the bio-

medical health care culture on behalf of clients. Cultural

brokering is similar to guideline 6, patient advocacy and em-

powerment, of the Guidelines for Implementing Culturally

Competent Nursing Care (Douglas et al, 2014). It is impor-

tant to understand both your culture and that of the client

and to resolve or decrease problems that result from indi-

viduals in either culture not understanding the other person’s

values. To illustrate, migrant workers tend to have high oc-

cupational mobility; many are poor and have limited formal

education. They may seek health care only when they are ill

and cannot work. Whenever a nurse interacts with them, it is

important to teach them about prevention, health mainte-

nance, environmental sanitation and pesticides, and nutri-

tion because it may be the only opportunity that the nurse

will have to treat a particular migrant worker. Nurses also

should advocate for the rights of the migrant worker to re-

ceive quality health care. For example, the nurse may contact

the migrant health services for follow-up or referral care for

the migrant worker. Advocacy is consistent with guideline 6

of the Guidelines for Implementing Culturally Competent

Nursing Care (Douglas et al, 2014).

INHIBITORS TO DEVELOPING CULTURAL COMPETENCE

Nurses may fail to provide culturally competent nursing care if

they do not understand transcultural nursing, their supervisors

are pressuring them to increase productivity by increasing their

caseloads, or they are pressured by colleagues who are not

knowledgeable about other cultures and who are critical or of-

fended when others use these concepts. These and similar issues

can inhibit delivery of culturally competent care and may result

in nurse behaviors such as stereotyping, prejudice and racism,

ethnocentrism, cultural imposition, cultural conlict, and cul-

tural shock.

• Stereotyping means attributing certain beliefs and behav-

iors about a group to an individual without giving adequate

attention to individual differences. Examples of stereotypes

79CHAPTER 5 Cultural Inluences in Nursing in Community Health

are “All Asian people are hardworking” and “All Chinese

people are good at math.”

• Prejudice refers to having a deeply held reaction, often

negative, about another group or person. For example, a

person may be viewed negatively because of skin color, race,

religion, or social standing, with no regard for the worth of

the person as an individual.

• Racism is a form of prejudice and refers to the belief that

persons who are born into a particular group are inferior, for

example, in intelligence, morals, beauty, or self-worth. Be-

cause of their race, individuals may be denied opportunities

that are available to people of other races. Racism can be one

of three forms: individual because of the characteristics of

the group of which the person is a member, such as skin

color, hair texture, or facial features; institutional, such as

discriminatory policies, priorities, and resource allocation

pertaining to certain groups; or cultural, in which a culture

is viewed in derogatory or stereotypical ways because of,

for example, how a group dresses or the language the group

uses. See Box 5.4 for examples of prejudice and racist

behaviors.

• Ethnocentrism, a type of cultural prejudice at the popula-

tion level, is the belief that one’s own group determines the

standards for behavior by which all other groups are to be

judged. Ethnocentric nurses are unfamiliar and uncomfort-

able with anything that is different from their culture. Their

inability to accept different worldviews often leads them to

devalue the experiences of others, judge them to be inferior,

and treat people who are different with suspicion or hostility

(Andrews and Boyle, 2012). Some American nurses may

think that the way we do something is the best (or only) way

to provide this care. Ethnocentrism contrasts with cultural

blindness, which is the tendency to ignore all differences

among cultures, to act as though these differences do not

exist, and as a result, to treat all people the same (when in

truth, each person is an individual with unique needs).

Nurses who say that they treat all clients the same, regardless

of cultural orientation, are demonstrating cultural blind-

ness.

• Cultural imposition involves the belief in one’s own superi-

ority, or ethnocentrism, and the act of imposing one’s values

on others. Nurses impose their values on clients when they

forcefully promote Western medical traditions while ignor-

ing the clients’ value of non-Western treatments such as

acupuncture, herbal therapy, or spiritual remedies. A goal

for nurses is to develop the approach of cultural relativism,

in which they recognize that clients have different ap-

proaches to their health, and that each culture should be

judged on its own merit and not on the nurse’s personal

beliefs.

• Cultural conlict is a perceived threat that may arise from

a misunderstanding of expectations between clients and

BOX 5.4 Types of Prejudice and Racist Behaviors

Overt Intentional Prejudice and Racism

Two homeless women, one African American and the other Irish American, are

clients at the neighborhood health care center. Both women are having inancial

dificulty. The African American client’s husband was laid off 4 years ago after

his company merged with another company. The Irish American client is under-

going radiation treatment for metastatic cancer and has lost her job as a result

of her prolonged illness. Both women are without health insurance. A nurse re-

ferred the Irish American client to social services but did not refer the African

American woman. The nurse believed that minority clients have direct experi-

ence with some local and national government programs; therefore these clients

know about available resources and can negotiate the social system for them-

selves and their families. In contrast, the nurse believed that the Irish American

woman had a catastrophic illness and had no experience negotiating govern-

ment programs, and therefore the nurse needed to advocate for her. The nurse,

not knowing the health-seeking behaviors of either client, stereotyped both

women and intentionally used her informational power to help one client while

denying assistance to the other client.

Overt Unintentional Prejudice and Racism

A nurse was assigned to make an initial visit to two clients recently discharged

from the hospital with a diagnosis of hypertension. The nurse performed physical

assessments on both clients. He developed an extensive culturally relevant

teaching plan with the Filipino American client that included information on so-

dium restriction and the effect on kidney functioning, ways to integrate cultural

foods into the diet, and support in lifestyle changes. With the Puerto Rican

American client, the nurse performed a routine physical assessment and did not

discuss the client’s culturally special dietary requirements. The nurse believed

that the Puerto Rican American client was not capable of understanding such

complex information and was going to continue to seek help from her curandera

(a folk practitioner) to manage the hypertension.

At the end of his visit, the nurse said to this client, “Take care of yourself. See

you next time.” This nurse did not realize that he had stereotyped the client and

that his actions were hurtful. He believed that he was providing quality care on

the basis of the client’s needs.

Covert Intentional Prejudice and Racism

A Native American nurse works in a home health agency that serves an ethni-

cally diverse community. The nurse has observed that the clients are always

among the poorest and live in the unsafe areas of the community, and she is

very concerned about her client care assignment. Her nonminority colleagues

are not assigned to those sections of the community. In a recent staff meet-

ing, she raised the concerns with her nursing supervisors. On hearing her

observations, the supervisors looked at her in a skeptical manner and asked

what she was talking about. This is covert racism because the nursing super-

visors were aware of the informal policy dictating that they assign minority

nurses to clients in a particular area of the community. They had discussed

the practice among themselves but would never admit to it. The supervisors

believed that the best way to ensure that minority clients would be the re-

cipients of culturally competent care was to assign a minority nurse to care

for them.

Covert Unintentional Prejudice and Racism

A lesbian middle-class couple legally adopted a physically challenged child.

Their insurance refuses to pay for the child’s medical care. The nurse, who has

been working for the agency for many years, is aware but failed to tell the par-

ents that the baby can qualify for Medicaid through the handicapped insurance

program, even though both parents work and their income is above the Medicaid

guidelines limit. This nurse was unaware that her dislike for the parents’ sexual

lifestyle inluenced her thinking (she had in the past provided heterosexual cou-

ples with information on how to apply for Medicaid).

80 PART 2 Inluences on Health Care Delivery and Nursing

nurses when either group is not aware of cultural differences

(Andrews and Boyle, 2012). Although cultural conlict is

unavoidable, it is important to know how to manage it while

delivering culturally competent care.

• Cultural shock is the feeling of helplessness, discomfort,

and disorientation experienced by an individual attempting

to understand or effectively adapt to another cultural group

that differs in practices, values, and beliefs. It results from

the anxiety caused by losing familiar sights, sounds, and

behaviors.

Being aware of clients’ cultural beliefs and knowing about

other cultures may help nurses be less judgmental, more accept-

ing of cultural differences, and less likely to engage in the

behaviors just listed that inhibit cultural competence.

CULTURAL NURSING ASSESSMENT

A cultural nursing assessment is a systematic way to identify

the beliefs, values, meanings, and behaviors of people while

considering their history, life experiences, and the social and

physical environments in which they live.

Skills such as listening, explaining, acknowledging, recom-

mending, understanding, and negotiating help the nurse be

nonjudgmental. It is vital that nurses listen to clients’ percep-

tions of their problems and, in turn, that nurses explain to cli-

ents the nurses’ perceptions of the problems. Nurses and clients

should acknowledge and discuss similarities and differences

between the two perceptions to develop suggestions and recom-

mendations for managing problems. Nurses also negotiate with

clients on nursing care actions to meet the needs of the clients.

Numerous tools are available to assist nurses in conducting

cultural assessments (Andrews and Boyle, 2012; Leininger,

2002b). The focus of such tools varies, and selection is deter-

mined by the dimensions of culture to be assessed.

During an initial contact with clients, nurses should perform

a general cultural assessment to obtain an overview of the clients’

characteristics. Nurses ask clients about their ethnic background,

language, education, religious afiliation, dietary practices, family

relationships, hospital experiences, occupation and socioeco-

nomic status, cultural beliefs, and language. Nurses also want to

know about clients’ distinctive features, perceptions of the health

issue, causation, treatment, anticipated results, and the impact

the issue might have on the client. This basic data can help nurses

understand the clients from the clients’ points of view and recog-

nize their uniqueness, thus avoiding stereotyping. Data for an

in-depth cultural assessment should be gathered over a period of

time and not restricted to the irst encounter with the client. This

gives both the client and the nurse time to get to know each other,

and it helps the client see the nurse in a helping relationship. An

in-depth cultural assessment should be conducted in two phases:

a data-collection phase and an organization phase.

The data-collection phase consists of three steps:

1. The nurse collects self-identifying data similar to those col-

lected in the brief assessment.

2. The nurse raises a variety of questions that seek information on

the clients’ perception of what brings them to the health care

system, the illness, and previous and anticipated treatments.

3. After the nursing diagnosis is made, the nurse identiies cul-

tural factors that may inluence the effectiveness of nursing

care actions.

FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES

The six quality and safety competencies for nurses that were identiied in the

Quality and Safety Education for Nurses (QSEN) project are client-centered care,

teamwork and collaboration, evidence-based practice, quality improvement,

safety, and informatics. Although each of these is important and pertinent to the

nursing actions taken with people from cultural groups other than that of the

nurse, perhaps the most signiicant is client-centered care. The chapter presents

many guidelines and principles for aiding nurses in providing culturally compe-

tent care. Client-centered care is often less than effective when the nurse and

client do not communicate effectively with one another. The lack of communica-

tion may occur when they speak different languages, when they have different

cultural practices and expectations that lead them to hear messages differently,

or when clients simply do not understand what the nurse is saying and are reluc-

tant to acknowledge it. Nurses must observe for both verbal and nonverbal cues

that a message is either understood or not understood. When the latter occurs,

the nurse should take action to clarify the message, and this may include asking

someone from that cultural group to assist or to enlist the aid of an interpreter

(Issel and Bekemeier, 2010).

The following targeted competency applies the QSEN competency of client-

centered interventions that relect cultural competence:

Targeted Competency: Client-Centered Intervention—Recognize the client

or designee as the source of control and full partner in providing compassion-

ate and coordinated interventions based on respect for client’s preferences,

values, and needs.

Important aspects of client-centered intervention include:

Knowledge: Describe strategies to empower clients or families in all aspects

of the health care process.

Skills: Communicate client values, preferences, and expressed needs to other

members of health care team.

Attitudes: Willingly support client-centered care for individuals and groups

whose values differ from own.

Client-centered care question: Competence in providing client-centered inter-

ventions involves not only effective interviewing of individual clients but developing

an awareness of their context. As a community-based clinician, it is helpful to famil-

iarize yourself with the cultural context of your clients. Learning about community

resources can sometimes be helpful in learning about the cultural context. You have

just been hired as a visiting nurse in a Hispanic community. What community re-

sources could you explore to assist you in providing effective client-centered care?

Answer:

• You might explore community centers. Where are they? How well frequented

are the community centers? Which programs are most popular? Which com-

munity center programs are health oriented?

• Are community members very involved with one or more churches? You might

familiarize yourself with elements of this faith tradition.

• Are there community elders who are publicly recognized as leaders in the

community? Can you meet with them to understand how the community has

changed and evolved over time?

Prepared by Gail Armstrong, PhD, DNP, ACNS-BC, CNE, Associate Professor, University of Colorado College of Nursing.

81CHAPTER 5 Cultural Inluences in Nursing in Community Health

In the organization phase, data related to the client’s and

family’s views on optimal treatment choices are examined,

and areas of difference between the client’s cultural needs and

the goals of Western medicine are identiied. Nurses may use

Leininger’s (2002a) three actions (discussed previously in this

chapter) to guide them in selecting and discussing culturally

appropriate interventions with clients.

The key to a successful cultural assessment lies in nurses be-

ing aware of their own culture. The nurse should consider the

following suggestions when eliciting cultural information:

• Be sensitive to the cues in the environment and be in tune

with the verbal and nonverbal communications before taking

action.

• Know about the resources in the community such as schools,

churches, clubs and other groups, hospitals, tribal councils,

restaurants, taverns, and bars.

• Know the speciic areas to focus on before beginning the

cultural assessment.

• Select a strategy for gathering cultural data. Possible strate-

gies include in-depth interviews, informal conversations,

observations of the client’s everyday activities or speciic

events, survey research, and a case-method approach to

study certain aspects of a client.

• Identify a conidante who will help “bridge the gap” between

cultures. Be aware that in some cultures the woman’s husband

or a close male family friend may be the person from whom

the nurse may need to obtain the cultural information.

• Know the appropriate questions to ask without offending

the client.

• Interview other nurses or health care professionals who have

worked with the speciic individual, family, or community to

get their input.

• Use a trained interpreter if the client has limited proiciency

with English.

• Talk with formal and informal community leaders to gain a

comprehensive understanding about signiicant aspects of

community life.

• Be aware that all information has both subjective and objec-

tive aspects, and verify and cross-check the information that

is collected before acting on it.

• Avoid the pitfalls that may occur when making premature

generalizations.

• Be sincere, open, and honest with yourself and the client.

BUILDING CULTURALLY COMPETENT ORGANIZATIONS

Although many of the same guidelines that apply to providing cul-

turally competent care also apply to building culturally competent

organizations, there are some areas that should be emphasized

at the organizational level. In considering how to build a more cul-

turally competent organization, it is useful to ask these questions:

1. Who lives in the community right now?

2. What kinds of diversity exists?

3. What kinds of relationships are established between cultural

groups?

4. Are the different cultural groups well organized?

5. What struggles exist between cultures?

6. What struggles exist within cultural groups?

7. Are these struggles openly recognized and talked about?

8. Are there efforts to build alliances and coalitions between

groups?

9. What issues do different cultural groups have in common

(Axner, 2015)?

Organizations have a culture that includes policies, proce-

dures, programs, and processes and that incorporates certain

values, beliefs, assumptions, and customs (Brownlee and Lee,

2015). Researchers at the University of Kansas have developed a

toolbox to help organizations become culturally competent.

They note that a culturally competent organizational model has

ive essential principles: (1) valuing diversity, (2) conducting

cultural assessment, (3) understanding the dynamics of differ-

ence, (4) institutionalizing cultural knowledge, and (5) adapt-

ing to diversity (Brownlee and Lee, 2015). These researchers

posit that diversity is reality and that changes in one part of the

world affect people everywhere. They cite the following steps as

key to building a multicultural organization that recognizes

diversity and aims to enable cultural differences to strengthen

rather than weaken the organization (Brownlee and Lee, 2015):

• Form a cultural competence committee.

• Write a mission statement.

• Find out what similar organizations have done, and develop

partnerships.

• Use free resources.

• Complete a comprehensive cultural competence assessment

of your organization.

• Find out which cultural groups exist in your community and

whether they access community services.

• Have a brown-bag lunch to get staff involved in discussion

and activities about cultural competence.

• Ask your personnel about their staff development needs.

• Assign part of your budget to staff development program-

ming in cultural competence.

• Include cultural competency requirement in job descriptions.

• Be sure your facility’s location is accessible and respectful of

difference.

• Collect resource materials on culturally diverse groups for

your staff to use.

• Build a network of natural helpers, community “informants”

and other “experts.”

P R A C T I C E A P P L I C A T I O N

Shu Ping was concerned about her father’s deteriorating health

and contacted her church friend, Ms. Johnson, a registered

nurse, for advice. A public health nurse had been visiting

the father since his recent discharge from the hospital, but the

father had asked this nurse not to discuss his diagnosis with his

family. After several weeks with the family, Ms. Johnson was

able to establish a close enough relationship with the father so

that she could talk with him privately about his health. He told

82 PART 2 Inluences on Health Care Delivery and Nursing

Ms. Johnson that he was diagnosed with cancer of the small

intestine, and he feared he was dying. He did not want the fam-

ily to know the “bad news.” He refused treatment because his

view was that people never got better after they were diagnosed

with cancer; they always died.

Which of the following actions by the public health nurse

would best demonstrate culturally competent care to the

family?

A. Discussing the medical treatment and surgical intervention

for cancer of the small intestine

B. Discussing with Shu Ping’s father the prognosis for a person

diagnosed with cancer of the small intestine in the United

States

C. With the father’s consent, requesting a conference involving

the primary physician, the father, and the family to discuss

the diagnosis and treatment options

D. Contacting the public health agency and discussing the

problem with them

Answers can be found on the Evolve website.

R E M E M B E R T H I S !

• The population of the United States is increasingly diverse.

Changes in immigration laws and policies have increased

migration, contributed to changes in community demo-

graphics, and heightened the need to recognize the impact of

culture on health care and the need for nurses to learn about

the culture of the individuals to whom they give care.

• Nurses who do not speak or understand the client’s language

should use an interpreter. In selecting an interpreter, nurses

should consider the clients’ cultural needs and respect their

right to privacy.

• Culture is a learned set of behaviors that is widely shared

among a group of people; the culture of people helps guide

individuals in problem solving and decision making.

• Members of minority groups are overrepresented on the

lower tiers of the socioeconomic ladder. Poor economic

achievement is also a common characteristic among popula-

tions at risk, such as those in poverty, the homeless, migrant

workers, and refugees. Nurses should be able to distinguish

between cultural issues and socioeconomic class issues and

not interpret behavior as having a cultural origin when, in

fact, it is based on socioeconomic class.

• Culturally competent nursing care is designed for a speciic

client, relects the individual’s beliefs and values, and is pro-

vided with sensitivity. Such nursing care helps improve

health outcomes and reduce health care costs.

• Nurses who are culturally competent use cultural knowledge

and speciic skills, such as intracultural communication and

cultural assessment, in selecting interventions to care for

clients.

• Four modes of action that nurses may use to negotiate with

clients and give culturally competent care are cultural pres-

ervation, cultural accommodation, cultural repatterning,

and cultural brokering.

• Barriers to providing culturally competent care are stereo-

typing, prejudice and racism, ethnocentrism, cultural impo-

sition, cultural conlict, and cultural shock.

• Nurses should perform a cultural assessment on every client

with whom they interact. Cultural assessments help nurses

understand clients’ perspectives of health and illness and

thereby guide them in discussing culturally appropriate

interventions. The needs of clients vary with their age, edu-

cation, religion, and socioeconomic status.

• Dietary practices are an integral part of the assessment

data. Efforts to understand dietary practices should go

beyond relying on membership in a deined group and

should include individual nutritional practices and reli-

gious requirements.

• A variety of steps can be taken to develop culturally compe-

tent organizations, and nurses can play a leading role in

doing so.

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February 26, 2015. http://www.migrationpolicy.gov/article/

frequently-requested-statistics-immigrants-and-immigration-

united-states/. Accessed January 8, 2016.

http://www.cdc.gov/immigrantrefugeehealth/guidelines/%0arefugee-guidelines.html

http://www.lawcom.com/immigration/chngs.shtml

http://www.minoritynurse.com

http://www.kff.org

http://www.immigrationforum.org/images/uploads/2010/ImmigrationBasics2010.pdf

http://www.minorityhealth.hhs.gov/templates/browse.aspx?lvl%ef%bc%9d2andlvlid%ef%bc%9d53

http://www.census.gov/hhes/www/poverty/data/threshld/index/html

http://www.census.gov/compendia/statab/

http://www.migrationpolicy.gov/article/%0afrequently-requested-statistics-immigrants-and-immigration-united-states/

“Environmental hazards inluence over 80% of the communi-

cable and noncommunicable diseases and injuries monitored

by WHO [World Health Organization]” and overall are respon-

sible for over one-half of the total burden of disease in the

world (WHO, 2011, p 1). Nurses can deine environment in a

variety of ways, including homes, schools, workplaces, and

communities. The environment is everything around us. Each

location holds potential health risks. It is both important for

and a responsibility of nurses to understand as much as possible

about these risks—how to assess them, how to eliminate or re-

duce them, how to communicate and educate about them, and

how to advocate for policies that support healthy environments.

We often take the environment for granted and may fail to see

the hazards in front of us. For example, how many of us know

Environmental Health

Barbara Sattler

6 C H A P T E R

After reading this chapter, the student should be able to:

1. Explain how the environment inluences human health and

disease.

2. Know which disciplines work most closely with nurses in

environmental health.

3. Describe legislative and regulatory policies that have inluenced

the effect of the environment on health and disease patterns.

O B J E C T I V E S

4. Describe the skills needed by nurses practicing in environ-

mental health, and apply the nursing process to the practice

of environmental health.

Historical Context

Environmental Health Sciences

Toxicology

Epidemiology

Multidisciplinary Approaches

Climate Change

Environmental Health Assessment

Air

Water

Land

Food

The Right to Know

C H A P T E R O U T L I N E

Risk Assessment

Assessing Environmental Health Risks in Children

Reducing Environmental Health Risks

Risk Communication

Ethics

Government Environmental Protection

Advocacy

Environmental Justice and Environmental Health Disparities

Unique Environmental Health Threats in the Health Care

Industry: New Opportunities for Advocacy

Referral Resources

Roles for Nurses in Environmental Health

agent, 88

bioaccumulated, 101

climate change, 89

compliance, 100

consumer conidence report (CCR),

enforcement, 99

environment, 84

environmental epidemiology, 88

environmental justice, 101

environmental standards, 100

epidemiological triangle, 88

epidemiology, 88

fracking, 93

host, 88

indoor air quality, 92

methylmercury, 101

monitoring, 100

nonpoint sources, 92

permitting, 99

persistent bioaccumulative toxins

(PBTs), 101

persistent organic pollutants

(POPs), 101

point sources, 92

right to know, 94

risk assessment, 94

risk communication, 98

toxicology, 87

K E Y T E R M S

85CHAPTER 6 Environmental Health

for certain that our drinking water is safe, or that the air we

breathe is free from pollutants that aggravate our individual

respiratory functions? Environmental health risks come in the

form of poor air and water quality, the use of pesticides, and

paint containing lead. Environmental hazards come in the

forms of biological, chemical, and radiological hazards. The

Environmental Protection Agency (EPA) lists six common air

pollutants. They are: ozone, particulate matter, carbon monox-

ide, nitrogen oxides, sulfur dioxide, and lead (EPA, 2015b).

As will be discussed later, the EPA also provides information

about safe drinking water and many of the other environmental

hazards.

A variety of factors, including genetics, socioeconomic

status, and environmental exposure, affect environmental

health. In evaluating environmental exposures in a home,

nurses’ assessments can begin with a set of questions: What

exposures can you identify in your own home? Do you use

pesticides? Does your home have lead-based paint? (The age

of a home is a good proxy for identifying the presence of

lead-based paint because it is most likely found in homes

built before 1978 when the use of lead was banned in house-

hold paint.) Is the paint chipping or peeling? Are any

of your appliances or heat sources producing unhealthy

levels of carbon monoxide? Have you checked your home

for radon, the second largest cause of lung cancer in the

United States? How about your workplace? Do you eat fish

on a regular basis? (Some fish can have unhealthy levels of

mercury.)

The American Nurses Association (ANA) recommends that

all nurses understand basic environmental health concepts,

including knowledge about environmental health and its effect

on nursing practice, the Precautionary Principle, and nurses’

rights to work in a safe workplace and use materials, products,

technology, and practices that relect an evidence-based ap-

proach. Other principles relate to quality assessment of the

environment, interdisciplinary work in environmental health,

involvement in research, and support of nurses who advocate

for a safe environment (ANA, 2007).

If children are in the home, are all the toxic cleaning mate-

rials and insecticides out of reach? Does the home or apart-

ment have lead in its paint? Many homes and apartments built

before 1978 have lead in the paint. Beginning in April 2010,

any contractor performing renovation or painting in a home,

child-care facility, or school built before 1978 and disturbing

more than 6 square feet must be trained and certiied in

how to prevent lead contamination (EPA, 2015a). We know

that exposure to lead can cause premature birth, learning dis-

abilities in children, hypertension in adults, and other health

problems (Fig. 6.1). The levels of the six common pollutants

measured by the EPA have been declining in recent years.

(EPA, 2015b). Thirty million Americans drink water that

exceeds one or more of the EPA’s safe drinking water stan-

dards, and 50% of Americans live in areas that exceed current

national ambient air quality standards. Given such reported

exposures, what is the role of nurses in community health?

Insecticides used in the home increase the risk of childhood

leukemia (Turner et al, 2010). Childhood leukemia is also

associated with prenatal exposures by parents who are ex-

posed to insecticides at work (Wigle et al, 2009). Exposure to

pesticides is especially problematic for children. Pesticides are

often found in lawn sprays and household bug sprays,

and they can also be found in foods such as strawberries,

blueberries, and apples (Gilden et al, 2010). Considering this

snapshot of the extent of environmental health issues, it is

clear why nurses need to be informed about the health of the

environment and its effect on people.

APPLYING CONTENT TO PRACTICE

Key documents that guide practice in both nursing and public health help

practitioners learn how to apply environmental health principles at home

and work. Speciically, the core competencies of the Council on Linkages

(2010) have, within the domain of public health science skills, a competency

that says practitioners will apply “the basic public health sciences (includ-

ing, but not limited to, environmental health sciences, health services ad-

ministration, and social and behavioral health sciences) to public health

policies and programs.” The Quad Council of Nursing (Swider et al, 2013)

updated the competences in 2013. The most explicit set of principles was

developed by the ANA (2007) in its Principles of Environmental Health for

Nursing Practice.

The ANA (2007) lists 10 principles of environmental health. Although all

10 are essential, 4 are mentioned here: Nurses should know about environ-

mental health concepts; participate in assessing the quality of the environ-

ment in which they practice; live and use the Precautionary Principle, which

refers to using products and practices that do not harm human health or the

environment; and take preventive action when uncertain. Another principle

points out that healthy environments are sustained through multidisci-

plinary collaboration, which is a key concept discussed throughout the

chapter.

FIG. 6.1 Child in home with lead-based paint. (From State of

Hawaii Department of Public Health. Retrieved September 2012

from http://hawaii.gov/health/environmental/noise/asbestoslead/

images2/child.jpg.)

http://hawaii.gov/health/environmental/noise/asbestoslead/images2/child.jpg

86 PART 2 Inluences on Health Care Delivery and Nursing

Chemical, biological, and radiological exposures that affect

our health come from the air we breathe, the water we drink,

the food we eat, and the products we use. Nurses need to know

how to assess for environmental health risks and develop edu-

cational and other preventive interventions to help individu-

als, families, and communities understand and, where possi-

ble, decrease the risks. The National Academy of Science’s

Institute of Medicine (IOM) recommends that all nurses have

a basic understanding of environmental health principles and

that these principles be integrated into all aspects of practice,

education, advocacy, policies, and research (Pope, Snyder, and

Mood, 1995). This chapter explores the basic competencies

recommended by the IOM (Box 6.1) and integrates them with

the ANA (2007) Principles of Environmental Health. Al-

though developed many years ago, the IOM principles remain

useful for today’s integration of environmental health into the

Standards for Environmental Health Nursing practice. Since

2008 the development of the irst environmental health nurs-

ing organization, the Alliance of Nurses for Healthy Environ-

ments (ANHE), and collaboration with other nursing organi-

zations, has been able to advance the recommendations of the

1995 IOM report (Leffers et al, 2014). The federal govern-

ment, like important nursing and public health associations,

has long recognized the importance of the relationship be-

tween environmental risks and diseases. Consistent with this

recognition, environmental health is one of the priority areas

HISTORICAL CONTEXT

Nurses, like physicians, have been taught little about the

environment and environmental threats to health. This

recognition led the IOM to evaluate the current state of

environmental health knowledge and skills applied in nurs-

ing. The IOM report Nursing, Health, and Environment

(Pope et al, 1995), written nearly two decades ago, noted that

the environment, as a determinant of health, is deeply rooted

in nursing’s heritage. As mentioned in Chapter 2, Florence

Nightingale, well known for her work in the Crimean

War, practiced and wrote about how the quality of the envi-

ronment influenced health and recovery from illness. She

talked about the importance to the patient’s health of fresh

air, pure water, adequate food, good drainage, cleanliness,

and light, especially good sunlight. Early in the 20th century,

Lillian Wald, who coined the term public health nurses,

and her colleague Mary Brewster worked tirelessly to im-

prove the environment of the Henry Street neighborhood

and used their network of influential contacts to make

changes in the physical environment and social conditions

that affected health (Wright, 2003). The need to pay close

attention to the environment and its effect on health is

as crucial today as it was in earlier times. The environment

is different than it was a century ago, and people have

made many of the detrimental changes. In addition to envi-

ronmental contamination, many of the human-made chemi-

cals can now also be found in our bodies (including in breast

milk) in measurable amounts. To understand the relationship

between the environment and health, some knowledge about

toxicology and other environmental sciences is necessary.

It is also important to know that people who live in poverty

are more likely to be exposed to environmental hazards in situa-

tions such as crowded living conditions, living closer to hazard-

ous wastes, having poorer-quality foods available to them, and

being exposed to hazards such as lead in paint, pollution in the

air or water, or hazardous jobs.

EH-8.1: Eliminate elevated blood lead levels in children.

EH-8.9: Minimize the risks to human health and the environment posed by

hazardous sites.

EH-8.10: Reduce pesticide exposures that result in visits to a health care

facility.

EH-8.11: Reduce the amount of toxic pollutants released into the environment.

EH-8.13: Reduce indoor allergen levels.

EH-8.18: Decrease the number of US homes that are found to have lead-based

paint or related hazards.

From US Department of Health and Human Services: Healthy People

2020, Washington, DC, 2010, US Government Printing Ofice.

HEALTHY PEOPLE 2020

Selected Objectives Related to Environmental

HealthBasic Knowledge and Concepts All nurses should understand the scientiic principles and underpinnings of the

relationship between individuals or populations and the environment (includ-

ing the work environment). This understanding includes the basic mechanisms

and pathways of exposure to environmental health hazards, basic prevention

and control strategies, the interdisciplinary nature of effective interventions, and

the role of research.

Assessment and Referral

All nurses should be able to successfully complete an environmental health

history, recognize potential environmental hazards and sentinel illnesses, and

make appropriate referrals for conditions with probable environmental causes.

An essential component is the ability to locate referral sources, access them,

and provide information to clients and communities.

Advocacy, Ethics, and Risk Communication

All nurses should be able to demonstrate knowledge of the role of advocacy

(case and class), ethics, and risk communication in client care and community

intervention with respect to potential adverse effects of the environment on

health.

Legislation and Regulation

All nurses should understand the policy framework and major pieces of legis-

lation and regulations related to environmental health.

BOX 6.1 General Environmental Health Competencies for Nurses

From Pope AM, Snyder MA, Mood LH, editors: Nursing, health, and

environment, Washington, DC, 1995, Institute of Medicine, National

Academies Press.

of the Healthy People 2020 objectives (see the Healthy People

2020 box).

87CHAPTER 6 Environmental Health

ENVIRONMENTAL HEALTH SCIENCES

TOXICOLOGY

Toxicology is the basic science that studies the health effects

associated with chemical exposures. Its corollary in health

care is pharmacology, which studies the human health effects,

both desirable and undesirable, associated with drugs. In

toxicology, only the negative effects of chemical exposures are

studied. However, the key principles of pharmacology and

toxicology are the same. Just as the dose of a drug inluences

its effectiveness and its toxicity, the quantity of an air or water

pollutant to which we may be exposed will determine the risk

for experiencing a negative health effect. Also, the timing of

exposure affects the risk for an untoward health effect. For

example, during embryonic and fetal development, exposure

to toxic chemicals can create immediate harm or create a

critical pathway for future disease. Very young children are

especially susceptible to exposures because of the immature

development of their systems.

Both drugs and pollutants can enter the body by a variety

of routes. Most drugs are given orally and are absorbed via

the gastrointestinal tract. Water- and food-associated pol-

lutants, including pesticides and heavy metals, enter the

body via the digestive tract. Some drugs are administered as

inhalants, and some pollutants in the air (including indoor

air) enter the body via the lungs. Some drugs are applied

topically. In work settings, employees can receive dermal

exposures from toxic chemicals when they immerse unpro-

tected hands in chemical solutions. Pollution can enter

the body via the lungs (inhalation), gastrointestinal tract

(ingestion), and skin and mucous membranes (dermal ab-

sorption). Some chemicals can cross the placental barrier

and affect the fetus. In addition to direct damage to cells,

tissues, organs, and organ systems, changes to the DNA

can occur from chemical exposures that can change gene

expression, which in turn, can predict disease. This latter

effect is the focus of a relatively new field of biological

study—epigenetics. Scientists now understand that many

variables predict disease outcomes, including environmen-

tal exposures.

When we administer medications to patients, we consider

age, weight, other drugs taken, and the underlying health status

of the person. We should also make it clear to clients that tak-

ing the prescription or over-the-counter drug more often than

recommended can have a toxic effect. Likewise, we must also

consider how environmental exposures affect community

members. For example, children are more vulnerable to almost

all pollutants. More vulnerable to foodborne and waterborne

pathogens are immunocompromised people, such as (1) those

infected with the human immunodeiciency virus (HIV),

(2) those who have acquired immunodeiciency syndrome

(AIDS), (3) those who are taking chemotherapeutic drugs, or

(4) those who are organ recipients. When assessing a commu-

nity’s environmental health status, be sure to review the gen-

eral health status of the community to identify members who

Knowing about chemicals and using that information in

practice can seem like a huge task. Fortunately, chemicals can be

grouped into families so that it is possible to understand the

actions and risks associated with these groups. The following

are examples:

1. Metals and metallic compounds, such as arsenic, cadmium,

chromium, lead, and mercury

2. Hydrocarbons, such as benzene, toluene, ketones, formalde-

hyde, and trichloroethylene

3. Irritant gases, such as ammonia, hydrochloric acid, sulfur

dioxide, and chlorine

4. Chemical asphyxiants, including carbon monoxide, hydro-

gen sulide, and cyanides

5. Pesticides, such as organophosphates, carbamates, and chlo-

rinated hydrocarbons

Technology helps us understand environmental threats.

The National Library of Medicine (NLM) has a set of user-

friendly online databases that focus on environmental health

and toxicology called TOXNET (see http://www.toxnet.nlm.

nih.gov). Using chemical name search terms and display

options of health effects, some potential environmental

CHECK YOUR PRACTICE:?

Many cities and counties sponsor medicine take-back programs during

which residents can drop off unused medicines. These community events

may be sponsored by the US Drug Enforcement Administration (DEA) or

by local law enforcement agencies. You can contact a city or county govern-

ment’s trash and recycling service to learn what is available in the local

area. Pharmacists are also a good source of information about disposing

of unused medicines. If no take-back program is available, follow these

steps:

• Mix medicines (do not crush tablets or capsules) with an unpalatable

substance such as kitty litter, dirt, or used coffee grounds.

• Place the mixture in a container, such as a sealed bag.

• Throw the container in your household trash.

• Scratch out all personal information on the prescription label of your empty

container or packaging, then dispose of the container.

• In 2015, the national take-back initiative was held on September 26, except

in Pennsylvania and Delaware, which chose September 12, 2015, and it

was discussed on the radio, on television, and in newspapers in many local

areas. At this time communities teamed up with local law enforcement

agencies. Since this program began in 2010, 2411 tons of unwanted,

unneeded, or expired medications have been taken back.

• There are a small number of drugs that that are especially harmful, and

possibly fatal, if only one dose is used by someone other than the person

for whom the medication was prescribed.

• The DEA provides a list of medications that can be disposed of by lushing

down the sink or toilet (see the DEA citation in the source note).

Drug Enforcement Administration: DEA Announces 10th National Drug

Take-Back. 2015. http://www.dea/gov/divisions/hq/2015/hq072815.shtml;

US Food and Drug Administration: “Disposal of unused medicines:

what should you know?” http://www.fda.gov/drug disposal. Washington,

DC, 2015, FDA. Retrieved February 2016.

may have higher risk factors as well as to assess the environ-

mental exposures. It is also important to teach community

residents how to effectively dispose of medications they no

longer need.

http://www.dea/gov/divisions/hq/2015/hq072815.shtml

http://www.fda.gov/drug%20disposal

http://www.toxnet.nlm.nih.gov

88 PART 2 Inluences on Health Care Delivery and Nursing

threats to health can be understood or ruled out. It is impor-

tant to remember that all nursing assessments, whether

of individuals or communities, must consider environmen-

tal exposures that may contribute to illness. Once you iden-

tify potential health risks, you can then develop a risk

reduction plan.

EPIDEMIOLOGY

Whereas toxicology is the science that studies the poisonous

effects of chemicals, epidemiology is the science that helps us

understand the strength of the association between exposures

and health effects in human populations. Chapter 9 discusses

epidemiology in detail. However, a few points are relevant here

because epidemiology is an applied science used in environ-

mental health. Epidemiological studies have helped explain

the association between learning disabilities and exposure to

lead-based paint dust, as well as asthma exacerbation and air

pollution (Smargiasssi et al, 2014; Habre et al, 2014) and gastro-

intestinal disease and exposure to Cryptosporidium in contami-

nated water (Yoder et al, 2012). Epidemiology also helps in the

examination of occupation-related illnesses. Environmental

surveillance efforts, such as childhood lead registries, use epide-

miological methods to track and analyze incidence, prevalence,

and health outcomes.

As discussed in Chapter 9, three major concepts—agent,

host, and environment—form the classic epidemiological

triangle. This simple model helps explain the often-complex

relationships among agent, which may include chemical mix-

tures (i.e., more than one agent); host, which may refer to a

community spanning different ages, both sexes, ethnicities,

cultures, and disease states; and environment, which may in-

clude dynamic factors such as air, water, soil, and food, as well

as temperature, humidity, and wind. Limitations of environ-

mental epidemiology include a reliance on occupational

health studies to characterize certain toxic exposures. Studies

are usually performed on healthy adults whose biological sys-

tems are different from those of neonates, pregnant women,

children, the immunosuppressed, and older adults. Geographic

information systems (GIS) are used in environmental health

studies to code data so that they can be related spatially to a

place on Earth. For example, a nurse could combine geograph-

ically related data to develop maps to note where the data

can be related. Speciically, by taking a data set that geographi-

cally notes where children under 10 years of age live and over-

laying another data set that notes geographic areas designated

by the age of housing stock, a public health nurse could deter-

mine locations with the largest number of children who live in

areas with older housing stock. Using this information, the

nurse could target a lead surveillance and educational program

(Fig. 6.2).

MULTIDISCIPLINARY APPROACHES

In addition to toxicology and epidemiology, some earth

sciences help explain how pollutants travel in air, water, and

soil. Geologists, meteorologists, and chemists all contribute

information to help understand how and when humans may be

exposed to hazardous chemicals, radiation (such as radon), and

biological contaminants. The public health ield also depends

on food safety specialists, sanitarians, radiation specialists, and

industrial hygienists.

The nature of environmental health requires a multidisci-

plinary approach to assess and decrease environmental health

risks. For instance, to assess and address a case of lead-based

paint poisoning, the team might include a housing inspector

with expertise in lead-based paint or a sanitarian to assess the

lead-associated health risks in the home; clinical specialists to

manage the clients’ health needs; laboratory workers to assess

lead levels in the clients’ blood as well as in the paint, house

dust, and drinking water; and lead-based paint remediation

specialists to reduce the lead-based paint risk in the home.

This approach could potentially involve the local health de-

partment, the state department of environmental protection,

the housing department, a tertiary care setting, and public or

private sector laboratories. It is important that nurses under-

stand the roles of each respective agency and organization,

know the public health laws (particularly as they pertain to

lead-based paint poisoning), and work with the community

to coordinate services to address the community’s needs. The

nurse also might set up a blood-lead screening program

through the local health department, educate local health

providers to encourage them to systematically test children

for lead poisoning, or work with local landlords to improve

the condition of their housing stock. Factors contributing to

Protect

Your

Family

From

Lead In

Your

Home

United States Environmental Protection Agency

EPA

United States Consumer Product Safety Commission

United States Department of Housing and Urban Development

FIG. 6.2 Lead paint warning. (From US Environmental Protec-

tion Agency.)

89CHAPTER 6 Environmental Health

CLIMATE CHANGE

According to the WHO, climate change “is a signiicant and

emerging threat to public health, and changes the way we must

look at protecting vulnerable populations” (WHO, 2015). The

2014 report of the Intergovernmental Program on Climate

Change (IPCC), a WHO-related group of scientists, concludes

that “climate change will act mainly, at least until the middle of

this century, by exacerbating health problems that already exist,

and the largest risks will apply to populations that are currently

most affected by climate-related diseases” (IPCC, 2014). Between

2030 and 2050 climate change is expected to cause approximately

250,000 additional deaths annually as a result of malnutrition,

malaria, diarrhea, and heat stress (WHO, 2015). Climate change

affects social and environmental determinants of health, includ-

ing clean air, safe drinking water, adequate food, and secure

shelter (WHO, 2015). In the United States we have seen some of

the earlier climate change predictions materialize: long-term

warming trends, extreme weather conditions leading to danger-

ous trafic conditions, as well as disruption in water supplies,

agriculture, ecosystems, and coastal communities. Children; the

elderly; the sick, especially those with chronic health conditions;

the poor; and some minority communities, especially those with

language barriers, mental health issues, and lack of access to com-

prehensive health care, are among the most vulnerable to these

health effects (Allen, 2015).

Climate changes around the world lead to global warming.

The greenhouse effect is inluencing the prevalence of global

warming. The greenhouse effect refers to the rise in temperature

that occurs when the Earth experiences certain gases in the at-

mosphere, such as water vapor, carbon dioxide, nitrous oxide,

and methane, which trap incoming solar radiation from the

sun (Afzal, 2007). A certain amount of the greenhouse effect is

essential for human life; however, an excess is dangerous. The

goal is to reduce the amount of heat in the environment, be-

cause high temperatures in the presence of sunlight and certain

air pollutants can lead to the formation of ground-level ozone.

Increased exposure to ozone is associated with increased risk of

premature mortality. This risk supports the growing trend to-

ward actions such as walking not driving, recycling, and pur-

chasing energy-eficient cars, appliances, and lightbulbs. Re-

member, electricity is wasted each day when lights are left on, so

teach clients to turn off lights when not using them to decrease

the amount of carbon dioxide (CO2) greenhouse gas emissions

(Fig. 6.3).

There are two concurrent categories of roles for nurses:

mitigation and response. There is still much we can do to

mitigate the steep upward slope that we are now observing for

temperatures, CO2 levels, desertiication, and sea water levels.

Working at the individual, community, institutional (school,

hospital, etc.), and governmental levels, there is much work to

be done to ensure energy-conserving policies and practices,

rational transportation practices, and changes in our con-

sumption patterns.

Regarding response preparation, public health nurses

must lead the development of contingencies for long-term,

high-heat weather conditions, as well as increased storm ac-

tivities (that include more severe storm patterns), more ex-

tensive ires in areas prone to ires, and the associated disaster

preparedness. Often, the recovery from extreme climate

change is long and complicated when people lose homes and

their possessions and when the community infrastructure,

including schools and hospitals, is damaged (Allen, 2015).

Standing water and warm temperatures are breeding grounds

for mosquitos, and this can increase the disease burden for

humans. Other climate-change events that affect health are

extreme heat events, air pollution, airborne allergens, and the

mental health risks associated with changes in climate that

lead to signiicant community and health disruption (Allen,

2015). For more on disaster preparedness, see Chapter 23 on

nurses’ roles in disaster management.

FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES

Targeted Competency: Function effectively within nursing and interpro-

fessional teams, fostering open communication, mutual respect, and shared

decision making to achieve quality client care.

Important aspects of safety include the following:

• Knowledge: Describe scopes of practice and roles of health care team

members.

• Skills: Assume role of team member or leader based on the situation.

• Attitudes: Value the perspectives and expertise of all health team members.

Safety Question: One of the objectives in Healthy People 2020 related

to environmental health is as follows: “Reduce pesticide exposures that

result in visits to a health care facility” (ED: 8-10). The public health nurse

who is working on a project to help mothers develop parenting skills visits

a new mother who lives and works on a large farm. When the nurse drives

into the farm on her way to the housing where workers live, she sees that

the fields are being sprayed with pesticides from a truck and that two

young children are riding in the back of the truck. What action should

she take?

Answer: At the individual level, she should talk with the owner or manager of

the farm and remind him or her of the toxicity of pesticides and the danger to those

who are in the vicinity of the spraying. She should recommend that he or she not

allow anyone to ride in the open portion of the vehicle and that the driver should

leave the window closed and wear a mask to protect his or her nose and mouth.

At the systems level, she should identify areas where the workers on the area

farms congregate, such as churches, social halls, and so forth. Then she should

ask if she could provide an educational program on the dangers of coming into

contact with pesticides. She could distribute pamphlets about this hazard in

local venues where both farm managers and workers will be able to access

them. What else might the nurse do?

the reduction of lead levels in the United States include

elimination of lead in paint, reduction of lead in gasoline,

reduction in the number of manufactured food and drink

cans and household plumbing components containing lead

solder, lead screening laws, and lead paint–abatement pro-

grams in communities.

The National Environmental Public Health Tracking Net-

work, known as the Tracking Network, is a surveillance system

90 PART 2 Inluences on Health Care Delivery and Nursing

Hurricanes pose enormous challenges for public health nurses in many ways, including

their effects on the environment. Reifsnider et al (2014) used a community-based study

that was in effect when Hurricane Ike struck the Texas coast. Their purpose was

to detail the challenges faced by public health nurse researchers when a costly hurri-

cane interrupts their ongoing study. Hurricane Ike was a Category 2 storm that was

the fourth most destructive hurricane to make landfall in the United States as of 2008.

The hurricane affected the physical, environmental, economic, and health and social

service subsystems of the community. A year later about 20% of the population had

failed to return to Galveston, Texas. The hurricane disproportionally affected low-

income residents. Also, all nonessential personnel were not allowed to return to

Galveston, an island, for weeks following the hurricane, and this included researchers.

The researchers in this National Institutes of Health (NIH)–funded study, titled

“Reducing Overweight Among Galveston WIC Participants,” had signiicant problems

due to damage to clinic sites and their subsequent closure and the inability to reach

Severe

weather

Cholera,

cryptosporidiosis,

camplyobacter, leptospirosis,

harmful algal blooms

is ing

More extre m

et e m

pe ra

ture s

Inc re

as in

CO 2 l

ev e ls

R ising

se a levels

ea th

e r

Air

pollution

IMPACT OF CLIMATE CHANGE ON HUMAN HEALTH

Injuries, fatalities,

mental health impacts

Asthma,

cardiovascular disease

Malaria, dengue,

encephalitis, hantavirus,

Rift Valley fever,

Lyme disease,

chikungunya,

West Nile virus

Forced migration,

civil conflict,

mental health impacts

Malnutrition,

diarrheal disease

Respiratory

allergies, asthma

Heat-related illness

and death,

cardiovascular failure

Extreme

heat

Environ-

mental

degrad-

ation

Water and food

supply impacts

Water quality

impacts

Increasing

allergens

Changes

in vector

ecology

FIG. 6.3 Climate effects on health. (From CDC, Climate and Health, 2015, www.cdc.gov/

climateandhealth/effects/default.htm. Retrieved February 2016.)

EVIDENCE-BASED PRACTICE

Reifsnider E, Bishop, SL, An, K, Mendias, E, Welker-Hood, K, Moramarco ME and Davila YR: 2014. We stop for no storm: coping with an environmental

disaster and public health research, Public Health Nursing 31(6):500-507.

residents due to lack of telephones and electricity. The WIC clinics in Galveston

County did resume operations after 2 months, but many participants could not be

located. The researchers creatively found ways to adapt or modify their study to ac-

complish their goals despite the disruption to their original plan and patient population.

Nurse Use

These researchers learned irsthand the importance of storing their research

documentation away from potential looding and having multiple ways to reach

the research team. They learned how important it is to create emergency contact

cards and have an emergency contact procedure. The article clearly describes

what can go wrong when a disaster hits a community and interrupts the usual

environment, including the technological systems as well as water, air, soil, and

so forth. The authors identify many lessons they learned from this disaster that

can be transferred to other environmental disasters.

coordinated by the Centers for Disease Control and Preven-

tion (CD) that collects, integrates, analyzes, interprets, and

disseminates data from environmental hazard monitoring and

from human exposure and health effects surveillance. At pres-

ent the CDC is funding 23 states and New York City to build

local tracking networks. On the Tracking Network website,

you can view maps, tables, and charts about the following:

• Chemicals and other substances found in the environment

• Selected chronic diseases and conditions

• Conditions or issues in the area where you live

• Pesticide exposure and pesticide-related illnesses (Anderko

et al, 2014; CDC, 2014).

ENVIRONMENTAL HEALTH ASSESSMENT

Environmental health risks can be assessed in various ways. You

might assess by environmental factors such as air, water, soil, or

food. Or you could assess by setting, such as urban, rural, or sub-

urban. You can also divide the environment into functional loca-

tions, such as home, school, workplace, and community. Each of

these locations may provide unique environmental exposures and

overlapping exposures. For instance, ethylene oxide, the toxic gas

used to sterilize equipment in hospitals, is typically found only in

a workplace. However, pesticides might be found in all four areas.

When assessing environments, determine whether an exposure is

in the air, water, soil, or food (or a combination) and whether it is

http://www.cdc.gov/climateandhealth/effects/default.htm

91CHAPTER 6 Environmental Health

A mnemonic was developed to help health professionals re-

member the questions to ask when taking an environmental

history and determine the environmental exposure history.

Exposures may occur in any setting in which people spend

time; be sure to assess them all. The “I PREPARE” mnemonic

can be used when assessing an individual, family, or community

(Box 6.2).

A windshield survey is a helpful first step to understand-

ing the potential environmental health risks in a community.

If the community is urban, the age and condition of the

housing and potential trash problems (and the associated

pest problems) can be easily determined by driving around

the neighborhood. Note also the proximity to factories,

dumpsites, major transportation routes, and other sources

of pollution.

In rural communities, pay attention to the use of aerial and

other types of pesticide and herbicide spraying. Do people use

wood-burning stoves? Do you see or suspect contaminated

waterways, and are there industrial-type agricultural practices

that might contribute to pollution?

Prepared by Grace Paranzino, RN, MPH, for the Agency for Toxic Substances and Disease Registry (ATSDR). For more information, contact ATSDR

at 1-888-42-ATSDR, or visit the ATSDR’s website at http://www.atsdr.cdc.gov.

BOX 6.2 The “I PREPARE” Mnemonic

An exposure history should identify current and past exposures, have a prelimi-

nary goal of reducing or eliminating current exposures, and have a long-term

goal of reducing adverse health effects. The “I PREPARE” mnemonic consigns

the important questions to categories that can be easily remembered.

I Investigate Potential Exposures

Investigate potential exposures by asking,

• Have you ever felt sick after coming in contact with a chemical, pesticide, or

other substance?

• Do you have any symptoms that improve when you are away from your home

or work?

P Present Work

At your present work,

• Are you exposed to solvents, dust, fumes, radiation, loud noise, pesticides, or

other chemicals?

• Do you know where to ind material data safety sheets on the chemicals with

which you work?

• Do you wear personal protective equipment?

• Are work clothes worn home?

• Do coworkers have similar health problems?

R Residence

At your place of residence,

• When was your residence built?

• What type of heating do you have?

• Have you recently remodeled your home?

• What chemicals are stored on your property?

• Where does your drinking water come from?

E Environmental Concerns

In your living environment,

• Are there environmental concerns in your neighborhood (i.e., air, water, soil)?

• What types of industries or farms are near your home?

• Do you live near a hazardous waste site or landill?

P Past Work

About your past work,

• What are your past work experiences?

• What is the longest job you held?

• Have you ever been in the military, worked on a farm, or done volunteer or

seasonal work?

A Activities

About your activities,

• What activities and hobbies do you and your family engage in?

• Do you burn, solder, or melt any products?

• Do you garden, ish, or hunt?

• Do you eat what you catch or grow?

• Do you use pesticides?

• Do you engage in any alternative healing or cultural practices?

R Referrals and Resources

Use these key referrals and resources:

• Environmental Protection Agency (http://www.epa.gov)

• National Library of Medicine, TOXNET programs (http://www.nlm.nih.gov)

• Agency for Toxic Substances and Disease Registry (http://www.atsdr.cdc.gov)

• Association of Occupational and Environmental Clinics (http://www.aoec.org)

• Material safety data sheets (http://www.hazard.com/msds)

• Occupational Safety and Health Administration (http://www.osha.gov)

• Local health department, environmental agency, poison control center

E Educate

Use this checklist of educational materials:

• Are materials available to educate the client?

• Are alternatives available to minimize the risk for exposure?

• Have prevention strategies been discussed?

• What is the plan for follow-up?

a chemical, biological, or radiological exposure. In any form of

assessment, be sure to cover past and present conditions in work,

home, and community environments. The How To box demon-

strates how to apply the nursing process to environmental health.

HOW TO Apply the Nursing Process to Environmental Health If you suspect that a client’s health problem is inluenced by environmental

factors, use the nursing process, noting the environmental aspects of the

problem in every step of the process as follows:

1. Assessment: Include inventories and history questions that cover

environmental issues as a part of the general assessment.

2. Diagnosis: Relate the disease and the environmental factors in the diagnosis.

3. Goal setting: Include outcome measures that mitigate and eliminate the

environmental factors.

4. Planning: Look at community policy and laws as methods to facilitate the care

needs for the client; include environmental health personnel in the planning.

5. Intervention: Coordinate medical, nursing, and public health actions to

meet the client’s needs.

6. Evaluation: Examine criteria that include the immediate and long-term re-

sponses of the client, as well as the recidivism of the problem for the client.

http://www.epa.gov

http://www.nlm.nih.gov

http://www.atsdr.cdc.gov

http://www.aoec.org

http://www.hazard.com/msds

http://www.osha.gov

http://www.atsdr.cdc.gov

92 PART 2 Inluences on Health Care Delivery and Nursing

In addition to the tools used for a general community assess-

ment, some speciic tools are available to detect the environmen-

tal health risks within a community. The Right to Know section

of the chapter describes the types of information available to the

public about air and water emissions, drinking water quality,

and other environmental sources. In addition, Appendix B.3 is a

community health assessment tool that provides an example of

an environmental health assessment form. Observe also for

positive environmental factors such as green spaces in parks and

gardens, bike and walking paths, and water features.

AIR

Air pollution is a signiicant contributor to health problems. Air

pollution is divided into two major categories: point sources,

often called ixed sites, which are individual, identiiable sites,

such as smokestacks, and nonpoint sources, which include ve-

hicles, such as cars, trucks, and buses. The Clean Air Act, passed

in 1970, regulates air pollution from both point sources and

nonpoint sources. Motor vehicles are the greatest single source

of air pollution in the United States. The burning of fossil fuels

(diesel, industrial boilers, and power plants) and waste incin-

eration are two other major contributors. The single greatest

source of mercury in our air is coal-ired power plants. Health

effects associated with air pollution include asthma and other

respiratory diseases, cardiovascular diseases (including heart

disease and hypertension), cancer, immunological effects, re-

productive health problems (including birth defects), infant

deaths, and neurological problems (Smargiassi et al, 2014).

According to WHO (2013), approximately 235 million people

suffer from asthma; it is common among children, and the

strongest risk factors are genetic factors and inhaled substances

and particles that provoke an allergic response or irritate the

airways. Also, many people do not know that a pea-sized

amount of mercury is suficient to contaminate a 25-acre lake

and make its ish unit to eat. Mercury, like lead, is an element,

and it persists in the fresh waterways and oceans from which we

continue to get our ish. We cannot readily take these elements

out once they have been released into the environment; our job

is to focus on policies that prevent them from being released.

You can learn the major pollutants being released in your

zip code area and other geographically related environmental

information by accessing http://www.epa.gov/enviro/.

Indoor air quality in the workplace, schools, and homes is a

growing concern because of the alarming rise in the incidence

of asthma in the United States, particularly among children.

Both the EPA and the American Lung Association provide ex-

cellent materials on indoor air quality. The EPA has a free kit

called Indoor Air Quality: Tools for Schools, which includes a

video and materials to help people improve the air quality in a

school building. The major culprits contributing to poor in-

door air are carbon monoxide, dust, molds, dust mites, cock-

roaches, pests and pets, cleaning and personal care products

(particularly aerosols), lead, and, of course, environmental to-

bacco smoke (Fig. 6.4). It is important to assess both the envi-

ronmental exposures and the human health status in a com-

munity. Health status is assessed using local, state, and national

health data; by collecting our own data; or by a combination of

Lightning

Volcanos

Wildfires

Forests

Livestock

Cities

Airplanes

Cars, Trucks, Buses, Motorcycles

Fertilizer

Natural

Area

Mobile

Pollutant Emissions

Stationary

Industry, Power Plants, Sewage Treatment

FIG. 6.4 Air pollution. Air pollution comes from a wide range of sources. The EPA’s Envirofacts

site (http:www.epa.gov/enviro/) allows you to check the air and other pollutants in your zip

code. (From National Park Service. Sources of air pollution, www.nature.nps.gov. Accessed

May 7, 2017.)

http://www.epa.gov/enviro/

http://www.nature.nps.gov

93CHAPTER 6 Environmental Health

the two. Box 6.3 provides governmental, nongovernmental pro-

fessional, and other online resources.

Carbon monoxide is a particularly dangerous gas that can be

emitted into the air. It is an odorless, colorless, tasteless gas that

is produced when carbon-containing fuels, such as oil, kero-

sene, coal, or wood, are not completely combusted; it can also

build up as a result of inadequate natural gas ventilation. Poi-

soning by carbon monoxide occurs most often in the fall

and winter when buildings are being heated. When teaching

clients how to avoid exposure to carbon monoxide, be sure to

advise them to be aware of the possibility of faulty furnaces,

motor vehicles, stoves and gas ranges, and vented gas heaters,

which are common sources of carbon monoxide poisoning

(Rosenthal, 2006). Because carbon monoxide is so dificult to

detect, it is the leading cause of death attributable to poisoning

in industrialized nations.

Fracking presents a number of public health issues because

of its effects on both water and air. It is the process of drilling

down into the earth and then directing a pressurized mixture

of water, sand, and chemicals into the shale to allow the gas to

low out of the head of the well. Up to 600 chemicals are used

in fracking, and many are known to be carcinogens and toxic.

See http://www.dangersoffracking.com for details. The ANHE

has an excellent fact sheet on public health and fracking. It

provides a list of select pollutants associated with fracking

that have known health effects. In general, public health issues

related to fracking relate to the chemicals that pollute the

water and air. Air pollution from drilling and fracking opera-

tions comes from shale drilling, gas processing, gas escapes,

and diesel exhaust, which have a negative effect on air quality.

There is a range of hazardous air emissions associated with a

range of diseases, including asthma, chronic obstructive pul-

monary disease, and cancer, to name a few. In addition, the

chemicals often get into drinking water, especially water from

private wells. Speciically, drinking water can be contaminated

through methane migration, spills and leaks of fracking

chemicals and luids, radiation, and mismanagement of frack-

ing water. Additionally, the process of fracking consumes huge

amounts of water (ANHE, 2013).

WATER

Water is necessary for all forms of life. Human bodies are 70%

water. Only 2.5% of the water on this planet is freshwater, and

saltwater comprises the rest. Much of the freshwater is in the ice

of the polar icecaps; groundwater makes up most of what re-

mains, leaving only 0.01% in lakes, creeks, streams, rivers, and

rainfall. People’s lives are tied to a safe and adequate water sup-

ply. Water is necessary for the production of food—another

essential to life. The quality of the soil is affected by its water

supply, the chemicals that are intentionally added by humans,

and the deposition of pollutants from the air. Soil that is free

BOX 6.3 Environmental Health Resources

Resources for Environmental Assessments

• American Nurses Association (http://www.nursingworld.org): provides infor-

mation on workplace health and safety and environmental health as it pertains

to nursing.

• US Environmental Protection Agency (EPA) (http://www.epa.gov): provides a

range of timely information. For example, in January 2016, the website had

a feature related to storm preparedness. Other EPA resources include the

following:

• Envirofacts (http://www3.epa.gov/enviro/): search by location and ind

the environmental concerns related to air, water, toxic emissions, and

compliance.

• IAQ Tool for Schools (http://www.epa.gov/iaq-schools): for a free copy of

the EPA’s IAQ Tools for Schools.

• Safe water (https://www.epa.gov/ground-water-and-drinking-water)

• “Surf Your Watershed” database (https://cfpub.epa.gov/surf/locate/

index.cfm)

• Ofice of Pesticides (http://www.epa.gov/pesticides)

• Children’s page (http://www.epa.gov/children)

• EPA lead programs (http://www.epa.gov/lead)

• Advisories and technical resources for ish and shellish consumption

(https://www.epa.gov/ish-tech)

• Local Poison Control: call 1-800-222-1222

• Housing and Urban Development lead programs (https://portal.hud.gov/

hudportal/HUD?src5/program_ofices/healthy_homes/leadinfo)

• The National Lead Information Center: 1-800-424-LEAD

• National Pesticide Telecommunications Network: 1-800-858-7378

• Health Care Without Harm (http://www.noharm.org): a resource for the

health care sector to play a leading role in promoting the health of people and

the environment. Resources include safer chemicals, healthy food systems,

green building and energy, pharmaceuticals, and green purchasing.

• Toxtown (http://toxtown.nlm.nih.gov): an NLM site where a visitor can travel

to different locations, including farms, towns, cities, ports, and border re-

gions, and learn about environmental health issues in each area.

• EnviRN (www.envirn.org): this site from the Alliance of Nurses for Healthy

Environments (ANHE) is an active learning environment for all nurses in the

area of environmental health. There were four featured topics in January

2016: fracking and public health, climate change and health, vulnerable popu-

lations, and nursing and environmental health.

Resources on Environmental Health Risks Associated

with the Health Care Industry

• Children’s Environmental Health Network (http://www.CEHN.org): a great

online resource guide, as well as a manual for health professionals on chil-

dren’s environmental health basics.

• Healthy Schools Network (http://www.healthyschools.org): great resources

on school-based environmental health risk.

• Center for Health, Environment, and Justice (http://www.chej.org):

excellent resources for communities that are experiencing environmental

challenges.

• Centers for Disease Control and Prevention (CDC) National Center

for Environmental Health (NCEH) (http://www.cdc.gov/nceh): provides

expertise in environmental pesticide surveillance and disease outbreak

investigations.

• Agency for Toxic Substances and Disease Registry (ATSDR) (http://atsdr.cdc.

gov): offers hazardous chemical fact sheets and an A–Z list of toxic

substances and their characteristics, risks, and health effects.

• American Lung Association (http://www.lungusa.org): good resources on

reducing environmental asthma triggers (1-800-LUNG-USA, which is

800-586-4872).

• Consumer Product Safety Commission (http://www.cpsc.gov)

http://www3.epa.gov/enviro/

http://www.epa.gov

http://www.epa.gov/iaq-schools

https://www.epa.gov/ground-water-and-drinking-water

https://cfpub.epa.gov/surf/locate/index.cfm

http://www.epa.gov/pesticides

http://www.epa.gov/children

http://www.epa.gov/lead

https://www.epa.gov/fish-tech

https://portal.hud.gov/hudportal/HUD?src=/program_offices/healthy_homes/leadinfo

http://www.noharm.org

http://toxtown.nlm.nih.gov

http://www.envirn.org

http://www.CEHN.org

http://www.healthyschools.org

http://www.chej.org

http://www.cdc.gov/nceh

http://atsdr.cdc.gov

http://www.lungusa.org

http://www.cpsc.gov

http://www.dangersoffracking.com

94 PART 2 Inluences on Health Care Delivery and Nursing

from harmful contaminants and pathogens is basic to life and

health.

Discharges into water bodies from industries and from

wastewater treatment systems can contribute to the degrada-

tion of water quality. Water quality is also affected by nonpoint

sources of pollution, such as stormwater runoff from paved

roads and parking lots, erosion from clear-cut tracts of land

(after timbering and mining), and runoff from chemicals added

to soil, such as fertilizers. The chain of potential damage contin-

ues with the additives to farm produce and animal diets, such

as antibiotics and growth hormones (which are then consumed

by humans).

LAND

Past and present use of land can affect a community’s health.

Local governments determine land use through their zoning

laws. For example, a zoning law would prevent a housing de-

velopment from being built on top of a previously used land-

ill that is now illed in and may look attractive. Agricultural

soil is affected by its water supply, the chemicals that are

added by people, and the pollutants that are deposited in the

land from the air. A growing source of concern is what is re-

ferred to as “urban sprawl and the built community.” The built

environment includes “building conditions, neighborhood

design, recreational area safety and accessibility, and transpor-

tation infrastructure” (Lopez and Welker-Hood, 2007, p 56).

Lead also can get into the soil. When lead-containing paint

chips are scraped from a wall, they become airborne in the

breathing space for a brief time and then end up in nearby

soil. Children play in the soil, where their hand-to-mouth ac-

tivity results in exposure to lead, which has developmental

and behavioral effects on them, both known and being discov-

ered through research.

There is beginning to be a correlation between the way in

which communities are conigured and obesity. That is, does the

community encourage and support walking or bike riding? Can

people shop without needing to do so via a motor vehicle? How

long is the average commute time? Is the environment totally

built up, and concrete, not grass, covers much of the area?

FOOD

Food and food production are a source of concern. In recent

years, foodborne illnesses have been associated with Salmonella

and Escherichia coli O157:H7 in foods such as chicken, eggs,

spinach, and hamburger. Good food preparation practices, such

as washing and adequate cooking temperature and time, can

prevent foodborne illnesses associated with most pathogens.

Local health departments are responsible for monitoring food

establishments (restaurants, food trucks, etc.) in the commu-

nity, and the US Department of Agriculture is responsible for

oversight of meat, poultry, ish, and produce production.

However, there are also environmental health risks posed by

the presence of pesticide residues in our food; the use of recom-

binant bovine growth hormone (rBGH), which is given to many

dairy cows; the administration of antibiotics to beef cattle, pigs,

and chickens at nontherapeutic doses that are given to promote

growth; and the use of genetically modiied organisms (GMOs)

for genetically engineered crops.

When assessing a community’s environmental health risks,

a nurse must consider air, water, soil, and food. It is impor-

tant that nurses understand the term “organic” regarding

food labeling. If a food is labeled “Certiied Organic,” this

is a meaningful term that has a legal US Department of Agri-

culture (USDA) deinition. For foods to carry the Certiied

Organic label, they must have been produced without the

use of pesticides, GMOs, or unnecessary (nontherapeutic)

antibiotics. If a food is merely labeled “organic,” the con-

sumer does not have the same guarantee regarding what

chemicals or farming practices have been used. When pur-

chasing foods directly from farmers through farm stands

or farmers’ markets, consumers can directly ask about the

chemicals and farm practices.

THE RIGHT TO KNOW

Several environmental statutes give the public the right to know

about hazardous chemicals in the environment. One of the right-

to-know laws allows health professionals and community mem-

bers to access, by zip code, information regarding major sources

of pollution being emitted into the air or water in their commu-

nity. The EPA has an “Envirofacts” section on its website that

provides data on sources of exposure by typing in a zip code.

Water suppliers that provide drinking water to consumers

are responsible for testing the water according to EPA stan-

dards. The results of the testing must be reported to those who

purchase the water, in the form of a consumer conidence re-

port (CCR). Nurses should review CCRs, sometimes referred

to as right-to-know reports, to learn what pollutants have been

found in the drinking water. If the drinking water poses an im-

mediate health threat, the water provider must send emergency

warnings to the community via the local newspapers, radio,

and television. The Freedom of Information Act is a federal law

that allows citizens to request public documents.

Employees have the right to know, through the federal

Hazard Communication Standard, about the hazardous chem-

icals with which they work. This standard requires employers

(including hospitals) to maintain a list of all hazardous chemi-

cals used on-site. Each of these chemicals should have an

associated chemical information sheet, known as a material

safety data sheet (MSDS), written by the chemical manufac-

turer. These safety sheets, available to any employee or his or

her representative, should provide information about the

chemical makeup, the health risks, and any special guidance on

safe use and handling (e.g., requirements for protective gloves

or respiratory protection). For more information on work-

place health and safety, see http://www.osha.gov.

RISK ASSESSMENT

Currently, the EPA uses the process of risk assessment when

it develops health-based standards. The term risk assessment

refers to a process to determine the probability of a health

http://www.osha.gov

95CHAPTER 6 Environmental Health

threat associated with an exposure. The following discussion

describes the four phases of a risk assessment related to chem-

ical exposures.

First, by accessing toxicological or epidemiological data,

determine whether a chemical is known to be associated with

negative health effects (in animals or humans). Remember,

the available toxicological data will probably be based on

animal studies (from which the potential effects on humans

are estimated), whereas the results of the epidemiological

studies will be for human health effects.

Second, determine whether the chemical has been released

into the environment via the air, water, soil, or food. Environ-

mental professionals, such as sanitarians, food inspectors, air

and water pollution scientists, meteorologists, environmental

engineers, and others, can test for the presence of the sus-

pected chemical in the various media (air, water, soil, food).

In performing a risk assessment, determine whether multiple

sources of the questionable chemical are present. For exam-

ple, is lead found in the drinking water, in the ambient air,

and in the paint in houses in a given community? If so, the

lead will have a cumulative effect and be more of a danger.

In the third phase, estimate how much of the chemical

might enter the human body and by which route. This estimate

can be based on a one-time exposure, a short-term exposure,

or a projected lifetime exposure. Federal standards created for

air, water, and other pollutants are based on an estimation

of a lifetime exposure. However, in workplace settings, the

chemical exposure standards are based on an average exposure

during a typical work shift or are set for a maximum exposure

at any given time.

The inal stage of the risk assessment process takes into ac-

count all three of the previous steps and asks the following

questions:

• Is the chemical toxic?

• What are the source and amount of the exposure?

• What are the route and duration of the exposure for

humans?

The goal is to try to predict the potential for harm on

the basis of the estimated exposure. Like all science, risk as-

sessment is subject to interpretation, and there may be more

than one interpretation for each step, which could lead to

different recommendations. Also, environmental laws are

often contentious not only because of public or ecological

health concerns but also because economic interests are at

stake. Remember that for persons to be harmed by something

in the environment, the following factors must be in place

and connected:

1. A source of harm that has chemical and/or physical

properties

2. An environmental medium for transport—air, water (i.e.,

surface water or groundwater), or soil

3. A receptor population within the exposure pathway for

harm to human health

4. A route of exposure (for humans, these are inhalation,

ingestion, and skin absorption)

5. An adequate amount (dose) of the chemical to result in

human harm

ASSESSING ENVIRONMENTAL HEALTH RISKS IN CHILDREN

Toxic chemicals can have different effects depending on the

timing of exposure. During fetal development, there are peri-

ods of heightened sensitivity to the effects of toxic chemicals.

During such times, even extraordinarily small exposures can

prevent or change a process that may permanently affect nor-

mal development. The brain undergoes rapid structural and

functional changes during late pregnancy and in the neonatal

period. Therefore it is extremely important to safeguard

women’s environments when they are pregnant (Table 6.1).

Fish are a lean, low-calorie source of protein. However, some

ish may contain chemicals that could pose health risks. When

the level of contaminants is unsafe, people may be advised to

reduce or avoid eating certain ish caught in speciic locations.

The EPA provides speciic information to inform people about

the recommended level of consumption of ish in their local

waters (EPA, 2016). Advisories are available for all 50 states and

some US territories and tribes.

Nurses need to understand the implications that the ish

advisories have for their clients and communities while at the

same time counseling on the positive contribution of ish to a

nutritionally balanced diet. Because more than 100,000 chemi-

cals are used in the world, it is important to understand the

possible effects on health.

Companies are not required to divulge all of the results of

their private testing. A full battery of neurotoxicity tests is not

required even for pesticides that may be sprayed in nurseries and

labor and delivery areas, not to mention in homes. To make

things even more complicated, risks from multiple chemical ex-

posures are rarely considered when regulations are drafted. Such

an omission ignores the reality that both children and adults are

exposed to many toxic chemicals, often concurrently. The only

exception to this rule is in the case of regulations regarding pes-

ticides that are used on food (Fig. 6.5). This exception was created

Exposure Known/Suspected Effect

Anesthetic compounds Infertility, spontaneous abortion, fetal

malformations, low birthweight

Antineoplastics Infertility, spontaneous abortion

Dibromochloropropane Sperm abnormalities, infertility

Ionizing radiation Infertility, microcephaly, chromosomal

abnormalities, childhood malignancies

Lead Infertility, spontaneous abortion,

developmental disabilities

Manganese Infertility

Organic mercury Developmental disabilities, neurological

abnormalities

Organic solvents Congenital malformations, childhood

malignancies

Chlorinated biphenyls,

polybrominated biphenyls

Fetal mortality, low birthweight, congenital

abnormalities, developmental disabilities

TABLE 6.1 Environmental Agents Implicated in Adverse Reproductive Outcomes

From Aldrich T, Grifith J: Environmental epidemiology and risk assess-

ment, New York, 1993, Van Nostrand Reinhold.

96 PART 2 Inluences on Health Care Delivery and Nursing

by the 1996 Food Quality Protection Act, in which Congress ac-

knowledged that children eat foods that may be contaminated by

more than one pesticide residue. See Box 6.4 for the provisions

under the Food Quality Protection Act.

Children are especially at risk for environmental hazards

because of factors such as poverty, lack of access to health

care, and the dangerous environmental situations in which

they may live. Children are also at risk because of their size and

the immaturity of their systems, such as the respiratory system.

Infants and young children breathe more rapidly than adults,

and this increase in respiratory rate leads to a proportionately

greater exposure to air pollutants. While infants’ lungs are

developing, they are particularly susceptible to environmental

toxicants. Although full function of the lungs is attained at ap-

proximately age 6, changes continue to occur in the lungs

through adolescence (Dietert et al, 2000). Children are short,

and thus their breathing zones are lower than those of adults,

causing them to have closer contact with the chemical and bio-

logical agents on loors, carpeting, and the ground. Children

are also at risk during disasters. For example, after Hurricane

Katrina, a risk for children was inhaling the dangerous toxins

from tar balls. Because children are shorter than adults, they

were thus closer to the ground and subsequently closer to tar

balls than were adults, with greater risk of inhalation. Brief

exposure to the crude oil in tar balls can lead to contact derma-

titis and skin rashes; longer exposure can lead to erythema,

edema, and burning. Gastrointestinal and respiratory effects of

this exposure also can occur (Murray, 2011). Children of color

and poor children in America are disproportionately affected

by a range of environmental health threats, including lead expo-

sure, air pollution, pesticides, incinerator emissions, industrial

and agricultural chemicals, and exposures from hazardous-

waste sites (Suk and Davis, 2008).

Some of the health conditions in children that are associ-

ated with environmental factors include autism spectrum

disorder; cancer; respiratory diseases, including asthma;

obesity; and problems in neurodevelopment (American

Cancer Society [ACS], 2016; CDC, 2016). In regard to can-

cer, only a small percentage of childhood cancers are associ-

ated with heredity. However, exposure to ionizing radiation

increases the risk of childhood leukemia and possibly other

cancers. All of the causes of autism spectrum disorder are

not currently known. Environmental factors are thought

to be a possible cause, as are biologic and genetic factors.

The NIH has identified that understanding the effects of

environmental exposures on child health and development is

a priority. It has launched a 7-year initiative called the Envi-

ronmental Influences on Child Health Outcomes (ECHO)

program. The program supports studies that focus on

four key pediatric outcomes that are public health priorities:

(1) upper and lower airway; (2) obesity; (3) pre-, peri-, and

postnatal outcomes; and (4) neurodevelopment (US Depart-

ment of Health and Human Services, 2015). Clearly, the en-

vironment plays an important role in children’s health.

Think about this question: When building a school, should

the government require the same environmental assessment

of the land as it would if a commercial enterprise, like a ho-

tel, was being placed on the same site? Currently, it requires

less stringent environmental assessments.

FIG. 6.5 Aerial application of agricultural pesticides makes

it very dificult to control exposures. The chemicals get

Photo #87531230.)

BOX 6.4 Food Quality Protection Act of 1996

New provisions under the Food Quality Protection Act are related to protection

of infants and children from pesticide exposure from multiple sources:

• Health-based standard: A new standard of a reasonable certainty of “no

harm” that prohibits taking into account economic considerations when

children are at risk.

• Additional margin of safety: Requires that the Environmental Protec-

tion Agency (EPA) to use an additional 10-fold margin of safety when

adequate data exist to assess prenatal and postnatal developmental

risks.

• Account for children’s diet: Requires the use of age-appropriate esti-

mates of dietary consumption in establishing allowable levels of pesticides

on food to account for children’s unique dietary patterns.

• Account for all exposures: In establishing acceptable levels of a pesti-

cide on food, the EPA must account for exposures that may occur through

other routes, such as drinking water and residential application of the

pesticide.

• Cumulative impact: The EPA must consider the cumulative impacts of all

pesticides that may share a common mechanism of action.

• Tolerance reassessments: All existing pesticide food standards must

be reassessed over a 10-year period to ensure that they meet the new

standards to protect children.

• Endocrine disruption testing: The EPA must screen and test all pesti-

cides and pesticide ingredients for estrogen effects and other endocrine

disruptor activity.

• Registration renewal: Establishes a 15-year renewal process for

all pesticides to ensure that they have up-to-date scientiic evaluations

over time.

From the Environmental Protection Agency: Summary of the Food

Quality Protection Act, n.d. Retrieved July 25, 2016 from https://www.

epa.gov/laws-regulations/summary-food-quality-protection-act

https://www.epa.gov/laws-regulations/summary-food-quality-protection-act

97CHAPTER 6 Environmental Health

Children’s bodies also operate differently. Some of the pro-

tective mechanisms that are well developed in adults, like the

blood–brain barrier, are immature in young children, thereby

increasing their vulnerability to the effects of toxic chemicals.

Finally, the kidneys of young children are less effective at ilter-

ing out undesirable toxic chemicals, and these chemicals then

continue to circulate and accumulate.

Infants and young children drink more luids per body weight

than adults do, and this increases the dose of contaminants in

their drinking water, milk (hormones and antibiotics), and juices

(particularly pesticides). If an adult were to drink an amount of

water proportionate to the amount an infant drinks, the adult

would have to drink about 50 glasses of water a day. Children also

eat more per body weight, eat different proportions of food, and

absorb food differently from adults. Children consume much

greater quantities of fruits and fruit juices than adults do, once

again adding exposure to doses of pesticide residues.

REDUCING ENVIRONMENTAL HEALTH RISKS

Preventing problems is less costly, whether the cost is measured

in resources consumed or health effects. Education is a primary

preventive strategy. When examining the sources of environ-

mental health risks in communities and planning intervention

strategies, it is important to apply the basic principles of disease

prevention. For a home with lead-based paint, apply the pri-

mary prevention strategy of removing that speciic source of

lead. Good surveillance, a secondary prevention strategy, will

not prevent lead exposure, but it may help with early identiica-

tion of rising blood lead levels. For a symptomatic child

brought to a health care provider, a system should be in place

for specialists familiar with lead poisoning to provide immedi-

ate care; swift medical interventions to reduce blood levels of

lead can reduce the risk of further harm. This might be a ter-

tiary prevention response.

For workplace exposures, industrial hygienists have devel-

oped a list of precautions for avoiding or minimizing employee

exposures to potentially hazardous chemicals. Industrial hy-

gienists are public health professionals who specialize in work-

place exposures to hazards—physical, chemical, and biological—

that create conditions of health risk (Box 6.5). Once it is

established that a human health threat exists, develop a plan

of action to eliminate or manage (reduce) the risk. Risk man-

agement, which should be informed by the risk assessment

process, involves the selection and implementation of a strat-

egy to reduce risks, which can take many forms. For example,

the “Three R’s for Reducing Environmental Pollution” are as

follows:

1. Reduce: Reducing consumption reduces waste and unneces-

sary packaging and nonessentials.

2. Reuse: Choosing reusable rather than disposable products cre-

ates less waste (e.g., using glass dishes rather than paper ones).

3. Recycle: Recycling paper, glass, cans, and plastic decreases

pollution.

Risk assessment includes considering ways to dispose of

materials. Once waste products are generated, they must be

disposed of in one of the following three ways:

1. Incineration: Burning can change the chemical composition

through heat, but the products of burning, such as ash and

air emissions, must be controlled and disposed of using one

of the following two options.

2. Water discharge: When products are disposed of in water,

the water must be treated to ensure that the dose in the water

is not great enough to do harm.

3. Landilling or burying in soil: When using landills or bury-

ing products, protections must be put in place, such as liners

and leachate pumps and monitors, to avoid seepage of

harmful doses into the groundwater or air.

Each of the options for waste disposal is intended to provide

a way either to alter the waste product to a less toxic form

through chemical intervention (biodegradation) or to store the

product in a bio-unavailable form or place. Because all of the

options for disposal can be a problem, prevention is desirable.

Remember that human effects are intensiied in the most

sensitive, vulnerable environments, such as estuaries, the nurser-

ies for much of sea and coastal plant and animal life. Some of the

most valued food sources are also the most sensitive to pollu-

tion. Shellish are eficient ilters of contaminants in the water in

which they live. For example, oysters ilter and retain almost all

contaminants from the water in which they grow. It is impossi-

ble to rid them of contaminants after harvesting. The only pro-

tection for humans is to grow oysters in environments free from

harmful contamination. Safe seafood depends on clean water.

Another form of risk reduction is to reduce the risk from

exposure to ultraviolet rays. People need to avoid being outside

during peak sun hours and need to wear protective clothing

and/or sunblock. To reduce exposure to dangerous heavy metals,

special processes can be used at the water iltration plant that

supplies the public water. In the home, running the cold water

tap for 1 or 2 minutes each morning before collecting water for

coffee or drinking will reduce the presence of lead that may have

leached from old pipes (or the solder used on them) overnight.

In communities that report to the media the local pollution

levels, it is important to encourage residents to not exercise or

walk excessively outside when the air pollution index is high.

Individuals, communities, and nations can reduce risks. In re-

cent years, there have been global agreements to reduce persis-

tent pollutants and decrease global warming. However, not all

nations are subscribing to this goal. The national and interna-

tional news provide many examples of extreme pollution around

the world.

BOX 6.5 Industrial Hygiene Controls

• Substitute less hazardous or nonhazardous substances for hazardous ones

(e.g., use water-based instead of solvent-based products).

• Isolate the hazardous chemicals from human exposure (closed systems).

• Apply engineering controls (e.g., ventilation systems, including exhausts).

• Reduce the exposures through administrative controls (rotating employees).

• Use personal protective equipment (gloves, respirators, protective clothing).

• Educate employees about controls.

From Levy B, Wegman D: Occupational health: recognizing and pre-

venting work-related disease and injury, ed 5, Philadelphia, 2006,

Lippincott Williams & Wilkins.

98 PART 2 Inluences on Health Care Delivery and Nursing

Nursing interventions to reduce environmental health risks

can also take many forms. Education is a key nursing action. By

working with a variety of community members, nurses can

explain the relationship between harmful environmental expo-

sures and human health and guide the community toward risk

reduction based on both changes in individual behavior and

community-wide approaches. For example, a nurse could help

clients know how important it is to purchase a carbon monox-

ide detector. The detectors are designed to measure carbon

monoxide levels over time and sound an alarm when the levels

reach a speciic point. These devices are sold in many stores in

the United States.

RISK COMMUNICATION

Risk is a familiar term in nursing practice. We counsel people

about risks of pregnancy, communicable disease (especially

sexually transmitted disease), intentional and unintentional

injury, and personal health-related choices (e.g., smoking, alco-

hol consumption, diet). Risk assessment in environmental

health has focused on characterizing the hazard (i.e., the

source), its physical and chemical properties, its toxicity, and

the presence of (or potential for) other elements in the expo-

sure pathway—mode of transmission, route of exposure, recep-

tor population, and dose. Risk is typically viewed as the process

of estimating the likelihood of an unwanted, adverse effect and

the probable magnitude and intensity of that effect (Fair-

brother and Turnley, 2005). For example, an environmental risk

assessment of a contaminated site includes a calculation of the

dose that might be received through all routes of exposure, the

toxicity of the chemical, the size and vulnerability (e.g., age,

health) of the population potentially exposed (e.g., resident,

future resident, transient), and the likelihood of exposure.

Communication of risk is both an area of practice and a

skill. It involves understanding the outrage factors relevant to

the risk being addressed so that both can be incorporated in the

message, with the result that either action is taken to ensure

safety or unnecessary fear is reduced. Outrage factors are those

things that cause people to feel a sense of outrage toward a be-

havior. An example of raising outrage to produce action can be

seen in the way people respond to smokers who smoke in pub-

lic. Because of the fear of secondhand or involuntary, passive

smoking, people have advocated to stimulate public policy that

limits or bans smoking in public places. When the emphasis on

risk went from a voluntary choice of smokers to an involuntary

exposure of nonsmokers, the outrage level of the nonsmoking

public became high enough to result in legislation guaranteeing

smoke-free public spaces (e.g., public buildings, airplanes, res-

taurants). On the other hand, outrage diminishes when people

obtain information about a situation from a trusted source, and

nurses are often cited in surveys as trusted sources of informa-

tion on environmental risks.

Risk communication includes general principles of good

communication. It is a combination of the following:

• The right information: Accurate, relevant, and in a language

that audiences can understand. A good risk assessment is

essential information for shaping the message.

• To the right people: Those affected and those who may not be

affected but are worried. Information about the community

is essential and includes geographic boundaries, who lives

there (demographics), how they get information (i.e., lyers,

newspapers, radio, television, the Internet, text messages,

word of mouth), where they get together (i.e., school, church,

community center), and who within the community can

help plan the communication.

• At the right time: For timely action or to allay fear.

ETHICS

Public health has been deined as “what we, as a society, do

collectively to assure the conditions for people to be healthy”

(Public Health Leadership Society, 2002, p 22). Public health is

concerned with public goods that can be achieved through col-

lective action such as clean water, safe and adequate housing,

and public safety with societal regulation of shared risks (Easley

and Allen, 2007). The public health goal would likely ask indi-

viduals to sacriice some of their self-interests to beneit the

greater good of more people. This could be seen when compa-

nies are asked to reduce air or water pollution, even though it

might be expensive for them to do so to protect the health of

the people who might be affected. As discussed in Chapter 4,

understanding ethics is essential for nurses making their own

choices, in describing issues and options within groups, and in

advocating for ethical choices. When the sticking points are

around competing commodities (e.g., jobs versus environmen-

tal protection, production versus conservation, economic de-

velopment versus the health of the environment), the skillful

nurse can change the discussion from “either/or” to “both” by

opening new possibilities for ethical and mutually satisfactory

outcomes. The following ethical issues may arise in environ-

mental health decisions:

• Who has access to information and when?

• How complete and accurate is the available information?

• Who is included in decision making and when?

• What and whose values and priorities are given weight in

decisions?

• How are short-term and long-term consequences considered?

A review of ethical issues in Chapter 4 may help nurses de-

cide what actions they could and should take in regard to envi-

ronmental health issues.

LEVELS OF PREVENTION

Related to the Environment: Lead Exposure

Primary Prevention

Use only non–lead-based paint

Secondary Prevention

If lead is found in paint, remove this paint and replace with nonlead paint.

Tertiary Prevention

At the irst sign of symptoms of lead exposure, take steps to reduce blood lead

levels.

99CHAPTER 6 Environmental Health

GOVERNMENT ENVIRONMENTAL PROTECTION

The federal government is involved with many major pieces

of environmental legislation (Box 6.6). The government

manages environmental exposures through the development

and enforcement of standards and regulations that limit a

polluter’s ability to put hazardous chemicals into our food,

water, air, or soil. The government may also be involved in

educating the public about risks and risk reduction. Several

federal agencies are involved in environmental health regula-

tion, including the EPA, the Food and Drug Administration,

and the Department of Agriculture. In every state, an equiv-

alent state agency exists as well. The local health department

may manage environmental health issues at the city or

county level. However, environmental protection issues

are typically directed by the state using both federal and state

laws. The organization and approach to environmental

protection vary somewhat among states, but the common

essential strategies of prevention and control via the permit-

ting process, establishment of environmental standards, and

monitoring, as well as compliance and enforcement, are

found in every state.

Potentially harmful pollution that cannot be prevented

must be controlled. The irst step in the process of controlling

pollution is permitting, a process by which the government

places limits on the amount of pollution emitted into the air

or water. Industries and businesses whose processes will result

in releases (i.e., discharges, emissions) that have the potential

for harm are required to obtain environmental permits to

construct and operate. A range of permits may be required

(e.g., storm water control, construction, operations for air and

wastewater discharges, waste management). It is in the per-

mitting process that maximum opportunities to incorporate

prevention strategies can be exercised. For example, waste

minimization can be included as a permit condition, with the

agreement of the industry even if it is not required by law or

BOX 6.6 Environmental Laws

National Environmental Policy Act (NEPA)

The NEPA established the Environmental Protection Agency (EPA) and a national

policy for the environment and provides for the establishment of a Council on

Environmental Policy. All policies, regulations, and public laws shall be inter-

preted and administered in accordance with the policies set forth in this act.

Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA)

FIFRA provides federal control of pesticide distribution, sale, and use. The EPA

was given the authority to study the consequences of pesticide usage and re-

quires users such as farmers and utility companies to register when using pesti-

cides. Later amendments to the law required applicators to take certiication

examinations, registration of all pesticides used in the United States, and proper

labeling of pesticides that, if in accordance with speciications, will cause no

harm to the environment (summary from FIFRA, 1972).

Clean Water Act (CWA)

The CWA sets basic structure for regulating pollutants to US waters. The law

gave the EPA the authority to set efluent standards on an industry basis and

continued the requirements to set water quality standards for all contaminants

in surface water. The 1977 amendments focused on toxic pollutants. In 1987 the

CWA was reauthorized and again focused on toxic pollutants, authorized citizen

suit provisions, and funded sewage treatment plants.

Clean Air Act

The Clean Air Act regulates air emissions from area, stationary, and mobile

sources. The EPA was authorized to establish National Ambient Air Quality

Standards (NAAQSs) to protect public health and the environment. The goal was

to set and achieve the NAAQSs by 1975. The law was amended in 1977 when

many areas of the country failed to meet the standards. The 1990 amendments

to the Clean Air Act intended to meet unaddressed or insuficiently addressed

problems, such as acid rain, ground-level ozone, stratospheric ozone depletion,

and air toxins. Also in the 1990 reauthorization, a mandate for Chemical Risk

Management Plans was included. This mandate requires industry to identify

“worst-case scenarios” regarding the hazardous chemicals that they transport,

use, or discard (summary from Clean Air Act, 1970).

Occupational Safety and Health Act (OSHA)

The OSHA was passed to ensure worker and workplace safety. The goal was to

make sure employers provide an employment place free of hazards to health and

safety, such as chemicals, excessive noise, mechanical dangers, heat or cold

extremes, or unsanitary conditions. To establish standards for the workplace, the

act also created the National Institute for Occupational Safety and Health

(NIOSH) as the research institution for OSHA.

Safe Drinking Water Act (SDWA)

The SDWA was established to protect the quality of drinking water in the United

States. The SDWA authorized the EPA to establish safe standards of purity and

required all owners or operators of public water systems to comply with primary

(health-related) standards.

Resource Conservation and Recovery Act (RCRA)

The RCRA gave the EPA the authority to control the generation, transporta-

tion, treatment, storage, and disposal of hazardous waste. The RCRA also

proposed a framework to manage nonhazardous waste. The 1984 Federal

Hazardous and Solid Waste Amendments to this act required phasing out

land disposal of hazardous waste. The 1986 amendments enabled the EPA

to address problems from underground tanks storing petroleum and other

hazardous substances.

Toxic Substances Control Act (TSCA)

The TSCA gives the EPA the ability to track the 75,000 industrial chemicals

currently produced or imported into the United States. The EPA can require

reporting or testing of chemicals that may pose environmental health risks

and can ban the manufacture and import of those chemicals that pose an

unreasonable risk. TSCA supplements the Clean Air Act and the Toxic Release

Inventory.

Comprehensive Environmental Response, Compensation,

and Liability Act (CERCLA or Superfund)

This law created a tax on the chemical and petroleum industries and pro-

vided broad federal authority to respond directly to releases or threatened

releases of hazardous substances that may endanger public health or the

environment.

Superfund Amendments and Reauthorization Act (SARA)

SARA amended the CERCLA with several changes and additions. These changes

included increased size of the trust fund, encouragement of greater citizen par-

ticipation in decision making on how sites should be cleaned up, increased state

Continued

100 PART 2 Inluences on Health Care Delivery and Nursing

regulation. Once a condition exists in the permit, it has the

force of law.

The permitting process includes submission of an applica-

tion, which requires details on the proposed operation. Plans

are studied, engineering processes are modeled, validated,

and technical requirements are reviewed by appropriate regu-

latory experts. Usually some form of public participation is

required or included voluntarily. The public involvement can

include public notice, public comment, and public meetings

and hearings initiated by the regulatory agency. Public in-

volvement also can take the form of voluntary agreements

and dispute resolution between the industry and the com-

munity, which may or may not involve a government entity.

Limits on what an industry or business can release or emit

lawfully are based on environmental standards.

Environmental standards may be expressed as a permitted

level of emissions, a maximum contaminant level allowed, an

action level for environmental cleanup, or a risk-based calcula-

tion. A standard often relects the level of pollution that will

limit a number of excess deaths at a given level of exposure over

a speciied period. It is the responsibility of the polluters to oper-

ate within the standards. Compliance and enforcement are the

next steps for controlling pollutions. Compliance refers to the

processes for ensuring that permit and standard requirements

are met. Cleanup or remediation of environmental damage is

another control step. Public information and involvement pro-

cesses, such as citizen advisory panels or community forums, are

integral to the development of standards, ongoing monitoring,

and remediation. Monitoring procedures, which must use meth-

ods approved by the EPA or scientiic consensus, must follow

accepted protocols (e.g., maintaining a documented chain of

custody of samples to ensure accuracy and protection from con-

tamination at the laboratory after sampling).

ADVOCACY

The more than 3 million nurses in the United States today can and

should be a strong voice for change. As informed citizens, nurses

can work to protect the environmental health of clients, families,

and communities. Nurses are seen as trusted sources of informa-

tion, and they need to serve as reliable sources of environmental

health information. They can act in the best interest of public

health and use their abilities as educators, advocates, and com-

municators to affect public policy, laws, and regulations that pro-

tect public health. Nurses can serve as a resource for state and

federal legislators and their staff. Often, legislators are asked to

vote on environmental legislation without a sound understanding

of how the legislation may affect public health. Although not ev-

ery nurse can be an expert in all aspects of environmental health,

every nurse has a basic education in human health and can iden-

tify people who may be most vulnerable to environmental insult.

Nurses’ thoughts about the potential effects of new laws on the

health of individuals and communities are valuable to legislators.

As communicators and educators, nurses can do the following:

• Write letters to local newspapers responding to environmen-

tal health issues affecting the community.

• Participate in blogs or other web mediums that capture the

attention of people about the environment and threats to it.

• Serve as a credible source of information at community

gatherings, formal governmental hearings, and professional

nursing forums.

• Volunteer to serve on local, state, or federal commissions;

know the zoning and permit laws that regulate the effects of

industry and land use on the community.

• Read, listen, and ask questions. As informed citizens, nurses

can lead in fostering community action to address threats to

environmental health.

BOX 6.6 Environmental Laws—cont’d

involvement in every phase of the Superfund program, increased focus on human

health problems related to hazardous waste sites, new enforcement authorities

and settlement tools, emphasis on the importance of permanent remedies and

innovative treatment technologies in cleanup of hazardous waste sites, and

Superfund actions to consider standards in other federal and state regulations.

(Under Superfund legislation, the Federal Agency for Toxic Substances and

Disease Registry was established.)

Emergency Planning and Community Right to Know

Act (EPCRA)

The EPCRA, also known as Title III of SARA, was enacted to help local com-

munities protect public health safety and the environment from chemical

hazards. Each state was required to appoint a State Emergency Response

Commission that was required to divide the state into Emergency Planning

Districts and establish a Local Emergency Planning Committee (LEPC) for each

district.

National Environmental Education Act

The National Environmental Education Act created a new and better coordinated

environmental education emphasis at the EPA. It created the National Environ-

mental Education and Training Foundation.

Pollution Prevention Act (PPA)

The PPA focused industry, government, and public attention on reduction of the

amount of pollution through cost-effective changes in production, operation, and

use of raw materials. Pollution prevention also includes other practices that

increase eficient use of energy, water, and other water resources, such as

recycling, source reduction, and sustainable agriculture.

Food Quality Protection Act (FQPA)

The FQPA amended the Federal Insecticide, Fungicide, and Rodenticide Act and

the Federal Food, Drug, and Cosmetic Act. FQPA changed the way the EPA regu-

lates pesticides. The requirements included a new safety standard of reasonable

certainty of no harm to be applied to all pesticides used on foods.

Chemical Safety Information, Site Security, and Fuels

Regulatory Act (Amendment to Section 112 of the Clean

Air Act)

This act removed from coverage by the Risk Management Plan (RMP) any lam-

mable fuel when used as fuel or held for sale as fuel by a retail facility (lam-

mable fuels used as a feedstock or held for sale as a fuel at a wholesale facility

are still covered). The law also limits access to off-site consequence analyses,

which are reported in RMPs by covered facilities.

101CHAPTER 6 Environmental Health

ENVIRONMENTAL JUSTICE AND ENVIRONMENTAL HEALTH DISPARITIES

Some diseases differentially affect different populations. Cer-

tain environmental health risks disproportionately affect poor

people and people of color in the United States. A poor person

of color is more likely to (1) live near a hazardous waste site or

an incinerator, (2) have children who are exposed to lead, and

(3) have children with asthma, which has a strong association

with environmental exposures. Campaigns in communities of

color and poor communities to improve the unequal burden of

environmental risks strive to achieve environmental justice or

environmental equity.

In 1993 the Environmental Justice Act was passed, and in

1994 Executive Order 12898, Federal Actions to Address Envi-

ronmental Justice in Minority Populations, was signed. These

created policies to more comprehensively reduce the inci-

dence of environmental inequity by mandating that every

federal agency act in a manner to address and prevent illnesses

and injuries. Nursing interventions and involvement in envi-

ronmental health policies can have a signiicant effect on

the health disparities experienced by our most challenged

communities.

UNIQUE ENVIRONMENTAL HEALTH THREATS IN THE HEALTH CARE INDUSTRY: NEW OPPORTUNITIES FOR ADVOCACY

We rarely think of health care facilities as sources of environ-

mental harm. Nurses often lead in reducing the use of

mercury-containing products in hospitals. The use of

mercury-containing thermometers and sphygmomanome-

ters leads to a risk of breakage, which releases a highly toxic

substance into the workplace. Further, when a hospital uses

incineration to dispose of its waste, the mercury-containing

products will create signiicant releases of mercury into

the air, thus contaminating communities. This airborne

mercury will be present in raindrops. When airborne mer-

cury lands on water bodies (e.g., lakes, rivers, or oceans), it

is converted by the microorganisms in the water to methyl-

mercury, which is highly toxic to humans. The methylmer-

cury is then bioaccumulated in fish: as larger fish eat

smaller fish, the body burden of methylmercury increases

significantly.

Many synthetic chemicals that contaminate the environ-

ment are referred to as persistent bioaccumulative toxins

(PBTs) or persistent organic pollutants (POPs). These are

chemicals that do not break down in air, water, or soil, or in

the plant, animal, and human bodies to which they may be

passed. Ultimately, because humans are at the top of the food

chain, these chemicals may come to reside in our bodies. For

instance, lead, which should not be found in the human body,

can be found in the long bones of almost any human in

the world because of its ubiquitous use and presence in our

environment.

Dioxin, another pollutant that contaminates communities,

is created, in part, by the health care industry. Dioxins are cre-

ated when we manufacture or burn (incinerate) products that

contain chlorine, such as bleached white paper or polyvinyl

chloride (PVC) plastics. When dioxins are released into the en-

vironment, they are consumed by agricultural animals and by

ish. The dioxins are stored in fat cells as they work their way up

the food chain. This phenomenon has resulted in dioxin depo-

sition in breast tissue, and dioxin has been found in both cow

and human milk. Virtually all women now have dioxin in their

breast tissue. Dioxin, an endocrine-disrupting chemical and a

strong carcinogen, is associated with several neurodevelopmen-

tal problems, including learning disabilities and is now in every

human’s body. The solution to this problem is to stop releasing

dioxins into the environment. In the health care setting, one

way to eliminate the creation and release of dioxins is to stop

using products like PVC plastics and select safer alternatives by

employing environmentally preferable purchasing policies and

practices.

An international campaign called Health Care Without

Harm is working to reduce and eliminate the use of mercury

and PVC plastic in the health care industry and to eliminate

incineration of medical waste. The ANA was a founding mem-

ber of the Health Care Without Harm campaign, and nurses

have taken many leadership roles in the activities in the United

States and around the world. The Health Care Without Harm

website (http://www.noharm.org) provides outstanding infor-

mation on greening hospitals and resources about pollution

prevention in the health care sector.

REFERRAL RESOURCES

No single source of information about environmental health

is available, nor is there a single resource to which individuals

or a community can be referred if they suspect an environ-

mental problem. Information is widely accessible on the In-

ternet, but inding an actual person to assist you or the com-

munities you serve may not be as easy. One starting point may

be the environmental epidemiology unit or toxicology unit of

your state health department or environmental agency. An-

other local or state resource may be environmental health ex-

perts in nursing or medical schools or schools of public

health. The Association of Occupational and Environmental

Clinics (http://www.AOEC.org) is a national network of spe-

cialty clinics and individual practitioners available for consul-

tation and sometimes for the provision of educational pro-

grams for health professionals.

Local resources include local health and environmental

protection agencies, poison control centers, agricultural exten-

sion ofices, and occupational and environmental departments

in schools of medicine, nursing, and public health. Some local

and state agencies have developed topical directories to assist

in accessing the appropriate staff for speciic questions. Many

resources have websites that allow ready access through the

Internet and can be located by using any of the popular search

methods (see Box 6.3).

http://www.noharm.org

http://www.AOEC.org

102 PART 2 Inluences on Health Care Delivery and Nursing

ROLES FOR NURSES IN ENVIRONMENTAL HEALTH

Nurses are involved in many ways in environmental health,

whether in full-time work, as an adjunct to existing roles,

or as informed and involved citizens. Two of these nursing

roles are assessment and referral. Assessment and referral are

familiar parts of nursing practice, but they have speciic

meaning in environmental health. Assessment activities of

nurses can range from individual health assessments to being

full participants in community assessment or partners in a

speciic environmental site assessment. Referral resources

may vary in communities. One starting point may be the

environmental epidemiology or toxicology unit of the state

health department or environmental agency. Box 6.3 lists

several good referral sources. Some of the key nursing func-

tions that are discussed throughout the chapter include the

following:

• Community involvement and public participation: Orga-

nizing, facilitating, and moderating. Making public notices

effective, making public forums accessible, and welcom-

ing input. Making information exchange understandable

and problem solving acceptable to culturally diverse

communities are valuable contributions made by nurses.

Skills in community organizing and mobilizing can help

communities have a meaningful voice in decisions that

affect it.

• Individual and population risk assessment: Using nursing

assessment skills to detect potential and actual exposure

pathways and outcomes for clients cared for in the acute,

chronic, and healthy communities of practice.

• Risk communication: Interpreting and applying princi-

ples to practice. Nurses may serve as skilled risk commu-

nicators within agencies, working for industries, or work-

ing as independent practitioners. Amendments to the

Clean Air Act require major industrial sources of air emis-

sions to have risk management plans and to inform their

neighbors of speciics of the risks and plans (Clean Air

Act, 1996).

• Epidemiological investigations: Having the skills to

respond in scientifically sound and humanly sensitive

ways to community concerns about cancer, birth defects,

and stillbirths that citizens fear may have environmental

causes.

• Policy development: Proposing, informing, and monitor-

ing action from agencies, communities, and organization

perspectives.

The assimilation of the concepts of environmental health

into a nurse’s daily practice gives new life to the traditional

public health values of prevention, building community, and

social justice. There is great congruence with many personal,

religious, and spiritual values of stewardship of creation, pre-

serving the gifts of nature, and decision making that provides

for quality of life for present and future generations. It is a con-

text for practice in which nurses are welcomed and valued for

their contribution.

As nurses learn more about the environment, opportunities

for integration into their practice, educational programs, re-

search, advocacy, and policy work will become evident. Oppor-

tunities abound for those pioneering spirits within the nursing

profession who are dedicated to creating healthier environ-

ments for their clients and communities.

P R A C T I C E A P P L I C A T I O N

Two case scenarios related to exposure pathways are presented

here. The irst involves lead poisoning, and the second involves

gasoline contamination of groundwater.

At the county health department, a 3-year-old boy presents

with gastric upset and behavior changes that have persisted for

several weeks. Billy’s parents report that they have been reno-

vating their home to remove lead paint. They had been discour-

aged from routinely testing their child because their insurance

does not cover testing, and they could not ind information on

where to have the tests done. Their concern has heightened with

Billy’s persistent symptoms.

You test the level of lead in Billy’s blood and ind it to be

45 mg/dL. You research lead poisoning and discover that children

are at great risk because they absorb lead into the central nervous

system. You also ind that chronic lead poisoning may have long-

term effects, such as developmental delays and impaired learning

ability. You refer Billy to his primary-care physician. On further

investigation, you ind that Billy’s home was built before 1950

and is still under renovation. The sanitarian tests the interior

paint and inds a high lead content. Ample amounts of sawdust

from sanding are noted in various rooms of the home.

You determine that a completed exposure pathway exists.

A. What would you include in an assessment of this situation?

B. What prevention strategies would you use to resolve this

issue?

1. At the individual level?

2. At the population level?

A citizen calls the local health department to report that

his drinking water, from a private well, “smells like gasoline.”

A water sample is collected, and analysis reveals the presence

of petroleum products. A nearby rural store with a service

station has removed its old underground gasoline storage

tanks and replaced them, as required by law. Contaminated

soil from the old leaking tank has been removed, and a

well to monitor groundwater contamination is scheduled

for installation. However, sandy soil has allowed rapid move-

ment of the contamination through the groundwater, and

the plume has reached the neighbor’s drinking-water well at

levels that exceed the drinking-water standard.

What are some possible responses?

Answers can be found on the Evolve website.

103CHAPTER 6 Environmental Health

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R E M E M B E R T H I S !

• Nurses have responsibilities to be informed consumers and

to be advocates for citizens in their community regarding

environmental health issues.

• Models describing the determinants of health acknowledge

the role of the environment in health and disease.

• For many chemical compounds, whether new or familiar,

scientiic evidence of possible health effects is lacking.

• Prevention activities include education, waste minimizing, and

land-use planning. Control activities include environmental

permitting, environmental standards, monitoring, compliance

and enforcement, and cleanup and remediation.

• Each nursing assessment should include questions and ob-

servations about intended and unintended environmental

exposures.

• Environmental databases facilitate the easy and immediate

access to environmental data useful in assessment, diagnosis,

intervention, and evaluation.

• Risk communication is an important skill and must ac-

knowledge the outrage factor experienced by communities

with environmental hazards.

• Federal, state, and local laws and regulations exist to protect

citizens from environmental hazards.

• Environmental health practice engages multiple disciplines,

and nurses are important members of the environmental

health team.

• Environmental health practice includes principles of health

promotion, disease prevention, and health protection.

• The objectives of Healthy People 2020 address targets for the

reduction of risk factors and diseases related to environmen-

tal causes.

EVOLVE WEBSITE

http://evolve.elsevier.com/Stanhope/foundations

• NCLEX® Review Questions

• Practice Application Answers

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http://dx.doi:%2010.1038/jes.2014.21

104 PART 2 Inluences on Health Care Delivery and Nursing

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105

Government, the Law, and Policy Activism

Marcia Stanhope

7C H A P T E R

After reading this chapter, the student should be able to:

1. Discuss the structure of the US government and health care

roles.

2. Identify the functions of key governmental and quasi-

governmental agencies that affect public health systems and

nursing, both around the world and in the United States.

3. Contrast the primary bodies of law that affect nursing and

health care.

O B J E C T I V E S

4. Deine key terms related to policy and politics.

5. State the relationships among nursing practice, health

policy, and politics.

6. Develop and implement a plan to communicate with

policymakers on a chosen public health issue.

advanced-practice nurses, 120

Agency for Healthcare Research and

Quality (AHRQ), 112

American Nurses Association

(ANA), 118

block grants, 107

board of nursing, 115

categorical programs and

funding, 114

constitutional law, 115

devolution, 107

health policy, 106

judicial law, 115

legislation, 115

legislative staff, 119

licensure, 115

National Institute of Nursing

Research (NINR), 108

nurse practice act, 115

Occupational Safety and Health

Administration (OSHA), 110

Ofice of Homeland Security, 114

police power, 106

policy, 106

politics, 106

regulations, 115

US Department of Health and Human

Services (USDHHS), 106

World Health Organization

(WHO), 110

K E Y T E R M S

Deinitions

Governmental Role in US Health Care

Trends and Shifts in Governmental Roles

Government Health Care Functions

Healthy People 2020: An Example of National Health Policy

Guidance

Organizations and Agencies that Inluence Health

International Organizations

Federal Health Agencies

Federal Nonhealth Agencies

State and Local Health Departments

Impact of Government Health Functions and Structures

on Nursing

The Law and Health Care

Constitutional Law

C H A P T E R O U T L I N E

Legislation and Regulation

Judicial and Common Law

Laws Speciic to Nursing Practice

Scope of Practice

Professional Negligence

Legal Issues Affecting Health Care Practices

School and Family Health

Occupational Health

Home Care and Hospice

Correctional Health

The Nurse’s Role in the Policy Process

Legislative Action

Regulatory Action

The Process of Regulation

Nursing Advocacy

106 PART 2 Inluences on Health Care Delivery and Nursing

Nurses are an important part of the health care system and are

greatly affected by governmental and legal systems. Nurses who

select the community as their area of practice must be especially

aware of the impact of government, law, and health policy on

nursing, health, and the communities in which they practice.

Knowing how government, law, and political action have

changed over time is necessary to understand how the health

care system has been shaped by these factors. Also, understand-

ing how these factors have inluenced the current and future

roles for nurses and the public health system is critical for

establishing a better health policy for the nation.

Nurses have historically viewed themselves as advocates for

the health of the population. It is this heritage that has moved the

discipline into the policy and political arenas. To secure a more

positive health care system, nurse professionals must develop a

working knowledge of government, key governmental and quasi-

governmental organizations and agencies, health care law, the

policy process, and the political forces that are shaping the future

of health care. This knowledge and the motivation to be an agent

of change in the discipline and in the community are necessary

ingredients for success as a nurse working in the community.

DEFINITIONS

To understand the relationships among health policy, politics,

and laws, it is irst necessary to understand the deinitions of the

terms.

1. Policy is a speciic course of action to be followed by a gov-

ernment or institution to obtain a desired end.

2. Health policy is a set course of action to obtain a desired

health outcome for an individual, family, group, community,

or society.

Policies are made not only by governments but also by insti-

tutions such as a health department or other health care agency,

a family, or a professional organization.

Politics plays a role in the development of such policies. It is

found in families, professional and employing agencies, and

governments. Politics is the art of inluencing others to accept a

speciic course of action. Therefore political activities are used

to arrive at a course of action (the policy). Law is a system of

privileges and processes by which people solve problems based

on a set of established rules.

Laws govern the relationships of individuals and organiza-

tions to other individuals and to government. Through political

action, a policy becomes a law. After a law is established, regula-

tions further deine the course of action (policy) to be taken by

organizations or individuals in reaching an outcome. Govern-

ment is the ultimate authority in society and is designated to

enforce the policy—whether it is related to health, education,

economics, social welfare, or any other society issue. The fol-

lowing discussion explains the role of government in health

policy.

GOVERNMENTAL ROLE IN US HEALTH CARE

In the United States the federal and most state and local govern-

ments are comprised of three branches, each of which has

separate and important functions. The executive branch is

composed of the president (or governor or mayor) along

with the staff and cabinet appointed by this executive, various

administrative and regulatory departments, and agencies

such as the US Department of Health and Human Services

(USDHHS). The legislative branch (i.e., Congress at the federal

level) is made up of two bodies, the Senate and the House of

Representatives, whose members are elected by the citizens of

particular geographic areas. The judicial branch is comprised

of a system of federal, state, and local courts guided by the opin-

ions of the Supreme Court.

• The executive branch suggests, administers, and regulates

policy.

• The legislative branch identiies problems and proposes,

debates, passes, and modiies laws to address those problems.

• The judicial branch interprets laws and their meaning and

interprets states’ rights to provide health services to citizens

of the states.

One of the first constitutional challenges to a federal law

passed by Congress was in the area of health and welfare in

1937, after the 74th Congress had established unemploy-

ment compensation and old-age benefits for US citizens

(US Law, 1937b). Although Congress had created other

health programs previously, its legal basis for doing so had

never been challenged. In Steward Machine Co. v Davis

(US Law, 1937a), the Supreme Court (judicial branch) re-

viewed this legislation and determined, through interpretation

of the Constitution, that such federal governmental action

was within the powers of Congress to promote the general

welfare.

Most legal bases for the actions of Congress in health care

are found in Article I, Section 8, of the US Constitution, includ-

ing the following:

1. Provide for the general welfare

2. Regulate commerce among the states

3. Raise funds to support the military

4. Provide spending power

Through a continuing number and variety of cases and con-

troversies, these Section 8 provisions have been interpreted by

the courts to appropriately include a wide variety of federal

powers and activities. State power concerning health care is

called police power. This power allows states to act to protect

the health, safety, and welfare of their citizens. Such police

power must be used fairly, and the state must show that it has a

compelling interest in taking actions, especially actions that

might infringe on individual rights. Examples of a state using

its police powers include requiring immunization of children

before being admitted to school and requiring case inding, re-

porting, treating, and follow-up care of persons with tubercu-

losis. These activities protect the health, safety, and welfare of

state citizens.

TRENDS AND SHIFTS IN GOVERNMENTAL ROLES

The government’s role in health care at both the state and

federal level began gradually. Wars, economic instability, and

107CHAPTER 7 Government, the Law, and Policy Activism

political differences between parties all shaped the govern-

ment’s role. The irst major federal governmental action re-

lating to health was the creation in 1798 of the Public Health

Service (PHS). In 1934 Senator Wagner of New York initiated

the irst national health insurance bill. The Social Security

Act of 1935 was passed to provide assistance to older adults

and the unemployed; it also offered survivors’ insurance

for widows and children. In addition, it provided for child

welfare, health department grants, and maternal and child

health projects. In 1948 Congress created the National Insti-

tutes of Health (NIH). In 1965 it passed the most important

health legislation to date—creating Medicare and Medicaid

to provide health care service payments for older adults,

the disabled, and the categorically poor. These legislative

acts by Congress created programs that were implemented

by the executive branch. In March 2010 the most recent

legislation passed and signed by President Obama to improve

the health of the nation and access to care was the health

reform law, the Patient Protection and Affordable Care

Act (US Law, 2010). The legislation was designed to do the

following:

• “Rein in the worst excesses and abuses of the insurance in-

dustry with some of the toughest consumer protections this

country has ever known.”

• “Hold insurance companies accountable to keep premiums

down and prevent denials of care and coverage, including for

pre-existing conditions.”

• “Make health insurance affordable for middle class families

and small businesses with one of the largest tax cuts for

health care in history—reducing premiums and out-of-

pocket costs.”

• “Provide the security of knowing that if a job is lost,

changed, or a new business started, there will always be the

ability to purchase quality, affordable care in a new com-

petitive health insurance market that keeps costs down.”

• “Strengthen Medicare beneits with lower prescription

drug costs for those in the ‘donut hole,’ chronic care, free

preventive care, and nearly a decade more of solvency for

Medicare.”

• “Improve the nation’s iscal health by reducing the federal

deicit by more than $100 billion over the next decade, and

more than $1 trillion in the decade after that.”

By 2012 the law was simply referred to as the Affordable Care

Act (ACA). (See http://kff.org for updated outcomes of the

ACA implementation.)

The USDHHS (known irst as the Department of Health,

Education, and Welfare [DHEW]) was created in 1953. The

Health Care Financing Administration (HCFA) was created in

1977 as the key agency within the USDHHS to provide direc-

tion for Medicare and Medicaid. In 2002 the HCFA was re-

named the Centers for Medicare and Medicaid Services (CMS).

During the 1980s, a major effort of the administration was to

shift federal government activities, including federal programs

for health care, to the states. The process of shifting the respon-

sibility for planning, delivering, and inancing programs from

the federal level to the states level is called devolution. From

1980 until the present, Congress has increasingly funded health

programs by giving block grants to the states. Devolution pro-

cesses, including block granting, should alert professional

nurses that state and local policy is growing in importance in

the health care arena. With the new health reform law, stimulus

grants are being provided to state and local areas to improve

health care access (Health Resources and Services Administra-

tion [HRSA], 2015).

The role of government in health care is shaped both by the

needs and demands of its citizens and by the citizens’ beliefs

and values about personal responsibility and self-suficiency.

These beliefs and values often clash with society’s sense of re-

sponsibility and need for equality for all citizens. A recent fed-

eral example of this ideological debate occurred in the 1990s

over health care reform. The Democrats proposed the Health

Security Act of 1993, which failed to gain Congress’s approval.

In an effort to make some incremental health care changes,

both the Democrats and the Republicans in Congress passed

two new laws.

The Health Insurance Portability and Accountability Act

(HIPAA) allows working persons to keep their employee group

health insurance for up to 16 months after they leave a job

(US Law, 1996).

The State Child Health Improvement Act (SCHIP) of 1997

provides insurance for children and families who cannot other-

wise afford health insurance (US Law, 1997a).

This discussion has focused primarily on trends in and

shifts between different levels of government. An additional

aspect of governmental action is the relationship between gov-

ernment and individuals. Freedom of individuals must be

balanced with governmental powers. Since the terrorist attacks

on the United States in September (World Trade Center attack)

and October (anthrax outbreak) of 2001, much government

activity has been conducted in the name of protecting the

safety of US citizens. Government has a great deal of inluence

on the way health care services are delivered and on who re-

ceives care.

It is interesting to note that before September 11, 2001,

the Congress and president, recognizing that the public

health system infrastructure needed help, passed the Public

Health Threats and Emergencies Act (US Law, 2000) in 2000.

This law “addresses emerging threats to the public’s health

and authorizes the Secretary of HHS to take appropriate

response actions during a public health emergency, includ-

ing investigations, treatment, and prevention” (Katz et al,

2014, p 133). In June 2002 the Public Health Security and

Bioterrorism Preparedness and Response Act was signed into

law (US Law, 2002), with $3 billion appropriated by Con-

gress in December 2002 to implement the following antibio-

terrorism activities:

• Improving public health capacity

• Upgrading of the ability of health professionals to recognize

and treat diseases caused by bioterrorism

• Speeding the development of new vaccines and other coun-

termeasures

• Improving water and food supply protection

• Tracking and regulating the use of dangerous pathogens

within the United States (Katz et al, 2014)

http://kff.org

108 PART 2 Inluences on Health Care Delivery and Nursing

Yet there is considerable debate on just how much govern-

mental intervention is necessary and effective and how much

will be tolerated by citizens. For example, in 2010 approxi-

mately 49% of citizens were against the new health care reform

acts, and Republicans were seen as being obstructionists. In

2014, 50% of citizens were for government intervention and

50% against (Debate.org, 2013).

GOVERNMENT HEALTH CARE FUNCTIONS

Federal, state, and local governments carry out ive health

care functions, which fall into the general categories of direct

services, inancing, information, policy setting, and public

protection.

Direct Services Federal, state, and local governments provide direct health ser-

vices to certain individuals and groups. For example, the federal

government provides health care to members and dependents

of the military, certain veterans, and federal prisoners. State and

local governments employ nurses to deliver a variety of services

to individuals and families, frequently on the basis of factors

such as inancial need or the need for a particular service, such

as screening for hypertension or tuberculosis, immunizations

for children and older adults, and primary care for inmates in

local jails or state prisons.

Financing Governments pay for some health care services; the 2012

percentage of the bill paid by the government was about

45.3%, and this was projected to increase to 47.6% by the

year 2015. The government also pays for training some health

personnel and for biomedical and health care research

(National Center for Health Statistics [NCHS], 2014). How-

ever, as a result of the ACA, the government’s share of health

expenses dropped to 43.2% (NCHS, 2015). Support in the

following areas has greatly affected both consumers and

health care providers. Federal government inances the direct

care of clients through the Medicare, Medicaid, Social Secu-

rity, and SCHIP programs. State governments contribute to

the costs of Medicaid and SCHIP programs. Many nurses

have been educated with government funds through grants

and loans, and schools of nursing in the past have been

built and equipped using federal funds. Governments also

have inancially supported other health care providers, such

as physicians, most signiicantly through the program of

Graduate Medical Education funds.

The federal government invests in research and new pro-

gram demonstration projects, with the NIH receiving a large

portion of the monies. The National Institute of Nursing

Research (NINR) is a part of the NIH and, as such, provides

a substantial sum of money to the discipline of nursing for

the purpose of developing the knowledge base of nursing

and promoting nursing services in health care (NINR, 2014).

See the Evidence-Based Practice box for an example of

developing the knowledge base of nursing through funded

research.

Information All branches and levels of government collect, analyze, and

disseminate data about health care and the health status of

citizens. An example is the annual report Health, United

States, compiled each year by the USDHHS (NCHS, 2016).

Collecting vital statistics, including mortality and morbidity

data; gathering census data; and conducting health care status

surveys are all government activities. Table 7.1 lists examples

of available federal and international data sources on the

health status of populations in the United States and around

the world. These sources are available on the Internet and in

the governmental documents section of most large libraries.

This information is especially important because it can help

nurses understand the major health problems in the United

States and those in their own states and local communities.

Policy Setting Policy setting is a primary government function. Governments

at all levels and within all branches make policy decisions about

health care. These health policy decisions have broad implica-

tions for inancial expenses, resource use, delivery system change,

and innovation in the health care ield. One law that has played

a very important role in the development of public health policy,

public health nursing, and social welfare policy in the United

States is the Sheppard-Towner Act of 1921. Box 7.1 lists excerpts

from this act (Brown and Fee, 2013; US Law, 1921).

Public Protection The US Constitution gives the federal government the author-

ity to provide for the protection of the public’s health. This

EVIDENCE-BASED PRACTICE

Chronic obstructive pulmonary disease (COPD) is a serious, chronic, progres-

sive lower respiratory disorder that negatively affects several health indica-

tors, such as quality of life and functional status. The primary risk factor for

COPD is cigarette smoke, by exposure both directly (irsthand smoking) and

indirectly (secondhand smoke). Previous studies have shown a decrease in

hospitalization and mortality rates for respiratory diseases after implementa-

tion of smoke-free legislation. The purpose of this study was to determine the

impact of smoke-free municipal public policies on hospitalizations for COPD.

The researchers conducted a secondary analysis of hospital discharges with

primary diagnosis of COPD over an 8-year period (2003–2011). Controlling for

several factors, such as gender, age, and length of stay, researchers found that

those living in a community with comprehensive smoke-free laws or regula-

tions were 22% less likely to experience COPD hospitalizations than those

living in a community with weak to moderate laws or no laws.

Nurse Use

This study indicates that strong smoke-free public policies may protect against

COPD hospitalizations, thus having the potential to save lives and decrease

health care costs. This study supports the value of health policy, the beneits of

funding for research, and the need to evaluate the effectiveness of the policy in

accomplishing its purposes.

Data from Hahn EJ, Rayens, MK, Adkins S, et al: Fewer hospitalizations

for chronic obstructive pulmonary disease in communities with

smoke-free public policies, American Journal of Public Health, 104(6):

1059-1065, 2014.

109CHAPTER 7 Government, the Law, and Policy Activism

function is carried out in numerous ways, such as by regulating

air and water quality and by protecting the borders from an

inlux of diseases by controlling food, drugs, and animal trans-

portation. The Supreme Court interprets and makes decisions

related to public health, for example, afirming a woman’s rights

to reproductive privacy (Roe v Wade), requiring vaccinations,

and setting conditions for states to receive public funds for

highway construction and repair by requiring a minimum

drinking age.

HEALTHY PEOPLE 2020: AN EXAMPLE OF NATIONAL HEALTH POLICY GUIDANCE

In 1979 the Surgeon General issued a report that began a 20-

year focus on promoting health and preventing disease for all

Americans (DHEW, 1979). In 1989 Healthy People 2000 became

a national effort, with many stakeholders representing the per-

spectives of government, state, and local agencies; advocacy

groups; academia; and health organizations (USDHHS, 1991).

Throughout the 1990s, states used Healthy People 2000 ob-

jectives to identify emerging public health issues. The success

of this national program was accomplished and measured

through state and local efforts. The Healthy People 2010 docu-

ment focused on a vision of healthy people living in healthy

communities. Healthy People 2020 has four overarching goals,

found in the Healthy People 2020 box, which compares the goals

of Healthy People documents from 2000 to 2020 (USDHHS,

1991, 2000, 2010).

Organization Data Sources

International

United Nations

World Health

Organization

http://www.un.org/ Demographic Yearbook

http://www.who.int/en/ World Health

Statistics Annual

Federal

Department of Health

and Human Services

http://www.DHHS.gov

National Vital Statistics System

National Survey of Family Growth

National Health Interview Survey

National Health Examination Survey

National Health and Nutrition Examination Survey

National Master Facility Inventory

National Hospital Discharge Survey

National Nursing Home Survey

National Ambulatory Medical Care Survey

National Morbidity Reporting System

US Immunization Survey

Surveys of Mental Health Facilities

Estimates of National Health Expenditures

AIDS Surveillance

Nurse Supply Estimates

Department of

Commerce

http://www.commerce.gov

US Census of Population

Current Population Survey

Population Estimates and Projections

Department of Labor http://www.dol.gov

Consumer Price Index

Employment and Earnings

TABLE 7.1 International and National Sources of Data on the Health Status of the US Population

BOX 7.1 The Sheppard-Towner Act

The Sheppard-Towner Act did the following:

• Made nurses available to provide health services for women and children,

including well-child and child-development services

• Provided adequate hospital services and facilities for women and children

• Provided grants-in-aid for establishing maternal and child welfare programs

• Set precedents and patterns for the growth of modern-day public health policy

• Deined the role of the federal government in creating standards to be fol-

lowed by states in conducting categorical programs, such as today’s Special

Supplemental Nutrition Program for Women, Infants, and Children (WIC)

and Early Periodic Screening and Developmental Testing (EPSDT) programs

• Deined how the consumer could inluence, formulate, and shape public policy

• Deined the government’s role in research

• Developed a system for collecting national health statistics

• Explained how health and social services could be integrated

• Established the importance of prenatal care, anticipatory guidance, client

education, and nurse–client conferences, all of which are viewed today as

essential nursing responsibilities

1. Healthy People

2000 Goals

2. Healthy People

2010 Goals

3. Healthy People

2020 Goals

Increase the years of

healthy life for

Americans

Increase quality and

years of healthy

life

Attain high-quality,

longer lives free

of preventable

disease, disability,

injury, and premature

death

Reduce health

disparities among

Americans

Eliminate health

disparities

Achieve health equity,

eliminate disparities,

and improve the

health of all groups

Achieve access to

preventive services

for all Americans

Create social and physi-

cal environments that

promote good health

for all

Promote quality of life,

healthy development,

and healthy behav-

iors across all life

stages

From the US Department of Health and Human Services: Healthy

People 2000: national health promotion and disease prevention

objectives, Washington, DC, 1991, US Government Printing Ofice.

Retrieved Dec 2010 from http://www.health.gov/healthypeople; US

Department of Health and Human Services: Healthy People 2010:

understanding and improving health, ed 2, Washington, DC, 2000,

US Government Printing Ofice; US Department of Health and

Human Services: Healthy People 2020, Washington, DC, 2010,

US Government Printing Ofice.

HEALTHY PEOPLE 2020

A Comparison of the Goals of Healthy People 2000,

Healthy People 2010, and Healthy People 2020

http://www.un.org/

http://www.who.int/en/

http://www.DHHS.gov

http://www.commerce.gov

http://www.dol.gov

http://www.health.gov/healthypeople

110 PART 2 Inluences on Health Care Delivery and Nursing

ORGANIZATIONS AND AGENCIES THAT INFLUENCE HEALTH

INTERNATIONAL ORGANIZATIONS

In June 1945, after World War II, many national govern-

ments joined together to create the United Nations. By char-

ter, the aims and goals of the United Nations deal with

human rights, world peace, international security, and the

promotion of the economic and social advancement of all

the world’s peoples. The United Nations, headquartered in

New York City, is made up of six principal divisions, several

subgroups, and many specialized agencies and autonomous

organizations.

With the approval and support of the UN Commission on

the Status of Women, four world conferences on women have

been held. Others are being planned. At these conferences, the

health of women and children and their rights to personal, edu-

cational, and economic security as well as initiatives to achieve

these goals at the country level are debated and explored, and

policies are formulated (United Nations, 1975, 1980, 1985,

1995, 2000, 2010).

One of the special autonomous organizations growing out

of the United Nations is the World Health Organization

(WHO). Established in 1946, the WHO works with the United

Nations to achieve its goal to attain the highest possible level of

health for all persons. “Health for All” is the creed of the WHO.

Headquartered in Geneva, Switzerland, the WHO has six re-

gional ofices. The ofice for the Americas, in Washington, DC,

is known as the Pan American Health Organization. The WHO

provides services worldwide with the following aims (United

Nations, 2014):

• Promoting health

• Cooperating with member countries in promoting their

health efforts

• Coordinating the collaboration efforts among countries

• Disseminating biomedical research

Its services, which beneit all countries, include the following:

• Providing day-to-day information service on the occurrence

of internationally important diseases

• Publishing the international list of causes of disease, injury,

and death

• Monitoring adverse reactions to drugs

• Establishing world standards for antibiotics and vaccines

Assistance available to individual countries includes the

following:

• Supporting national programs to ight disease

• Training health workers

• Strengthening the delivery of health services

The World Health Assembly (WHA) is the WHO’s policy-

making body, and it meets annually. The WHA’s health policy

work provides policy options for many countries of the world in

their development of in-country initiatives and priorities; how-

ever, although important everywhere, WHA policy statements

are guides and not law. The WHA’s latest policy statement on

nursing and midwifery was released in 2003, and in 2010 the

WHO provided a document outlining strategic directions for

2011–2015 on implementing the WHA policy statement (WHA,

2003; WHO, 2010).

The current worldwide shortage of professional nurses is a

continuing concern on the WHO agenda and is being addressed

by country. The World Health Report, irst published in 1995, is

WHO’s leading publication. Each year the report combines an

expert assessment of global health, including statistics relating to

all countries, with a focus on a speciic subject. The main purpose

of the report was to provide countries, donor agencies, interna-

tional organizations, and others with the information they need

to help them make policy and funding decisions (WHO, 2016).

The presence of nursing in international health is increasing

to include the following:

• Direct health services in every country in the world

• Consultants

• Educators

• Program planners

• Evaluators

Nurses focus their work on a variety of public health issues:

• Health care workforce and education

• Environment

• Sanitation

• Infectious diseases

• Wellness promotion

• Maternal and child health

• Primary care

Dr. Naeema Al-Gasseer of Bahrain has served as the scientist

for nursing and midwifery at the WHO; Marla Salmon, former

dean of nursing at the University of Washington, chaired a

Global Advisory Group on Nursing and Midwifery; and Linda

Tarr Whelan served as the US ambassador to the UN Commis-

sion on the Status of Women. Virginia Trotter Betts, past presi-

dent of the American Nurses Association (ANA), served as a US

delegate to both the WHA and the Fourth World Conference on

Women in Beijing in 1995, where she participated on the nego-

tiating team of the conference to develop a platform on the

health of women across the life span. Many US nurse leaders,

such as Dr. Carolyn Williams, current author in this book, have

been WHO consultants. These examples show the impact that

nurses have on international public health policy.

FEDERAL HEALTH AGENCIES

Laws passed by Congress may be assigned to any administrative

agency within the executive branch of government for imple-

menting, supervising, regulating, and enforcing. Congress de-

cides which agency will monitor speciic laws. For example,

most health care legislation is delegated to the USDHHS. How-

ever, legislation concerning the environment would most likely

be implemented and monitored by the Environmental Protec-

tion Agency (EPA), and legislation concerning occupational

health is monitored by the Occupational Safety and Health

Administration (OSHA) in the US Department of Labor.

US Department of Health and Human Services The USDHHS is the agency most heavily involved with the

health and welfare of US citizens. It touches more lives than any

111CHAPTER 7 Government, the Law, and Policy Activism

other federal agency. The organizational chart of the USDHHS

(see Chapter 3, Fig. 3.1) shows and provides more discussion

for the key agencies within the organization. The following

agencies have been selected for their relevance to this chapter.

Health Resources and Services Administration

The Health Resources and Services Administration (HRSA) has

been a long-standing contributor to the improved health status

of Americans through the programs of services and health pro-

fessions education that it funds. The HRSA contains the Bureau

of Health Professions (BHPr), which includes the Division of

Nursing as well as the Divisions of Medicine, Dentistry, and

Allied Health Professions. The Division of Nursing is the key

federal focus for nursing education and practice, and it pro-

vides national leadership to ensure an adequate supply and

distribution of qualiied nursing personnel to meet the health

needs of the nation.

In 2013 the Division of Nursing had the following strategic

goals (USDHHS, 2013a):

• Increase access to quality care through improved composi-

tion, distribution, and retention of the nursing workforce

through inancial assistance.

• Identify and use data, program performance measures, and

outcomes to make informed decisions on nursing workforce

issues.

• Increase cultural competence in the nursing workforce.

• Increase diversity in the nursing workforce.

At the 122nd meeting of the Division of Nursing’s National

Advisory Council for Nursing Education and Practice (NACNEP),

the participants discussed the role of public health nurses in

participating in primary care in their communities (NACNEP,

2010). The speaker indicated several factors that need to be in place

to support the public health nurse role:

• Baccalaureate standard for entry into practice

• Ongoing stable funding for health departments

• Competitive salaries commensurate with responsibilities

• Interventions grounded in and responsive to community

needs

• Consideration of health determinants

• Experience in health promotion and prevention

• Long-term trusting relationships in the community (i.e., with

clients)

• Established network of community partners

• Commitment to social justice and eliminating health

disparities

Through the input of the NACNEP, the Division of Nurs-

ing sets policy for nursing nationally. At the 133rd meeting of

the NACNEP, the discussion had progressed to population

health and aimed to identify how nurses could best contribute

and lead population health initiatives and to identify the

training and skills that nurses would need in population

health (USDHHS, 2016).

Centers for Disease Control and Prevention The Centers for Disease Control and Prevention (CDC) serves as

the national focus for developing and applying disease preven-

tion and control, environmental health, and health promotion

and education activities designed to improve the health of the

people of the United States. The mission of the CDC is to pro-

mote health and quality of life by preventing and controlling

disease, injury, and disability. The CDC seeks to accomplish its

mission by working with partners throughout the nation and the

world in the following ways:

• Monitoring health

• Detecting and investigating health problems

• Conducting research that will enhance prevention

• Developing and advocating sound public health policies

• Implementing prevention strategies

• Promoting healthy behaviors

• Fostering safe and healthful environments

• Providing leadership and training

The disease outbreak that occurred in the summer of 2014

provides an example of how the CDC fulills its mission. The

Shiga toxin–producing Escherichia coli outbreak linked to raw

clover sprouts affected six states and 19 people, and 44% of

those affected were hospitalized. Idaho was determined to be the

most likely source of the outbreak. The CDC regularly collects

data from states about foodborne illnesses through the National

Notiiable Disease Surveillance System and on a weekly basis

through the Morbidity and Mortality Weekly Report (MMWR).

Because of the recognized increase in cases, states were asked to

report aggregate numbers of cases twice a week along with

foodborne-related hospitalizations and complications. The CDC

implemented an investigation to track the cases and worked with

state and local health departments to perform the following:

• Detect the possible outbreak.

• Deine and ind cases.

• Generate hypotheses about the likely source.

• Test the hypothesis.

• Find the point of contamination.

• Control the outbreak from further spread.

• Decide when the outbreak is over.

In the 3 months from June 2014 to August 2014, 19 cases

occurred in 6 states (CDC, 2014a). The six states involved and

number of cases were as follows: California (1), Idaho (3), Mich-

igan (1), Montana (2), Utah (1), and Washington (11). By August

2014 the CDC determined the outbreak to be over. Although few

people were involved in this outbreak, the outcome could have

been deadly for the persons who ate the sprouts.

While the Ebola virus of West Africa continues to spread, the

CDC is monitoring the effects of the virus as part of its global

monitoring system. The CDC has information and training

materials ready for those who may need them (CDC, 2014b).

The CDC took an active role in the recent outbreak of measles

that resulted from exposure to the virus at Disneyland in

California. This outbreak resulted in 140 people from seven

states being infected. On January 23, 2015, the CDC issued

a health advisory to all public health and health care facilities

nationwide (Zipprich et al, 2015). In addition, the CDC took

active roles in monitoring and tracking the Zika virus outbreaks

in the United States. By 2016, over 800 cases involving the virus

were reported in 45 states. At that point, all cases were caused by

travel to countries whose mosquitoes harbored the virus (CDC,

2016). Fig. 7.1 shows the location of the US Zika virus cases.

112 PART 2 Inluences on Health Care Delivery and Nursing

National Institutes of Health

Founded in 1887, the NIH today is one of the world’s foremost

biomedical research centers and the federal focus point for bio-

medical research in the United States. The NIH comprises 27

separate institutes and centers. The goal of NIH research is to

acquire new knowledge to help prevent, detect, diagnose, and

treat disease and disability, from the rarest genetic disorder to

the common cold, to lead to better health for everyone. The

NIH mission is to uncover new knowledge that will lead to bet-

ter health for everyone. The NIH works toward that mission by

conducting research in its own laboratories; supporting the re-

search of nonfederal scientists in universities, medical schools,

hospitals, and research institutions throughout the country and

abroad; helping in the training of research investigators; and

fostering communication of medical and health sciences infor-

mation (NIH, n.d.).

In late 1985 Congress overrode a presidential veto, allowing

the creation of the National Center for Nursing Research within

the NIH. In 1993 the center became one of the divisions of the

NIH and was renamed the National Institute of Nursing

Research (NINR).

The research and research-related training activities previ-

ously supported by the Division of Nursing were transferred to

the new institute. The NINR is the focal point of the nation’s

nursing research activities. It promotes the growth and quality

of research in nursing and client care, provides important lead-

ership, expands the pool of experienced nurse researchers, and

serves as a point of interaction with other bases of health care

research. The mission of NINR is to promote and improve the

health of individuals, families, communities, and populations.

NINR supports and conducts clinical and basic research and

research training on health and illness across the life span. The

research focus encompasses health promotion and disease pre-

vention, quality of life, health disparities, and end of life. NINR

seeks to extend nursing science by integrating the biological

and behavioral sciences, using new technologies to research

questions, improving research methods, and developing the

scientists of the future (NINR, n.d.).

Agency for Healthcare Research and Quality

The Agency for Healthcare Research and Quality (AHRQ) is

the lead federal agency charged with improving the quality,

safety, eficiency, and effectiveness of health care for all Ameri-

cans. As one of the 12 agencies within the USDHHS, AHRQ

supports health services research that will improve the quality

of health care and promote evidence-based decision making.

AHRQ is committed to improving care safety and quality by

developing successful partnerships and generating the knowl-

edge and tools required for long-term improvement. The goal

of AHRQ research is to promote measurable improvements

in health care in America. AHRQ organizes their measures

of health care quality into four Quality Indicator modules:

Prevention Quality Indicators, Inpatient Quality Indicators,

Patient Safety Indicators, and Pediatric Quality Indicators

(AHRQ, n.d.).

By examining what works and what does not work in health

care, the AHRQ fulills its missions of translating research

indings into better patient care and providing consumers,

1-11

12-22

23-49

50-100

101

Guam

CNMI

American

Samoa

Puerto Rico

U.S. Virgin Islands

UT CO

AZ NM

IL IN OH

VT NH

DE MD

KY WV

VA DC

NCTN OK AR

MS AL GA

CT NJ

States and territories reporting

Zika virus disease

Solid shading represents all

cases except for local

mosquito-borne transmission

Widespread local vector-borne transmission

Limited local vector-borne transmission*

FIG. 7.1 Laboratory-conirmed Zika virus disease cases reported to ArboNET by state or territory,

United States, 2015–2016, National Center for Emerging and Zoonotic Diseases (NCEZID),

Atlanta, Georgia.

113CHAPTER 7 Government, the Law, and Policy Activism

policymakers, and other health care leaders with information

needed to make critical health care decisions. In 1999 Congress,

through legislation, speciically directed the AHRQ to focus on

measuring and improving health care quality; promoting client

safety and reducing medical errors; advancing the use of infor-

mation technology for coordinating client care and conducting

quality and outcomes research; and seeking to eliminate dis-

parities in health care delivery for the priority populations of

low-income groups, minorities, women, children, older adults,

and individuals with special health care needs.

home health agencies, intermediate care facilities for the men-

tally retarded, and hospitals). It makes available to beneiciaries,

providers, researchers, and state surveyors information about

these activities and nursing home quality.

FEDERAL NONHEALTH AGENCIES

Although the USDHHS has the primary responsibility for fed-

eral health functions, several other departments of the executive

branch carry out important health functions for the nation.

Among these are the Departments of Defense, Labor, Agricul-

ture, and Justice.

• Department of Defense: The Department of Defense deliv-

ers health care to members of the military and their depen-

dents. In each branch of the uniformed services, nurses of

high military rank are part of the administration of these

health services (see www.defense.gov for more information).

• Department of Labor: The Department of Labor has two agen-

cies with health functions: OSHA and the Mine Safety and

Health Administration. Both are charged with writing safety and

health standards and ensuring compliance in the workplace.

• Department of Agriculture: The Department of Agriculture

is involved in health care primarily by administering the

Food and Nutrition Service. This service collaborates with

state and local government welfare agencies to provide food

stamps to needy persons to increase their food purchasing

power. Other programs include school breakfast and lunch

programs; the Special Supplemental Nutrition Program for

Women, Infants, and Children (WIC); and grants to states

for nutrition education and training.

• Department of Justice: Health services to federal prisoners

are administered within the Department of Justice. The Fed-

eral Bureau of Prisons is responsible for the custody and care

of approximately 214,000 federal offenders (Bureau of Federal

Prisons, 2014). The Medical and Services Division of the

Bureau of Prisons includes medical, psychiatric, dental, and

health support services.

STATE AND LOCAL HEALTH DEPARTMENTS

Depending on funding, public commitment and interest, and ac-

cess to other resources, programs offered by state and local health

departments vary greatly. Many state and local health oficials re-

port that employees in public health agencies lack skills in the core

sciences of public health and that this has hindered their effective-

ness. The lack of specialized education and skill is a signiicant

barrier to population-based preventive care and the delivery of

quality health care to the public. Public health workforce specialists

report that the number of retirees expected in this decade will re-

sult in a major shortage of public health workers, including nurses.

More often than at other levels of government, nurses at the local

level provide direct services. Some nurses deliver special or selected

services, such as follow-up of contacts in cases of tuberculosis

or venereal disease or providing child immunization clinics. Other

nurses have a more generalized practice, delivering services to

families in certain geographic areas (University of Michigan Center

of Excellence in Public Health Workforce Studies, 2013).

FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES

• Targeted competency: Quality improvement

• Knowledge: Describe strategies for learning about the outcomes of care

in the public setting.

• Skills: Seek information about outcomes of care for populations served in

care settings.

• Attitudes: Appreciate that continuous quality improvement is an essential

part of the daily work of all professionals.

QI Question

The Quad Council competency of policy development and program planning

skills indicates that the beginning public health nurse collects information that

will inform policy decisions. Also, the public health nurse describes the legisla-

tive policy development process and identiies outcomes of current health policy

relevant to public health nursing practice. The 2014 outbreak of the Ebola virus

in the United States brought quick recognition that there was a need for im-

provement in policies related to infectious disease control. What were the indi-

cators that the infection control policies in place were not suficient to prevent

the spread of disease? Describe the continuous quality improvement (CQI) data-

collection processes that determined the need for policy change. What role did

nurses and organized nursing play in improving the infection control policy and

guidelines nationally? What has been the outcome of the new policy, and how

were populations affected both locally and nationally?

The AHRQ has published protocols for care of clients with a

variety of health problems. These protocols have become the

standards of health care delivery. The agency maintains a clinical

practice guidelines clearinghouse for use by clinicians and others.

In addition, the AHRQ has a project called “Put Prevention into

Practice” to promote the use of standardized protocols for pri-

mary care delivery for clients across the age span (see Resource

Tool 7A for the Schedule of Clinical Preventive Services). These

protocols can be used by nurses in planning disease prevention

and health promotion activities for their clients.

Centers for Medicare and Medicaid Services

One of the most powerful agencies within the USDHHS is the

Centers for Medicare and Medicaid Services (CMS), which ad-

ministers Medicare and Medicaid accounts and guides payment

policy and delivery rules for services for the poor, elderly, dis-

abled, and unemployed. In addition to providing health insur-

ance, the CMS also performs various quality-focused health

care or health-related activities, including regulating laboratory

testing, developing coverage policies, and improving quality of

care. CMS maintains oversight of the surveying and certifying

of nursing homes and continuing care providers (including

http://www.defense.gov

114 PART 2 Inluences on Health Care Delivery and Nursing

At the local and state levels, coordinating health efforts

between health departments and other county or city depart-

ments is essential. Gaps in community coordination are show-

ing up in glaring ways as states and communities scramble to

address bioterrorism preparedness since September 11, 2001,

and since such natural disasters as Hurricane Katrina.

the symptoms, treatment, or mode of transmission of this dis-

ease. Most health professionals, including registered nurses

(RNs), currently working in the United States have never seen a

case of anthrax, smallpox, or plague, the three major biological

weapons of concern in the world today. The USDHHS and the

new federal Ofice of Homeland Security have provided funds

to address this serious threat to the people of the United States.

One of the irst things being done is the rebuilding of the crum-

bling public health infrastructures of each state to provide

surveillance, intervention, and communication in the face of

future bioterrorism events. On December 19, 2006, President

George W. Bush signed the Pandemic and All-Hazards Pre-

paredness Act (PAHPA), which was intended to improve the

organization, direction, and utility of preparedness efforts.

PAHPA, which was reauthorized by President Obama in 2013,

centralizes federal responsibilities, requires state-based account-

ability, proposes new national surveillance methods, addresses

surge capacity, facilitates the development of vaccines and other

scarce resources, and enables communities to build systems to

support populations during and after disasters (Morhard and

Franco, 2013; USDHHS 2013b).

THE LAW AND HEALTH CARE

The United States is a nation of laws, which are subject to the

US Constitution. The law is a system of privileges and processes

by which people solve problems on the basis of a set of estab-

lished rules. It is intended to minimize the use of force. Laws

govern the relationships of individuals and organizations to

other individuals and to government. After a law is established,

regulations further deine the course of actions to be taken by

the government, organizations, or individuals in reaching an

agreed-on outcome. Government and its laws are the ultimate

authority in society and are designed to enforce oficial policy,

whether it is related to health, education, economic, social wel-

fare, or any other societal issue. The number and types of laws

inluencing health care are ever increasing. Deinitions of law

include, but are not limited to, the following (Merriam-Webster

at http://www.merriam-webster.com/dictionary/law):

• A rule established by authority, society, or custom

• The body of rules governing the affairs of people, communi-

ties, states, corporations, and nations

• A set of rules or customs governing a discrete ield or activity

(e.g., criminal law, contract law)

These deinitions relect the close relationship of law to the

community and to society’s customs and beliefs. The law has

had a major impact on nursing practice. Although nursing

emerged from individual voluntary activities, society passed

laws to give formality to public health, and, through legal man-

dates (i.e., laws), positions and functions for nurses in commu-

nity settings were created. These functions in many instances

carry the force of law. For example, if the nurse discovers a per-

son with smallpox, the law directs the nurse and others in the

public health community to take speciic actions. In a mumps

outbreak, nurses and other health professionals are required to

report cases of mumps. This requirement for reporting helps

locate and treat cases as they occur, thus preventing further

spread of disease. Three types of laws in the United States have

Tammy Jones is the school nurse at Caseyville Middle School. The state re-

quires all entering sixth-grade students to have a current immunization certii-

cate on ile before the student’s enrollment. It is now 6 months into the school

year, and Ms. Jones is reviewing the students’ records. Ms. Jones inds that

several students do not have current immunization certiicates on ile. Al-

though the state law requires immunization certiicates, it does not specify the

course of action in cases of noncompliance.

Ms. Jones goes to her supervisor to discuss possible resolutions to the situ-

ation. Should they suspend the noncompliant students because the law states

the certiicate for immunization is required for enrollment? This solution could

mean many missed days of valuable lessons for the students. What implica-

tions for the students and the community could arise if the students continue

to go without immunizations?

Ms. Jones and her supervisor decide to contact each student and meet with

his or her family individually. The meetings reveal that many of the parents

have tried to get their child immunized but have not been able to do so because

of the costs of the shots or the inability to make an appointment at the busy

doctor’s ofice. Ms. Jones works with these families to make appointments at

the local health department to fulill the immunization requirement.

CASE STUDY

Child Immunization Policies

IMPACT OF GOVERNMENT HEALTH FUNCTIONS AND STRUCTURES ON NURSING

The variety and range of functions of governmental agencies

have had a major impact on the practice of nursing. Funding,

in particular, has shaped roles and tasks of population-centered

nurses. The designation of money for speciic needs, or cate-

gorical programs and funding, has led to special and more

narrowly focused nursing roles. Examples are in emergency

preparedness, school nursing, and family planning. Funds as-

signed to antibioterrorism cannot be used to support unrelated

communicable disease programs or family planning.

Since the events of September 11, 2001, the public and the

profession of nursing have been concerned about the ability of

the present public health system and its workforce to deal with

bioterrorism, especially outbreaks of deadly and serious com-

municable diseases. For example, smallpox vaccinations stopped

in 1972, but immunity lasts for only 10 years; as a result, although

there have been no reported cases of smallpox since the early

1970s, almost no one in the United States has immunity. Thus the

population is vulnerable to an outbreak of smallpox because it

could be used as a weapon of bioterrorism. Two laboratories in

the world retain a small amount of the smallpox virus. Because

of these potential threats, the US government has begun to in-

crease production of the smallpox vaccine and has enough vac-

cine to inoculate every person in the United States, if necessary

(see http://www.emergency.cde.gov for smallpox vaccination

facts). Few public health professionals are knowledgeable about

http://www.emergency.cde.gov

http://www.merriam-webster.com/dictionary/law

115CHAPTER 7 Government, the Law, and Policy Activism

particular importance to the nurse. They are constitutional law,

legislation and regulation, and judicial or common law.

CONSTITUTIONAL LAW

Constitutional law derives from federal and state constitutions. It

provides overall guidance for selected practice situations. For ex-

ample, on what basis can the state require quarantine or isolation

of individuals with tuberculosis? The US Constitution speciies

the explicit and limited functions of the federal government. All

other powers and functions are left to the individual states. The

major constitutional power of the states relating to population-

centered nursing practice is the state’s right to intervene in a

reasonable manner to protect the health, safety, and welfare of its

citizens. The state has police power to act through its public health

system, but it has limits. First, it must be a “reasonable” exercise

of power. Second, if the power interferes with or infringes on

individual rights, the state must demonstrate that there is a “com-

pelling state interest” in exercising its power. Isolating an individual

or separating someone from a community because that person has

a communicable disease has been deemed an appropriate exercise

of state powers. The state can isolate an individual, such as some-

one who has tuberculosis and is noncompliant with treatment,

even though it infringes on individual rights (such as freedom and

autonomy), under the following conditions (Cole, 2014):

1. A compelling state interest exists in preventing an epidemic.

2. The isolation is necessary to protect the health, safety, and wel-

fare of individuals in the community or the public as a whole.

3. The isolation is done in a reasonable manner.

In such circumstances the community’s rights are more im-

portant than the individual’s rights when there is a threat to the

health of the public.

LEGISLATION AND REGULATION

Legislation is law that comes from the legislative branches of the

federal, state, or local government. This is referred to as statute

law because it becomes coded in the statutes of a government

(Birkland, 2015). Much legislation has an effect on nursing.

Regulations are speciic statements of law related to deining or

implanting individual pieces of legislation. For example, state

legislatures enact laws (statutes) establishing boards of nursing

and deining terms such as registered nurse and nursing practice.

Every state has a board of nursing. The board may be found

either in the department of licensing boards of the health depart-

ment or in an administrative agency of the governor’s ofice.

Created by legislation known as a state nurse practice act, the

board of nursing is made up of nurses and consumers. The func-

tions of this board are described in the nurse practice act of each

state and generally include licensing and examination of regis-

tered nurses and licensed practical nurses; approval of schools

of nursing in the state; revocation, suspension, or denying of

licenses; and writing of regulations about nursing practice and

education. The state boards of nursing operationalize, imple-

ment, and enforce the statutory law by writing explicit statements

(called rules) on what it means to be a registered nurse, and on

the nurse’s rights and responsibilities in delegating work to others

and in meeting continuing education requirements.

All nurses employed in community settings are subject to

legislation and regulations. For example, home health care

nurses employed by private agencies must deliver care ac-

cording to federal Medicare or state Medicaid legislation and

regulations, so the agency can be reimbursed for those ser-

vices. Private and public health care services rendered by

nurses are subject to many governmental regulations for

quality of care, standards of documentation, and conidenti-

ality of client records and communications. All state health

departments have a public health practice reference that gov-

erns the practice of nurses and others and state public health

laws that deine the essential public health services that must

be offered in the state, as well as the optional services that

may also be offered.

JUDICIAL AND COMMON LAW

Both judicial law and common law have a great impact on nurs-

ing. Judicial law is based on court or jury decisions. The opin-

ions of the courts are referred to as case law (Birkland, 2015). The

court uses other types of laws to make its decisions, including

previous court decisions or cases. Precedent, one principle of

common law, means that judges are bound by previous decisions

unless they are convinced that the older law is no longer relevant

or valid. This process is called distinguishing, and it usually in-

volves a demonstration of how the current situation in dispute

differs from the previously decided situation. Other principles of

common law, such as justice, fairness, respect for an individual’s

autonomy, and self-determination, are part of a court’s rationale

and the basis on which to make a decision.

LAWS SPECIFIC TO NURSING PRACTICE

Despite the broad nature and varied roles of nurses in practice, two

legal areas are most applicable to nurse practice situations. The irst

is the statutory authority for the profession and its scope of prac-

tice, and the second is professional negligence or malpractice.

SCOPE OF PRACTICE

The issue of scope of practice involves deining nursing, setting

its credentials, and then distinguishing among the practices of

nurses, physicians, and other health care providers. The issue is

especially important to nurses in community settings, who have

traditionally practiced with much autonomy.

Health care practitioners are subject to the laws of the state

in which they practice, and they can practice only with a license.

The states’ nurse practice acts differ somewhat, but they are

the most important statutory law affecting nurses. The nurse

practice act of each state accomplishes at least four functions:

(1) deining the practice of professional nursing, (2) identifying

the scope of nursing practice, (3) setting educational qualiica-

tions and other requirements for licensure, and (4) determin-

ing the legal titles nurses may use to identify themselves. The

usual and customary practice of nursing can be determined

through a variety of sources, including the following:

1. Content of nursing educational programs, both general and

special

116 PART 2 Inluences on Health Care Delivery and Nursing

2. Experience of other practicing nurses (peers)

3. Statements and standards of nursing professional organizations

4. Policies and procedures of agencies employing nurses

5. Needs and interests of the community

6. Updated literature, including research, books, texts, and

journals

All of these sources can describe, determine, and reine the

scope of practice of a professional nurse. Every nurse should

know and follow closely any proposed changes in the practice

acts of nursing, medicine, pharmacy, and other related profes-

sions. The nurse should always examine all legislation, rules,

and regulations related to nursing practice. For example, a re-

view of the Pharmacy Act will let the nurse know whether to

question the right to dispense medications in a family planning

clinic in a local health department. Deining the scope of prac-

tice makes it necessary to clarify independent, interdependent,

and dependent nursing functions.

Just as practice acts vary by state, so do the evolving issues

and tensions of scopes of practice among the health profes-

sions. In the past few years, several state legislatures (work-

ing closely with the National Council of State Boards of

Nursing) have embarked on a legislative effort to develop the

Interstate Nurse Licensure Compact. The compact allows

mutual recognition of generalist nursing licensure across

state lines in the compact states. By 2015, 25 states had

adopted the compact (National Council of State Boards of

Nursing, 2015.)

PROFESSIONAL NEGLIGENCE

Professional negligence, or malpractice, is deined as an act (or

a failure to act) that leads to injury of a client. To recover money

damages in a malpractice action, the client must prove all of the

following:

1. The nurse owed a duty to the client or was responsible for

the client’s care.

2. The duty to act the way a reasonable, prudent nurse would

act in the same circumstances was not fulilled.

3. The failure to act reasonably under the circumstances led to

the alleged injuries.

4. The injuries provided the basis for a monetary claim from

the nurse as compensation for the injury.

Reported cases involving negligence and population-centered

nurses are very few in number.

The author of this chapter has known of some cases in

the community that related to serious side effects from child

vaccinations. In one instance, the family was new to the

community, and the child was enrolling in school. By state

law the child had to be vaccinated for childhood communi-

cable disease before entering school. The public health nurse

asked the mother of the child about the child’s history of

vaccinations and the family physician’s certiicate of immuni-

zations. The mother indicated that they had recently moved

to the community and that she could not ind the record.

The mother assured the nurse that immunizations were

needed. In an attempt to be accommodating, the nurse ac-

cepted the mother’s knowledge regarding the need for

vaccination and proceeded to vaccinate the child. In a brief

time period the child developed complications from the

immunizations, speciically, a severe neurological disorder.

The family sued the nurse and the health department for

negligence.

An integral part of all negligence actions is the question of

who should be sued. In the eyes of the law, the “prudent nurse”

practicing anywhere in the United States is used as the example,

or standard, by which to judge the competency of a nurse’s

practice. When a nurse is employed and functioning within the

scope of employment, the employer is responsible for the

nurse’s negligent actions. This is referred to as the doctrine of

respondeat superior. By directing a nurse to carry out a particu-

lar function, the employer becomes responsible for negligence,

along with the individual nurse. Because employers are usually

better able to pay for the injuries suffered by clients, they are

sued more often than the nurses themselves, although an in-

creasing number of judgments include the professional nurse

by name as a codefendant.

Thus it is imperative that all nurses engaged in clinical prac-

tice carry their own professional liability insurance. Nurses may

have personal immunity for particular practice areas, such as

giving immunizations. In some states, the legislature has

granted personal immunity to nurses employed by public agen-

cies to cover all aspects of their practice under the legal theory

of sovereign immunity (Cherry and Jacobs, 2013).

In the immunization case described previously, the nurse

was judged to be negligent and was held liable for the injury

to the child because she did not follow the protocol of the

health department or the school system. She neglected to

obtain the necessary documents from the previous school

system or the physician to determine the actual status of

the child’s immunizations. Both the health department and

the school system had sovereign immunity and were not held

liable and could show the protocol the nurse was directed to

follow.

Nursing students need to be aware that the same laws and

rules that govern the professional nurse govern them. Students

are expected to meet the same standard of care as that met by

any licensed nurse practicing under the same or similar circum-

stances. Students are expected to be able to perform all tasks

and make clinical decisions on the basis of the knowledge they

have gained or been offered, according to their progress in their

educational programs and along with adequate educational

supervision.

CHECK YOUR PRACTICE?

As a student, you are working as a school health nurse along with an employee

of the health department in your community. The state law requires that upon

entry into the school system, all children must be vaccinated for childhood com-

municable diseases. The nurses in the schools may administer the vaccines if a

child needs any or all of the required immunizations. A family has recently

moved into your school district, and the parents cannot ind the immunization

record from the prior school system or from the physician in the previous com-

munity. The mother insists that the vaccinations are not up to date and wants

the child to be able to enter school immediately. You are aware that it only takes

one sick child for a major outbreak. To reduce the risk and protect the school

population from communicable disease outbreaks, what should you do?

117CHAPTER 7 Government, the Law, and Policy Activism

LEGAL ISSUES AFFECTING HEALTH CARE PRACTICES

Speciic legal issues of nursing vary depending on the setting in

which care is delivered, the clinical arena, and the nurse’s func-

tional role. The law, including legislation and judicial opinions,

signiicantly affects each of the following areas of nursing prac-

tice. Nurses responsible for setting and implementing program

priorities need to identify and monitor laws related to each

special area of practice.

SCHOOL AND FAMILY HEALTH

Nurses employed by health departments or boards of education

may deliver school and family health nursing. School health legis-

lation establishes a minimum of services that must be provided to

children in public and private schools. For example, most states

require that children be immunized against certain communica-

ble diseases before entering school. Children must have had a

physical examination by that time, and most states require at least

one physical at a later time in their schooling. Legislation also

speciies when and what type of health screening will be con-

ducted in schools (e.g., vision and hearing testing). These require-

ments are found in statutory laws of states. Some states are now

requiring a simple dental examination in schools for the purpose

of referring children to a dental health professional if needed.

Statutes addressing child abuse and neglect make a large

impact on nursing practice within schools and families. Most

states require nurses to notify police and/or a social service

agency of any situation in which they suspect a child is being

abused or neglected. This is one instance in which the law man-

dates that a health professional breach client conidentiality to

protect someone who may be in a helpless or vulnerable posi-

tion. There is civil immunity for such reporting, and the nurse

may be called as a witness in a court hearing of the case.

OCCUPATIONAL HEALTH

Occupational health is another special area of practice that has

speciic legal requirements as a result of state and federal stat-

utes. Of special concern are the state workers’ compensation

statutes, which provide the legal foundation for claims of work-

ers injured on the job. Access to records, conidentiality, and the

use of standing orders are legal issues that have great practice

signiicance to nurses employed in industries.

HOME CARE AND HOSPICE

Home care and hospice services rendered by nurses are shaped

through state statutes and have speciic nursing requirements

for licensure and certiication. Compliance with these laws is

directly linked to the method of payment for the services. For

example, a service must be licensed and certiied to obtain pay-

ment for services through Medicare. Federal regulations imple-

menting Medicare and Medicaid have an enormous effect on

much of nursing practice, including how nurses record details

of their visits, record time spent in care activities, and docu-

ment client care and the client’s status and progress.

In addition, many states have passed laws requiring nurses to

report elder abuse to the proper authorities, as is done with chil-

dren and youth. Laws affecting home care and hospice services

have focused on issues such as the right to death with dignity,

rights of residents of long-term facilities and home health clients,

deinitions of death, and the use of living wills and advance direc-

tives. The legal and ethical dimensions of nursing practice are

particularly important. Individual rights, such as the right to re-

fuse treatment, and nursing responsibilities, such as the legal duty

to render reasonable and prudent care, may appear to be in con-

lict in delivering home and hospice services. Much case discus-

sion (sometimes including outside ethics consultation) may be

needed to resolve such conlicts.

CORRECTIONAL HEALTH

Correctional health nursing practice is signiicantly shaped by

federal and state laws and regulations and by recent Supreme

Court decisions. The laws and decisions primarily relate to the

type and amount of services that must be provided for incarcer-

ated individuals. For example, physical examinations are required

for all prisoners after they are sentenced. Regulations specify ba-

sic levels of care that must be provided for prisoners, and access

to care during illness is a particular focus. Court decisions requir-

ing adequate health services are based on constitutional law. If

minimal services are not provided, it is a violation of a prisoner’s

right to freedom from cruel and unusual punishment. Such deci-

sions provide a framework that strongly inluences the setting of

nursing priorities. For example, providing care to the sick would

take priority over wellness or health education classes.

THE NURSE’S ROLE IN THE POLICY PROCESS

The number and types of laws inluencing health care are in-

creasing. Because of this, nurses need to be involved in the

policy process and understand the importance of involvement

of nursing to the clients they serve.

For nurses to effectively care for their client populations and

their communities in the complex US health care system, profes-

sional advocacy for logical health policy that considers equality is

essential. Professional nurses working in the community know all

too well about the health care problems they and their clients

encounter daily, and it is through policy and political activism

that both big-picture and long-term solutions can be developed.

Although the term policy may sound rather lofty, health

policy is quite simply the process of turning health problems

into workable action solutions. Health policy is developed on

the three-legged stool of access, cost, and quality.

The policy process, which is very familiar to professional

nurses, includes the following:

• Statement of a health care problem

• Statement of policy options to address the health problem

• Adoption of a particular policy option

• Implementation of the policy product

• Evaluation of the policy’s intended and unintended conse-

quences in solving the original health problem

Thus the policy process is very similar to the nursing process,

but the focus is on the level of the larger society, and the adoption

118 PART 2 Inluences on Health Care Delivery and Nursing

strategies require political action. For most professional nurses,

action in the policy arena comes most easily and naturally

through participation in nursing organizations such as the

American Nurses Association (ANA) at the state level, the As-

sociation of Community Health Nursing Educators (ACHNE) or

the Association of Public Health Nurses at the national or state

level, and certain specialty organizations such as the American

Public Health Association (APHA).

The nurse’s basic understanding of the political process

should include knowing who the lawmakers are, how bills be-

come laws (see Fig. 7.2), the process of writing regulations

(see Fig. 7.3), and methods of inluencing the process and

Compromise version

voted on

HR 1

Introduced in

House

S 2

Introduced in

Senate

Referred to

subcommittee

Referred to

subcommittee

Referred to

House committee

Referred to

Senate committee

Reported by

full committee Reported by

full committee

Rules committee

action

Compromise version

voted on

Conference action

Presidential action

Issue Identified

The Federal Level

Nursing Involvement

Provide testimony

Send emails and

make phone calls

Send letter to

President

Continue lobbying

efforts

Provide member of Congress

with information

to draft bill

Provide testimony

and information

to committee

members

Lobby members

in district and

Washington, DC

Floor ActionFloor Action

VETOED SIGNED

House debate,

vote on passage

Senate debate,

vote on passage

1 A bill goes to full committee first, then to special subcommittees for hearings, debate, revisions, and approval. The same

process occurs when it goes to full committee. It either dies in committee or proceeds to the next step. 2 Only the House has a Rules Committee to set the “rule” for floor action and conditions for debate and amendments. In the

Senate, the leadership schedules action. 3 The bill is debated, amended, and passed or defeated. If passed, it goes to the other chamber and follows the same path.

If each chamber passes a similar bill, both versions go to conference. 4 The President may sign the bill into law, allow it to become law without his signature, or veto it and return it to Congress.

To override the veto, both houses must approve the bill by a two-thirds majority vote.

FIG. 7.2 How a bill becomes a law. (From Mason DJ, Leavitt JK, Chaffee MW: Policy and politics

in nursing and health care, ed 7, St Louis, 2016, Elsevier.)

119CHAPTER 7 Government, the Law, and Policy Activism

shaping of health policy. With this knowledge, nurses can inlu-

ence nursing practice at local, state, and national levels.

LEGISLATIVE ACTION

It is often helpful to review the legislative and political processes

that may have been a part of high school education. It becomes

important material to remember as a professional career is em-

barked upon.

The people within geographic jurisdictions elect their legis-

lative representatives and senators. An important part of the

legislative process is the work of the legislative staff. These in-

dividuals do the legwork, research, paperwork, and other ac-

tivities that move policy ideas into bills and then into law. In

addition to the individual legislator’s ofice, the congressional

committee staffs are also important. They are usually experts in

the content of the work of a committee, such as a health and

welfare committee. Frequently, developing a working relation-

ship with key legislative staffers can be as important to achiev-

ing a policy objective as the relationship with the policymaker

(i.e., the legislator).

The legislative process begins with ideas (policy options) that

are developed into bills. After a bill is drafted, it is introduced

to the legislature, given a number, read, and assigned to a com-

mittee. Hearings, testimony, lobbying, education, research, and

informal discussions follow. If the bill is passed from the legisla-

tive committee, the entire House hears the bill, amends it as

necessary, and votes on it. A majority vote moves the bill to the

other House, where it is read and amended, and then a vote is

taken. Fig. 7.2 shows the necessary formal process of the legisla-

tive pathway.

Nurses can be involved in the legislative process at any point.

Many professional nursing associations have legislative com-

mittees made up of volunteers, governmental relations staff

professionals, and sometimes political action committees

(PACs), all engaged in efforts to monitor, analyze, and shape

health policy.

Common methods of inluencing health policy outcomes in-

clude face-to-face encounters, personal letters, mail-grams, elec-

tronic mail, telephone calls, testimony, petitions, reports, position

papers, fact sheets, letters to the editor, news releases, speeches,

coalition building, demonstrations, and lawsuits. Depending on

the issue, any of these can be effective. Although most business,

including politics and the policy agendas, depends on the Inter-

net today for instant communication and quick response, all of

these methods continue to be of great importance in inluencing

policy agendas. For example, if a face-to-face encounter is used

with a legislator or a staffer, these persons can put a “face on the

policy agenda,” and the reality that the policy affects real persons

is an important consideration when the legislator or staff pushes

Changes in

practice

occur

Legislation

passed

by Congress President

signs bill

into law

Executive

department

studies law

President

assigns

law to Executive

department

Time set

for hearing

and public

comments

Final

regulations

published

Regulations

drafted

and

published

Final

regulations

drafted

FIG. 7.3 The process of writing regulations.

120 PART 2 Inluences on Health Care Delivery and Nursing

the policy agenda forward. Tips on communication and visiting

legislators and their staffs, as well as general tips on political

action, are presented in Boxes 7.2, 7.3, and 7.4.

Political activities in which nurses can and should be involved

are varied and include being informed voters (a must!), partici-

pating in a political party, registering others to vote, getting out

the vote, fund-raising for candidates, building networks or com-

munication links for issues (e.g., a phone tree or Internet distri-

bution list), and participating in organizations to ensure their

effective involvement in health policy and politics. To communi-

cate effectively, present a simple argument with examples; con-

sider the culture, age, and educational backgrounds of the person

with whom you are communicating; target your communication

toward the issue; do not use jargon; indicate the expertise you

bring to the table; use data to support your argument; and show

the relevance to nursing and to the legislator. Above all, be polite!

The direct reimbursement of advanced-practice nurses

(APNs) in the Medicare program is one example of how nurses

can use their inluence. The inclusion of amendments to Medi-

care that authorized APN reimbursement regardless of specialty

or client location in the Balanced Budget Act of 1997 required

the sustained efforts of the ANA and other national nursing or-

ganizations over a long period (Nursing World, Legislative

Branch, 2000; USDHHS, Centers for Medicare and Medicaid

Services, 2015). During that time, individual nurses provided

testimony to Congress and to MEDPAC (the physicians’ political

action committee) on the importance of direct reimbursement

to APNs. Many APNs worked closely and vigorously with their

congressional representatives to lobby for this Medicare amend-

ment. Even more wrote letters and provided position papers

and fact sheets to help legislators understand the value of APNs.

Although the process took more than 10 years to be fully

BOX 7.2 Tips for Visits With Legislators

BOX 7.3 Tips for Writing to Legislators

• Call ahead and ask how much time the staff or legislator is able to give you.

• When you arrive, ask if the appointment time is the same or if a scheduled

vote on the House or Senate loor is going to need the legislator’s attention

and you will need to reschedule your appointment.

• Engage in small talk at the beginning of the conversation only if the staff or

legislator has time.

• Structure time so that the issue can be presented briely.

• Allow an opportunity for the staff or Congress member to seek clarity or ask

questions.

• Do not assume that the legislator or the legislator’s staff is well informed

on the issue.

• Numbers count. If the views you express are shared by a local nurses’ orga-

nization or by nurses employed at a health care facility, let the legislator

know.

• Invite Congress members and their staffs to conferences or meetings of

nurses’ organizations or to tour nursing education facilities to meet others

interested in the same policy issues.

• If appropriate, invite the media and let the legislator know.

• Send future invitations.

• Provide a one-page summary that gives key points at the conclusion of

every meeting.

• Communicate in writing to express opinions.

• Acknowledge the Congress member’s work as positive or negative, but be

courteous.

• Follow up on meetings or phone calls with a letter or e-mail message.

• Share knowledge about a particular problem.

• Recommend policy solutions.

• The letter should be typed, a maximum of two pages, and focused on one

or two issues at most.

• The purpose of the letter should be stated at the beginning.

• Present clear and compelling rationales for your concern or position on an

issue.

• If the purpose of the letter is to express disappointment regarding a stance

on an issue or a vote that has been cast, the letter should be as positive as

possible.

• Write letters thanking a Congress member for taking a particular position

on an issue.

• A letter to the editor of the local newspaper or a nursing newsletter praising

a legislator’s position (with a copy forwarded to the legislator) is welcome

publicity, especially during an election year.

• Review the major points covered in person and answer any questions that

were raised during conversation.

• Have business cards for yourself and include them with letters.

• Address written correspondence as follows (the same general format

applies to state and local oficials):

US Senator US Representative

Honorable Jane Doe Honorable Jane Doe

United States Senate House of Representatives

Washington, DC 20510 Washington, DC 20515

Dear Senator Doe: Dear Representative Doe:

Modiied from Mason DJ, Leavitt JK, Chaffee MW: Policy and politics

in nursing and health care, ed 5, St Louis, 2007, Elsevier.

BOX 7.4 Tips for Action

• Become involved in the state nurses’ association.

• Build communication and leadership skills.

• Increase your knowledge about a range of professional issues.

• Expand and strengthen your professional network.

• Serve on committees and in elected positions.

• Build relationships within the profession and with representatives of public-

and private-sector organizations with an interest in health care.

• Participate in political activities.

• Be aware of what is taking place in health care beyond the environment and

the practice in which you work.

• Be well informed across a range of health-related issues.

• Identify yourself as a nurse with associated education and expertise.

• Let people know that nurses are capable of functioning in many different

roles and making substantial contributions.

• Be conident.

• Do not burn bridges behind you. On another occasion, they may provide the

only route to your destination.

• Be friendly.

• Lend a hand to other nurses. It beneits all of us.

• If you are new to the policy arena, seek support from many people of

diverse backgrounds. Accomplished people, whether nurses or not, often

value mentoring others.

Modiied from Mason DJ, Leavitt JK, Chaffee MW: Policy and politics

in nursing and health care, ed 5, St Louis, 2007, Elsevier.

Modiied from Mason DJ, Leavitt JK, Chaffee MW: Policy and politics

in nursing and health care, ed 5, St Louis, 2007, Elsevier.

121CHAPTER 7 Government, the Law, and Policy Activism

achieved, APN reimbursement in Medicare became a reality.

Both the nursing profession and clients beneit from this change

The ANA was likewise a strong supporter of the Patient Safety

Act of 1997 (ANA, 1997). This law requires health care agencies

to make public some information on nursing staff levels, staff

mix, and outcomes, and it requires the USDHHS to review and

approve all health care acquisitions and mergers. All of these

requirements are intended to determine any long-term effect on

the health and safety of clients, communities, and staff.

On the state legislative level, all 50 states have passed title

protection for registered nurses; this was achieved by indi-

vidual nurses, state nurses associations, and various nursing

specialty groups participating in the legislative process

with the 50 state legislators. Title protection means that only

certain nurses who meet state criteria can call themselves

advanced-practice nurses.

REGULATORY ACTION

The regulatory process, although it may not be as visible a pro-

cess as legislation, also can be used to shape laws and dramati-

cally affect health policy. This process should be on the radar

screen of professional nurses who wish to successfully partici-

pate in policy activity.

At each level of government, the executive branch can and, in

most cases, must prepare regulations for implementing policy and

new programs. These regulations are detailed, and they establish,

ix, and control standards and criteria for carrying out certain

laws. Fig. 7.3 shows the steps in the typical process of writing

regulations. When the legislature passes a law and delegates its

oversight to an agency, it gives that agency the power to make

regulations. Because regulations low from legislation, they have

the force of law.

THE PROCESS OF REGULATION

After a law is passed, the appropriate executive department be-

gins the process of regulation by studying the topic or issue.

Advisory groups or special taskforces are sometimes formed to

provide the content for the regulations. Nurses can inluence

these regulations by writing letters to the regulatory agency in

charge or by speaking at open public hearings. Many letters are

now accepted via the Internet.

After rewriting, the proposed regulations are put into inal

draft form and printed in the legally required publication (e.g.,

at the federal level, the Federal Register). Similar registers exist

in most states, in which regulations from state executive depart-

ments, including state health departments, are published. Pub-

lic comment is called for in written form within a given period.

Revisions made to proposed regulations are based on public

comment and public hearing. Depending on the amount and

content of the public reaction, inal regulations are prepared, or

the area and issues are studied further. Final published regula-

tions carry the force of law. When regulations become effective,

health care practice is changed to conform to the new regula-

tions. Monitoring administrative regulations is essential for the

professional nurse, who can inluence regulations by attending

the hearings, providing comments, testifying, and engaging in

lobbying aimed at individuals involved in the writing. Concrete,

written suggestions for revision submitted to these individuals

are frequently persuasive and must be acknowledged by the gov-

ernment in publishing the inal rules. An excellent example of

how nurses must continue to inluence health policy outcomes,

even after positive legislation has passed, occurred after the pas-

sage of the Balanced Budget Act (BBA) of 1997 (US Law, 1997b).

The HCFA began to implement the BBA through the publication

of draft regulations seeking to deine APN practice and Medicare

reimbursement. The nursing community responded vigorously

with negative opinions about the initial restrictive deinitions

and requirements. Their reactions were effective and reshaped

the inal regulations to recognize the state deinitions for APN

practice autonomy.

Final regulations, published in a code of regulations (both

federal and state), usually lead to changes in practice. For ex-

ample, Medicare regulations setting standards for nursing homes

and home health are incorporated into these agencies’ manuals.

In the case of APN reimbursement, some Medicare iscal inter-

mediaries have had dificulty in recognizing APNs as appropri-

ate providers, but professional nursing organization advocates

have forcefully addressed these implementation barriers.

NURSING ADVOCACY

Advocacy begins with the art of inluencing others (politics) to

adopt a speciic course of action (policy) to solve a societal

problem. This is accomplished by building relationships with

the appropriate policymakers—the individuals or groups that

determine a speciic course of action to be followed by a gov-

ernment or institution to achieve a desired end (policy out-

come). Relationships for effective advocacy can be built in vari-

ous ways. In January 2006, Medicare Part D—the prescription

drug beneit policy—became effective. Public health profes-

sionals were needed to assist vulnerable persons to understand

the value of enrolling in Part D, to educate them on how to

use the beneits, and to ensure that the populations who are

“dually” enrolled in both Medicare and Medicaid are registered.

Coordinating efforts among civic, religious, and health care

agencies to provide health education is a necessity.

Likewise, when the Affordable Care Act was passed it was

essential to get the word out to communities and to Medicaid

recipients, the unserved, the working poor, and others who

could receive both preventive and other sources of health care

through the programs established by this act (US Law, 2010).

A letter or visit to the district, state, or national ofice of a

legislator to discuss a particular policy or health care issue can

be interesting, educational, and effective. Contributions of

money, labor, expertise, or inluence also may be welcomed by

the policymakers involved in setting a course of action to obtain

a desired health outcome for an individual, a family, a group, a

community, or society (health policy). Additionally, it is possi-

ble to develop a grassroots network of community and profes-

sional friends with a mutual interest in health policy advocacy.

The network may be able to promote health policy initiatives

for the community. During the Obama presidential campaign,

122 PART 2 Inluences on Health Care Delivery and Nursing

many advocacy networks were established via the Internet, and

money was solicited using this process.

Many special interest groups in health care have the poten-

tial, desire, and resources to inluence the health policy process.

A tremendous advantage that nursing has in advocating for is-

sues and in inluencing policymakers is the force of its numbers

because nursing is the largest of the health professions. How-

ever, nursing must organize its numbers in such a way that each

nurse joins with others to speak with one voice. The greatest

effect will be had when all nurses make similar demands for

policy outcomes (see the Applying Content to Practice box

at the end of chapter for an example of nurses’ input into the

Affordable Care Act).

Advocacy by expert and committed health professionals

works; it can bring about positive change for the profession, the

community, and the clients that nurses serve. Keeping up to

date on issues within government, professional organizations,

law, and public policy is vitally important. Informed activism

directed toward a professional role, image, and value for profes-

sional nurses and toward a health care system in the United

States that provides universal access to health care that is of

high quality and is affordable should be a lifelong commitment

for all professional nurses.

APPLYING CONTENT TO PRACTICE

The information here gives an example of how the policy process works and

how the reader can use the content in this chapter. This example involves a

nursing organization and its individual members. Whether you are a member

of a group or working on your own to inluence health policy, the steps de-

scribed here apply.

Over a 15-month time frame, the American Nurses Association (ANA) was

involved in advocating for health care reform. During the presidential cam-

paign, candidates were educated about the nursing profession and the ANA’s

Agenda for Health System Reform. The ANA and its members participated in

national media interviews and local media events. The message was that the

association and its members believed that health care is a basic right. The

ANA collaborated with the nursing community to outline the profession’s pri-

orities as proposals were developed in Congress. Testimony was given before

three key congressional committees. ANA representatives met with White

House and congressional health care reform staff and took part in two presi-

dential press conferences at the White House.

As reported by the ANA, thousands of nurses joined the ANA’s health care

reform team, sending letters to representatives of Congress, sharing their

stories, and meeting with members of Congress. They also participated in

rallies and events.

For more information on ANA’s health care reform work, visit http://www.

rnaction.org/toolkit.

P R A C T I C E A P P L I C A T I O N

R E M E M B E R T H I S !

Larry was in his inal rotation in the Bachelor of Science in Nurs-

ing program at State University. He was anxious to complete his

inal nursing course because on graduation he would begin a

position as a staff nurse specializing in school health at the local

health department. His wife was expecting their irst child, and

she had been receiving prenatal care at the health department.

Larry was aware that a few years ago, the federal government

had, by law, provided block grants to states for primary care,

maternal–child health programs, and other health care needs of

states. He had read the Federal Register and knew that the regu-

lations for these grants had been written through USDHHS

departments. He was aware that these regulations did not

require states to fund speciic programs.

• The legal basis for most congressional action in health care

can be found in Article I, Section 8, of the US Constitution.

• The four major health care functions of the federal govern-

ment are direct service, inancing, information, and policy

setting.

• The goal of the World Health Organization is the attainment

by all people of the highest possible level of health.

• Many federal agencies are involved in government health

care functions. The agency most directly involved with the

health and welfare of Americans is the US Department of

Health and Human Services.

• Most state and local governments have activities that affect

nursing practice.

Larry read in the local newspaper that the health department

was closing its prenatal clinic at the end of the month. When his

state had received its block grant, the state decided to spend the

money for programs other than prenatal care. Larry found that

a 3-year study in his own state showed improved pregnancy

outcomes as a result of prenatal care. The results were further

improved when the care was delivered by population-centered

nurses.

Larry was concerned that as a student, he would have little

inluence. However, he decided to call his classmates together to

plan a course of action.

What would such an action plan include?

Answers can be found on the Evolve website.

• The variety and range of functions of governmental agencies

have had a major impact on nursing. Funding, in particular,

has shaped the role and tasks of nurses.

• The private sector (of which nurses are a part) can inluence

legislation in many ways, especially through the process of

writing regulations.

• The number and types of laws inluencing health care are

increasing. Because of this, involvement in the political pro-

cess is important to nurses.

• Professional negligence and the scope of practice are two

legal aspects particularly relevant to nursing practice.

• Nurses must consider the legal implications of their own

practice in each clinical encounter.

http://www.rnaction.org/toolkit

123CHAPTER 7 Government, the Law, and Policy Activism

• The federal and most state governments comprise three

branches—the executive, the legislative, and the judicial.

• Each branch of government plays a signiicant role in health

policy.

• The US Public Health Service was created in 1798.

• The irst national health insurance legislation was challenged

in the Supreme Court in 1937.

• Health, United States (NCHS, 2016) is an important source

of data about the nation’s health care problems.

• In 1921 the Sheppard-Towner Act was passed, and it had an

important inluence on child health programs and community-

oriented nursing practice.

• The Division of Nursing, the National Institute of Nursing

Research, and the Agency for Healthcare Policy and Research

are governmental agencies important to nursing.

• Nurses, through state and local health departments, function

as consultants, direct-care providers, researchers, teachers,

supervisors, and program managers.

• The state governments are responsible for regulating nursing

practice within the state.

• Federal and state social welfare programs have been devel-

oped to provide monetary beneits to the poor, older adults,

the disabled, and the unemployed.

• Social welfare programs affect nursing practice. These pro-

grams improve the quality of life for special populations,

thus making the nurse’s job easier in assisting the client with

health needs.

• The nurse’s scope of practice is deined by legislation and by

standards of practice within a specialty.

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125

Economic Inluences

Marcia Stanhope

8C H A P T E R

After reading this chapter, the student should be able to:

1. Relate public health and economic principles to nursing

and health care.

2. Identify major factors inluencing national health care

spending.

3. Describe the role of government and other third-party

payers in health care inancing.

O B J E C T I V E S

4. Identify mechanisms for public health inancing of services.

5. Discuss the implications of health care rationing from an

economic perspective.

6. Evaluate levels of prevention as they relate to public health

economics.

capitation, 143

covered lives, 143

diagnosis-related groups (DRGs),

133

economics, 126

effectiveness, 143

eficiency, 143

enabling, 141

fee-for-service, 143

gross domestic product (GDP), 135

health care rationing, 127

health economics, 126

human capital, 130

inlation, 126

intensity, 130

managed care, 141

means testing, 136

Medicaid, 128

medical technology, 131

Medicare, 136

prospective payment system (PPS),

139

public health economics, 126

retrospective reimbursement, 142

return on investment, 130

safety net providers, 129

third-party payers, 130

K E Y T E R M S

Public Health and Economics

Factors Affecting Resource Allocation in Health Care

The Uninsured

The Poor

Access to Health Services

Rationing Health Care

Healthy People 2020

Primary Prevention

The Context of the US Health System

First Phase

Second Phase

Third Phase

Fourth Phase

Challenges for the 21st Century

C H A P T E R O U T L I N E

Trends in Health Care Spending

Factors Inluencing Health Care Costs

Demographics Affecting Health Care

Technology and Intensity

Chronic Illness

Financing of Health Care

Public Support

Public Health

Other Public Support

Private Support

Health Care Payment Systems

Paying Health Care Organizations

Paying Health Care Practitioners

Economics and the Future of Nursing Practice

Strong evidence suggests that poverty can be directly related to

poorer health outcomes. Poorer health outcomes lead to reduced

educational outcomes for children, poor nutrition, low productiv-

ity in the adult workforce, and unstable economic growth in a

population, community, or nation. However, improving health

status and economic health depends on the “degree of equality” in

policies that improve living standards for all members of a popula-

tion, including the poor. To move toward improving a population’s

health there must be an “investment in public health” by all levels

of government (Robert Wood Johnson Foundation [RWJF], 2013).

Estimates indicate that public spending on health care makes

a difference but needs the support of increased private health

126 PART 2 Inluences on Health Care Delivery and Nursing

care spending to improve the overall health status of popula-

tions (Trust for America’s Health, 2013a, 2013b, 2014). The

following facts are known from the literature (Kaiser Family

Foundation [KFF], 2013; RWJF, 2013; DeNavas-Walt et al.,

2013; US Department of Health and Human Services

[USDHHS], 2016c):

• In 2012, approximately 48 million (15.4%) of the estimated

311.1 million people in the United States were without

health insurance (DeNavas-Walt et al., 2013). Over the past

decade, the number of uninsured individuals had in-

creased, largely due to the struggling economy and weak

job market (KFF, 2013). As the Affordable Care Act (ACA)

was implemented, the uninsured rate dropped to 10.7% in

2015, and new and affordable options became available.

This reduced the number of uninsured individuals and

families by 8.8 million people by 2014, the year the ACA

was fully implemented (The Commonwealth Fund, 2016;

KFF 2015a).

• The rate of uninsured remains higher among people with

lower incomes and lower among those with higher incomes.

Households of three with less than $20,000 in annual in-

come are at the highest risk for being uninsured (KFF,

2015a).

• Adults are more likely to be uninsured than children (KFF,

2015a).

• Young adults (ages 19–25 years) account for a dispropor-

tionately large share of the uninsured, largely due to their

low incomes (KFF, 2015; USDHHS, 2016c).

• The uninsured rate for all children was 8.9% in 2012. For

children living in poverty the uninsured rate was 12.9%,

which was higher than the rate for children not in poverty

(7.7%) (DeNavas-Walt et al, 2013). This rate has declined

since 2014 but is still higher for children in poverty than

those not in poverty (KFF, 2015a).

• Nonwhites are more likely to be uninsured than whites (KFF,

2015a).

• Most of the uninsured are in low-income working families

(KFF, 2015a).

• About 80% are from families with one or more workers

(full or part time).

• About 50% are from families who are at 200% of the

poverty level. This percentage has improved and dropped

from 400% in 2012.

• Individuals without health insurance continue to have worse

access to care than those with insurance coverage (KFF,

2015a).

• Those without health insurance are more likely to be hospi-

talized for preventable problems, and when hospitalized,

they receive fewer diagnostic and therapeutic services; they

also have higher mortality rates than those with insurance

(KFF, 2015a).

• Adults without insurance are nearly twice as likely to report

being in fair or poor health than those with private insur-

ance (KFF, 2012a).

• Studies indicate that gaining health insurance restores access

to health care considerably and reduces the adverse effects of

having been uninsured (KFF, 2012a).

• The poor have been more likely to receive health care

through publicly funded agencies. The rates of low-income/

no-income persons receiving health care have dropped in

those states that have participated in the Medicaid expansion

program offered through the ACA (The Commonwealth

Fund, 2016).

• Some persons who are eligible for insurance coverage under

the ACA do not sign up due to lack of information or enroll-

ment barriers, and some simply do not believe in the ACA

(KFF, 2015a).

• An emphasis on individual health care will not guarantee

improvement of a population or a community’s health (see

Chapter 3 for more discussion).

Approximately 97% of all health care dollars are spent for

individual care, whereas only 3% is spent on population-level

health care. The 3% includes monies spent by the government

on public health, as well as the preventive health care dollars

spent by private sources. The conclusion from these igures is

that there is not a large investment in the public’s health or

population health in the United States (National Center for

Health Statistics [NCHS], 2016).

The United States spends more on health care than any other

nation. The cost of health care has been rising more than the

rate of inlation since the mid-1960s. Yet the US population

does not enjoy better health than nations that spend far less

than the United States. To highlight this point, the majority

(79%) of the uninsured are citizens of the United States, with

the remaining being lawfully present and undocumented non-

citizens (KFF, 2012a). The current health care system is at a

point at which it is not affordable (Turnock, 2016; Trust for

America’s Health, 2013b). Knowledge about health economics

is particularly important to community-oriented nurses be-

cause they are the ones who are often in a position to allocate

resources to solve a problem or to design, plan, coordinate, and

evaluate community-based health services and programs.

PUBLIC HEALTH AND ECONOMICS

Economics is the science concerned with the use of resources,

including the production, distribution, and consumption of

goods and services. Health economics is concerned with how

scarce resources affect the health care industry (McPake et al,

2013; Phelps, 2012). Public health economics then focuses on

the production, distribution, and consumption of goods and

services as related to public health (Centers for Disease Control

and Prevention [CDC], 2015). Economics provides the means

to evaluate society’s attainment of its wants and needs in rela-

tion to limited resources. In addition to the day-to-day decision

making about the use of resources, focus is on evaluating

economics in health care (McPake et al, 2013; Phelps, 2012).

Although in the past, focus on evaluation of public health eco-

nomics has been limited, it is becoming more obvious what

evaluating public health and preventive care can do in terms of

cost savings and, more importantly, quality of life (Trust for

America’s Health, 2013b). This type of evaluation will help

present challenges to public policymakers (legislators). Public

health inancing often causes conlict because the views and

127CHAPTER 8 Economic Inluences

priorities of individuals and groups in society may differ from

those of the public health care industry. If money is spent on

public health care, money for other public needs, such as educa-

tion, transportation, recreation, and defense, may be limited.

When trying to argue that more money should be spent for

population-level health care or prevention, data must be avail-

able from this report and more reports like it to show the in-

vestment is worthwhile. Public health inance is a growing

ield of science and practice that involves the acquisition,

management, and use of monies to improve the health of

populations through disease prevention and health promo-

tion strategies. This ield of study also focuses on evaluating

the use of the money and the impact on the public health

system (Honoré, 2012).

Although the public health system had been considered for

many years to involve only government public health agencies,

such as health departments, today the public health system is

known to be much broader and includes schools, industry, me-

dia, environmental protection agencies, voluntary organiza-

tions, civic groups, local police and ire departments, religious

organizations, industry and business, and private-sector health

care systems, including the insurance industry. All can play a

key role in improving population health (Institute of Medicine,

2003; Trust for America’s Health, 2013a).

The goal of public health inance is “to support population

focused preventive health services” (Honoré, 2012). Four prin-

ciples are suggested that explain how public health inancing

may occur.

• The source and use of monies are controlled solely by the

government.

• The government controls the money, but the private sector

controls how the money is used.

• The private sector controls the money, but the government

controls how the money is used.

• The private sector controls the money and controls how it is

used. (Sturchi and Goel, 2012)

When the government provides the funding and controls the

use, the monies come from taxes, user fees (e.g., license fees,

purchase of alcohol and cigarettes), and charges to consumers

of the services. Services offered at the federal government level

include the following:

• Policymaking

• Public health protection

• Collecting and sharing information about US health care

and delivery systems

• Building capacity for population health

• Direct-care services

Select examples of services offered at the state and local levels

include the following:

• Maternal and child health

• Family planning

• Counseling

• Preventing communicable and infectious diseases (see

Chapters 7 and 28 for more examples)

When the government provides the money but the private

sector decides how it is used, the money comes from business

and individual tax savings related to private spending for illness

prevention care. When a business provides disease prevention

and health promotion services to their employees and some-

times families, such as immunizations, health screening, and

counseling, the business taxes owed to the government are re-

duced. This is considered a means by which the government

provides money through tax savings to businesses to use for

population health care.

When the private sector provides the money but the gov-

ernment decides how it is used, either voluntarily or involun-

tarily, the money is used for preventive care services for speciic

populations.

• A voluntary example is the private contributions made to

reaching Healthy People 2010 goals.

• An involuntary example is the Occupational Safety and

Health Administration’s requirement that industry adhere to

certain safety standards for the use of machinery, air quality,

ventilation, and eyewear protection to reduce disease and

injury. This has the effect of reducing occupation-related

injuries in the population as a whole.

When the private sector is responsible for both the money

and its use of resources, the beneits incurred are many. For

example, an industry may offer inluenza vaccine clinics for

workers and families that may lead to “herd immunity” in the

community (see Chapter 9). A business or community may

institute a “no smoking” policy that reduces the risk for smok-

ing-related illnesses to workers, family, and the consumers of

the business’s services. A voluntary philanthropic organization

may partner with a local school system to improve school-

linked clinical services, such as immunizations, preventive den-

tal care, mental health coverage, and laboratory tests (Minyard

et al, 2016).

These are but a few examples of how public health services

and the ensuring of a healthy population are not only govern-

ment related. The partnerships between government and the

private sector are necessary to improve the overall health status

of populations.

FACTORS AFFECTING RESOURCE ALLOCATION IN HEALTH CARE

The distribution of health care is affected largely by the way in

which health care is inanced in the United States. Third-party

coverage, whether public or private, greatly affects the distribu-

tion of health care. Also, socioeconomic status affects health

care consumption because it determines the ability to purchase

insurance or to pay directly out-of-pocket expenses. The effects

of barriers to health care access and the effects of health care

rationing on the distribution of health care follow. Although

the barriers are still issues, changes to the barriers to access and

distribution are improving.

THE UNINSURED

In 1996, 68% of the total US population had private health in-

surance. An additional 15% received insurance through public

programs, and 17% (37 million people) were uninsured. In 2008

the number of uninsured persons had increased to 47 million.

128 PART 2 Inluences on Health Care Delivery and Nursing

By 2012 the number had grown to 48 million persons (DeNavas-

Walt et al, 2013). The typical uninsured person was a member of the

workforce or a dependent of this worker. Uninsured workers are

likely to be in low-paying jobs, part-time or temporary jobs, or jobs

at small businesses (KFF, 2015a). These uninsured workers cannot

afford to purchase health insurance, or their employers may not

offer health insurance as a beneit. Others who are typically unin-

sured are young adults (especially young men), nonwhites, persons

younger than 65 years of age in good or fair health, and the poor or

near poor. The following may be the case for these individuals:

• May be unable to afford insurance

• May lack access to job-based coverage

• Because of their age or good health status, may not perceive

the need for insurance

Because of the eligibility requirements for Medicaid, the near

poor are actually more likely to be uninsured than the poor

because they cannot afford even the cost of health care through

the national or state health care marketplaces and are not eli-

gible for tax credits (KFF, 2015b).

The ACA passed in 2010 was a result of a promise to the

American public by President Obama that health care reform

would occur as part of his presidential agenda to address the

issues affecting the uninsured and underinsured. Basically, this

law addresses the following:

• Quality, affordable health care for all Americans

• A deined role of public programs

• Improving the quality and eficiency of health care

• Prevention of chronic disease and improving public health

• Health care workforce

• Transparency and program integrity

• Improving access to innovative medical therapies

• Community living assistance services and supports

• Revenue provisions

Before this act was passed, the following situations were

the case:

• Twenty-ive states were considering making it mandatory for

employers to provide coverage.

• Seven states were looking at approaches to universal coverage.

• Six states were considering the development of universal

health care plan commissions.

Only three states had passed comprehensive health care reform

by 2008—Massachusetts, Maine, and Vermont. State iscal capac-

ity, structural deicits, and then a worsening economy and severe

state budget shortfalls had limited states’ ability to further ad-

vance coverage initiatives. The experiences of pace-setting states

informed the federal action, with the ACA which was attempting

to address the iscal crisis, because it was dificult for many states

to achieve health care reform on their own. By 2015 only 29 states

had participated in the Medicaid expansion program to increase

the numbers of eligible persons for health insurance in their

states (KFF, 2015b).

As the health care reform debate continues, the impact of

federal reform on states will have differential effects. In general,

states will be greatly affected (some positive/some negative) if

they are states with the following (KFF, 2015b):

• More extensive poverty

• Higher budget shortfalls

• Lower eligibility levels for public programs

• Higher rates of uninsured

• Greater shortages in primary-care direct-services providers

Those states that have accepted the opportunity for Medic-

aid expansion have experienced increased numbers of enrollees

in health care, thereby reducing the numbers of uninsured;

improved budgets overall but some tax increases; and increased

administrative costs initially, with drops in the second year.

There have been improvements in preventive care to the low-

income populations as well. Those states that have budget

shortfalls, more extensive poverty levels, and fewer health care

providers to meet the demands may not see overall beneit from

the ACA (KFF, 2015c).

THE POOR

Socioeconomic status is inversely related to mortality and mor-

bidity for almost every disease. Poor Americans with an income

below the poverty level have a mortality rate nearly three times

that of middle-income Americans, even after accounting for

age, sex, race, education, and risky health behaviors (such as

smoking, drinking, overeating, and lack of exercise) (RWJF,

2013). Historically, the link between poor health and socioeco-

nomic status resulted from poor housing, malnutrition, inade-

quate sanitation, and hazardous occupations. Today, explana-

tions include the cumulative effects of various characteristics

that explain the concept of poverty. These characteristics in-

clude low educational levels, unemployment or low occupa-

tional status (blue collar or unskilled laborer), low wages, being

a child or being older than 65 years, and being a member of a

minority group (NCHS, 2016).

ACCESS TO HEALTH SERVICES

Access to health services is a public health issue (USDHHS,

2016a). Medicaid is intended to improve access to health care

for the poor. Although persons with Medicaid have improved

access (approximately twofold) in contrast to the uninsured,

Medicaid recipients are only about half as likely to obtain

needed health services (e.g., medical-surgical care, dental care,

prescription drugs, eyeglasses) as the privately insured. Specii-

cally, the poorest Americans have Medicaid insurance, yet they

also have had the worst health (KFF, 2015b).

The primary reasons for delay, dificulty, or failure to access

care have included the inability to afford health care and a vari-

ety of insurance-related reasons, such as the following:

• The insurer not approving, covering, or paying for care

• The client having preexisting conditions

• Physicians refusing to accept the insurance plan

The ACA addresses these reasons, with those enrolled in the

marketplaces knowing what their plans will cover and including

preexisting conditions. There may still be providers who will

not accept the health plans.

Other barriers to seeking health care may include lack of

transportation, physical barriers, communication problems,

childcare needs, lack of time or information, or refusal of ser-

vices by providers. Additionally, lack of after-hours care, long

129CHAPTER 8 Economic Inluences

ofice waits, and long travel distance are cited as access barriers.

Community characteristics contribute to the ability of indi-

viduals to access care. For example, the prevalence of managed

care and the number of safety net providers, for those who are

not eligible or have not enrolled in the marketplaces, as well as

the wealth and size of the community, affect accessibility. It

should be noted that by 2014, unless an individual reported ap-

proximately $10,500 on income tax forms or was a member of

a family of four with income of less than $20,300, all persons

were required to have health insurance coverage or pay a pen-

alty (KFF, 2012b).

Because reimbursement for services provided to Medicaid

recipients has been low, physicians were discouraged from serv-

ing this population. Thus people on Medicaid frequently had

no primary-care provider and often relied on the emergency

department for primary-care services. Although physicians

have been able to choose clients based on their ability to pay,

emergency departments have been required by law to evaluate

all clients regardless of their ability to pay. Emergency depart-

ment copayments were usually modest and were frequently

waived if the client was unable to pay. Thus low out-of-pocket

costs provided incentives for Medicaid clients and the unin-

sured to use emergency departments for primary-care services.

With the ACA (PL 111-148), some of the issues and barriers

that have previously existed may disappear. Continuation of the

issues and barriers depends on whether Congress decides to

repeal all or part of the ACA or change some of the mandates

in the law. By 2014, Medicaid recipients beneited from the law

in its current structure as follows:

1. Expansion of Medicaid to include all non–Medicare eligible

persons under age 65 with incomes up to 133% of federal

poverty level.

2. All Medicaid-eligible persons were guaranteed a benchmark

beneit package.

3. States were given the option to develop a basic health plan

for uninsured individuals who did not qualify for the Med-

icaid program, at 133% to 200% of poverty level. As indi-

cated, only 29 states chose to participate by 2016.

Poverty-level income is adjusted annually for each state by

the federal government to indicate how much money an indi-

vidual or families may earn to qualify for subsidies such as food

stamps, Medicaid, and the Children’s Health Insurance Pro-

gram. In 2016 the federal poverty level for an individual was

$11,880; for a family of four, the poverty level was $24,300

(USDHHS, 2016c). If an individual’s income was at 133% of

the poverty level, then the individual earned no more than

$15,800 (USDHHS, 2016c).

RATIONING HEALTH CARE

Rationing health care in any form implies reduced access to care

and potential decreases in the acceptable quality of services of-

fered. For example, a health provider’s refusal to accept Medi-

care or Medicaid clients is a form of rationing. As with access to

care, rationing health care is a public health issue. Where care is

not provided, the public health system and nurses must ensure

that essential clinical services are available. Managed care was

thought to offer the possibility of more appropriate health care

access and better-organized care to meet the basic health care

needs of the total population. A shift in the general approach to

health care from a reactionary, acute-care orientation toward a

proactive, primary prevention orientation is necessary to

achieve not only a more cost-effective but also a more equitable

health care system in the United States. The ACA, despite pro-

viding coverage to more people, will not do away with rationing

because the new law provides for a four-tiered plan (bronze,

silver, gold, platinum) by creating state-based American Health

Beneit Exchanges. Persons at differing levels of poverty will

have reductions in out-of-pocket expenses based on income up

to 400% of the poverty level and may receive tax credits and

subsidies to assist with out-of-pocket expenses (US Law,

PL 111-148, 2010).

HEALTHY PEOPLE 2020

Healthy People 2020 (USDHHS, 2010) goals are examples of

strategies to provide better access for all people. The Levels of

Prevention box shows the levels of economic prevention

strategies.

HEALTHY PEOPLE 2020

Objectives Related to Access to Care

• AHS-1: Increase the proportion of persons with health insurance.

• AHS-6: Reduce the proportion of individuals who experience dificulties or

delays in obtaining necessary medical care, dental care, or prescription

medicines.

LEVELS OF PREVENTION

Economic Prevention Strategies

Primary Prevention

Work with legislators and insurance companies to provide coverage for health

promotion to reduce the risk for diseases.

Secondary Prevention

Encourage clients who are pregnant to participate in prenatal care and the

Special Supplemental Nutrition Program for Women, Infants, and Children

(WIC) to increase the number of healthy babies and reduce the costs related to

preterm baby care.

Tertiary Prevention

Participate in home visits to mothers who are at risk for neglecting babies, to

reduce the costs related to abuse.

CHECK YOUR PRACTICE?

At the local nurse-managed clinic for mothers and new babies, you are as-

signed to assist mothers in understanding the beneits of primary prevention.

You are focusing on the Special Supplemental Nutrition Program for Women,

Infants, and Children (WIC) program and are encouraging mothers to partici-

pate in this program to help their babies have a good start toward a healthy

life. Why do you think such a program is important, and why is primary preven-

tion even a focus in health care delivery?

130 PART 2 Inluences on Health Care Delivery and Nursing

PRIMARY PREVENTION

Society’s investment in the health care system has been based

on the premise that more health services will result in better

health, but factors not related to health care also have an ef-

fect. Of the four major factors that affect health—personal

behavior (or lifestyle), environmental factors (including phys-

ical, social, and economic environments), human biology, and

the health care system—medical services are said to have the

least effect. Behavior and lifestyle have been shown to have the

greatest effect, with the environment and biology accounting

for the greatest effect on the development of all illnesses

(NCHS, 2016).

Despite the signiicant impact of behavior and environment

on health, estimates indicate that most of the health care dollars

are spent on secondary and tertiary care. Such a reactionary,

secondary-care system results in high-cost, high-technology,

and disease-speciic care and is consistent with the US system’s

traditional emphasis on “sickness care.” A more proactive in-

vestment in disease prevention and health promotion targeted

at improving health behaviors, lifestyle, and the environment

has the potential to improve the health status of populations,

thereby improving the quality of life while reducing health care

costs. The USDHHS has argued that a higher value should be

placed on primary prevention. The goal of this approach is to

preserve and maximize human capital by providing health

promotion and social practices that result in less disease. An

emphasis on primary prevention has the goal of reducing dol-

lars spent and increasing the quality of life.

The return on investment in primary prevention through

gains in human capital has, unfortunately, not been acknowl-

edged in the past. The ACA is designed to acknowledge and

improve primary prevention access and improve the return on

investment of dollars in health care. In the past, large invest-

ments in primary prevention and public health care were not

made. Reasons given for this lack of emphasis on prevention in

clinical practice and lack of inancial investment in prevention

included the following:

• Provider uncertainty about which clients should receive

services and at what intervals

• Lack of information about preventive services

• Negative attitudes about the importance of preventive care

• Lack of time for delivery of preventive services

• Delayed or absent feedback regarding the success of preven-

tive measures

• Less reimbursement for these services than for curative

services

• Lack of organization to deliver preventive services

• Lack of use of services by the poor and the elderly

• More out-of-pocket expenses for the poor and those who

lack health insurance

A focus on prevention could mean reducing the need for

and use of medical, dental, hospital, and health provider ser-

vices as they are delivered today. With the increasing costs of

health care and consumer demand and the changes in inanc-

ing mechanisms, there is a new trend toward inancing more

preventive care services and offering some of these services free

(US Law, 2010).

Today, third-party payers are beginning to cover preventive

services, recognizing that the growth of the health care system

can no longer be supported. Under capitated health plans,

health care providers stand to make money by keeping clients

healthy and reducing health care use. Through combining client

interests with inancial interests of the health care industry,

primary prevention and public health can be raised to the status

and priority of acute care and chronic care. Support for an in-

creasing national investment in primary prevention is sound

and long-standing. Despite dificulties, methods for determin-

ing prevention effectiveness, such as cost-effectiveness analysis

(CEAs) and cost/beneit analysis (CBAs), are becoming stan-

dard and used more widely. Two agendas for preventive services

are published that promote the preventive agenda:

• The US Preventive Services Task Force’s Guide to Clinical

Preventive Services (Agency for Healthcare Research and

Quality [AHRQ], 2014) is for clinicians in primary care and

outlines the regular screening and risk factors to look for at

various ages.

• The Community Preventive Services Task Force’s (2015)

publication The Community Guide emphasizes population-

level interventions to promote primary prevention.

Regardless of the method, prevention effectiveness analyses

(PEAs) are outcome oriented. This area of research seeks to

link interventions with health outcomes and economic out-

comes and to reveal the tradeoffs between the two. Since the

public health movement of the mid-19th century, public

health oficials, epidemiologists, and nurses have been work-

ing to advance the agenda of primary prevention to the fore-

front of the health care industry. Today these efforts continue

across various disciplines and in both the public and the pri-

vate sectors, and through the efforts for health care reform

(US Law, 2010).

THE CONTEXT OF THE US HEALTH SYSTEM

The US health care system is a diverse collection of industries

involved directly or indirectly in providing health care services.

The major players in the industry are the health professionals

who provide health care services, pharmacy and equipment

suppliers, insurers (public, government, private), managed care

organizations (health maintenance organizations, preferred

provider organizations), and other groups, such as educational

institutions, consulting and research irms, professional associ-

ations, and trade unions. Today the health care industry is large,

and its characteristics and operations differ between rural and

urban geographic areas.

In the 21st century, health policy and national politics relect

the importance of health care delivery in the general economy.

Conlicts arise between competing special-interest groups that

have different goals and objectives when it comes to the pro-

ducing and consuming of health services. To some degree this

is caused by federal and state policy changes about how health

services are inanced (public and private).

Fig. 8.1 illustrates the four basic components that make up

the framework of health services delivery: service needs and

intensity, facilities, technology, and labor. Intensity is the extent

of use of technologies, supplies, and health care services by or

131CHAPTER 8 Economic Inluences

for the client. Intensity includes and is a partial measure of the

use of technology (NCHS, 2016). Medical technology refers to

the set of techniques, drugs, equipment, and procedures used

by health care professionals in delivering medical care to indi-

viduals. It also includes information technology and the system

within which such care is delivered (NCHS, 2016).

Health care systems have developed in four phases from the

1800s to today. These developmental stages correspond to dif-

ferent economic conditions. Developmentally, the four compo-

nents of the health services delivery framework have changed

over time, relecting changes in morbidity and mortality, na-

tional health policy, and economics (Fig. 8.2).

FIRST PHASE

The irst developmental stage (1800–1900) was characterized by

epidemics of infectious diseases, such as cholera, typhoid,

smallpox, inluenza, malaria, and yellow fever. Health concerns

of the time related to social and public health issues, including

contaminated food and water supplies, inadequate sewage dis-

posal, and poor housing conditions (Shi and Singh, 2014).

Family and friends provided most health care in the home.

Hospitals were few in number and suffered from overcrowding,

disease, and unsanitary conditions. Sick persons who were

cared for in hospitals often died as a result of these conditions.

Most people avoided being cared for in a hospital unless there

was no alternative. In this irst developmental phase, health care

was paid for by individuals who could afford it, through barter-

ing with physicians, or through charity from individuals or or-

ganizations. The irst county health departments were estab-

lished in 1908.

Technology to aid in disease control was very basic and prac-

tical but in keeping with the knowledge of the time. The physi-

cian’s “black bag” contained the few medicines and tools avail-

able for treatment. The economics of health care was inluenced

by the types of health care providers and the number of practi-

tioners, with the labor force composed mostly of physicians and

nurses who attained their skills through apprenticeships or on-

the-job training. Nurses in the United States were predomi-

nantly female, and education was linked to religious orders that

expected service, dedication, and charity (Knickman and

Kovner, 2015). The focus of nursing was primarily to support

physicians and assist clients with activities of daily living.

SECOND PHASE

The second developmental stage (1900–1945) of US health

care delivery was focused on the control of acute infectious

diseases. Environmental conditions inluencing health began

Service intensity Facilities

FIG. 8.1 Components of health services development.

Stage 1

1800-1900

• Infectious epidemics

• Inadequate and unsafe

hospital care

• Minimal technology

• Experience-based

training

• Acute infections, trauma

• Specialty hospitals emerge

• Therapeutic advances

• Shift to science-based

training

• Chronic diseases

• Increasing numbers and

types of facilities

• “Durable” technologies—

therapeutics and

diagnostics

• Development of medical

specialties, new “types”

of employees

• Emergence of new and

old infectious diseases

• Mergers, “integration”

• “Super” drug therapies,

computerization, “service”

technologies

• Primary care, “turf” issues,

interprofessisonal care

teams

• Managed care

• Health care/insurance reform

Stage 2

1900-1945

Stage 3

1945-1984

Stage 4

1984-present

FIG. 8.2 Developmental framework for health service needs and intensity, facilities, tech-

nology, and labor.

132 PART 2 Inluences on Health Care Delivery and Nursing

to improve, with major advances in water purity, sanitary

sewage disposal, milk and water quality, and urban housing

quality. The health problems of this era were no longer mass

epidemics, but rather individual acute infections or traumatic

episodes (Shi and Singh, 2014).

Hospitals and health departments experienced rapid growth

during the late 1800s and early 1900s as technological advances

in science were made (Knickman and Kovner, 2015). In addi-

tion to private and charitable inancing of health care, city,

county, and state governments were beginning to contribute by

providing services for poor persons, state mental institutions,

and other specialty hospitals, such as tuberculosis hospitals.

Public health departments were emphasizing case inding and

quarantine. Although health care was paid for primarily by in-

dividuals, the Social Security Act of 1935 signaled the federal

government’s increasing interest in addressing social welfare

problems.

Clinical medicine entered its golden age during this period.

Major technological advances in surgery and childbirth and the

identiication of disease processes, such as the cause of perni-

cious anemia, increased the ability to diagnose and treat dis-

eases. The irst serological tests used as a tool for diagnosis and

control of infectious diseases were developed in 1910 to detect

syphilis and gonorrhea (Shi and Singh, 2014). The irst virus

isolation techniques were developed to ilter yellow fever virus,

for example. The discovery and development of pharmacologi-

cal agents, such as insulin in 1922 for the control of diabetes,

sulfa drugs in 1932 for the treatment of infectious diseases, and

antibiotics such as penicillin in the 1940s, eradicated certain

infectious diseases, increased treatment options, and decreased

morbidity and mortality (Shi and Singh, 2014).

Advances in technology and knowledge shifted physician edu-

cation away from apprenticeships to scientiically based college

education, which occurred as a result of the Flexner Report in

1910. Nurses were trained primarily in hospital schools of nurs-

ing, with an emphasis on following and executing physicians’ or-

ders. Nurses in training were unmarried and under the age of 30.

They provided the bulk of care in hospitals (Knickman and

Kovner, 2015). Public health nurses, who tracked infectious dis-

eases and implemented quarantine procedures, worked more

collegially with physicians (Knickman and Kovner, 2015). In this

period the university-based nursing programs were established to

accommodate the expanding practice base of nursing. Client edu-

cation became a nursing function early in the development of the

health care delivery system.

THIRD PHASE

The third developmental stage (1945–1984) included a shift

away from acute infectious health problems of previous stages

toward chronic health problems such as heart disease, cancer,

and stroke. These illnesses resulted from increasing wealth and

lifestyle changes in the United States. To meet society’s needs,

the number and types of facilities expanded to include, for ex-

ample, hospital clinics and long-term care facilities. The Joint

Commission on Accreditation of Hospitals, established in 1951

and later renamed The Joint Commission on Accreditation of

Healthcare Organizations (and now called The Joint Commis-

sion [TJC]), focused on the safety and protection of the public

and the delivery of quality care.

Changes in the overall health of the American society also

shifted the focus of technology, research, and development.

Major technological advances included developments in the

realms of chemotherapeutic agents; immunizations; anesthe-

sia; electrolyte and cardiopulmonary physiology; diagnostic

laboratories with complex modalities such as computed to-

mography; organ and tissue transplants; radiation therapy;

laser surgery; and specialty units for critical care, coronary

care, and intensive care. The irst “test-tube baby” was born

through in vitro fertilization, and other fertility advances soon

emerged. Negative staining techniques for screening viruses

with the electron microscope became available in the 1960s

(Shi and Singh, 2014).

Health care providers constituted more than 5% of the total

US workforce during this period. The three largest health care

employers were hospitals, convalescent institutions, and physi-

cians’ ofices. Between 1970 and 1984 alone, the number of

persons employed in the health care industry grew by 90%. The

number of personnel employed in the community also in-

creased. The expansion of care delivery into other sites, such as

community-based clinics, increased not only the number but

also the types of health care employees.

Technological advances brought about increased special

training for physicians and nurses, and care was organized

around these specialties. The ongoing shortage of nurses

throughout the century was being seen in the 1970s and early

1980s. Nursing education expanded from hospital-based di-

ploma and university-based baccalaureate education to include

associate degree programs at the entry level. As the diploma

schools of nursing began closing in the early to mid-1980s, the

number of baccalaureate and associate degree programs began

to increase. Graduate nursing education expanded to include

the nurse practitioner (NP) and clinical nurse specialist (CNS)

to meet increasing demands for the education of nurses in a

specialty such as public health. The irst doctoral programs in

nursing were instituted to build the scientiic base for nursing

and increase the number of nurse faculty members.

The role of the commercial health insurance industry in-

creased, and a strong link between employment and the provi-

sion of health care beneits emerged. Furthermore, the federal

government’s role expanded through landmark policymaking

that would affect health care delivery well into the 21st century.

Speciically, the passage of Titles XVIII and XIX of the Social

Security Act (1965) created the Medicare and Medicaid pro-

grams, respectively. The health care system appeared to have

access to unlimited resources for growing and expanding.

Throughout the 20th century, many public health advances

were achieved. The life expectancy of US citizens increased and

has been related to public health activities. The most important

achievements were in vaccinations, improved motor vehicle

safety, safer workplaces, safer and healthier foods, healthier

mothers and babies, family planning, luoride in drinking wa-

ter, and recognition of tobacco as a health hazard (Shi and

Singh, 2014).

133CHAPTER 8 Economic Inluences

FOURTH PHASE

The fourth developmental stage (1984 to the present) has been

a period of limited resources, with an emphasis on containing

costs, restricting growth in the health care industry, and reorga-

nizing care delivery. For example, amendments were made to

the Social Security Act in 1983 that created diagnosis-related

groups (DRGs) and a prospective system of paying for health

care provided to Medicare recipients. The 1997 Balanced Bud-

get Act legislated additional federal changes in Medicare and

Medicaid. Private-sector employer concerns about the rising

costs of health care for employees and fear of proit losses

spurred a major change in the delivery and inancing of health

care. Managed care systems were developed during this time.

This period has included drastic change in the settings and

organization of health care delivery. Transforming health care

organizations became commonplace, and buzz words of the pe-

riod were reorganization, reengineering, restructuring, and down-

sizing. Organization mergers occurred at an increased rate to

consolidate care, save money, and coordinate care across the con-

tinuum (i.e., from “cradle to grave”). Merger discussions focused

on horizontal integration, which indicated the union of similar

agencies (e.g., a merger of hospitals) and vertical integration

between different types of organizations (e.g., an acute care hos-

pital, a long-term care institution, and a home health facility).

Initially these pressures brought about hospital closings and

a shifting of care to other settings, such as ambulatory and

community-based clinics and specialty diagnostic centers that

offer technologies such as magnetic resonance imaging (MRI)

and sonography. Rehabilitative, restorative, and palliative care,

once delivered in the hospitals, was shifted to other settings,

such as subacute care hospitals, specialty rehabilitation hospi-

tals, long-term care institutions, and even individual homes.

Although the basis of care delivery was no longer the traditional

acute care hospital, the nature of the care delivered in hospitals

changed remarkably, as evidenced by the following:

• Patients admitted to hospitals were more acutely ill.

• The length of stay for patients admitted to hospitals became

shorter.

• Care delivery became more intense as a result of the irst two

items.

The widespread use of computers and the Internet has en-

abled society to become increasingly sophisticated about

health. The public’s increasing knowledge about health care

and their awareness of health care advances have inluenced

the demand for health care, such as diagnostic and therapeutic

services for treatment. Furthermore, pharmaceutical compa-

nies and other technological suppliers actively marketed their

products through television, printed advertisements, the Inter-

net, and other sources, so clients rapidly become aware of the

new technologies.

Health professionals depend on technology to care for cli-

ents. Distance, as a barrier to the diagnosis and treatment of

disease, has been overcome through the use of telehealth. The

insurance industry has become the principal buyer of technol-

ogy for the client. They often make decisions about when and

whether a certain technology will be used for a client problem.

Nurses have become dependent on technologies to monitor cli-

ent progress, make decisions about care, and deliver care in in-

novative ways.

The shift away from traditional hospital-based care to the

community, together with the need to consider new models of

care, brought about an increased emphasis on providing pri-

mary care, on developing care delivery teams, and on collabo-

rating in practice and education. The substitution of one type

of health personnel for another was occurring to control care

delivery costs. As examples, the NPs were replacing physicians

as primary-care providers and unlicensed personnel were re-

placing staff nurses in hospitals and long-term care facilities.

These replacements caused much debate, with territorial, or

“turf,” battles, for example, between physicians and nurses.

The increase in specialization by health professionals has led

to changes in certiication, qualiications, education, and stan-

dards of care in health professions. These factors, in turn, have

caused an increase in the number and kinds of providers to

meet the demands of the health care system (Lockard and Wolf,

2012). The Bureau of Labor Statistics (BLS) predicted that

health care employment would be among the top eight profes-

sional and related industries, with signiicant employment

growth of 16% from 2014 to 2024 (BLS, 2015).

In the last part of the 20th century, molecular tools were

developed that provide a means of detecting and characterizing

infectious disease pathogens and a new capacity to track the

transmission of new threats, such as bioterrorism, and deter-

mine new ways to treat them.

CHALLENGES FOR THE 21ST CENTURY

In the 21st century the emergence of new and the reemergence

of old communicable and infectious diseases are occurring, as

well as larger foodborne disease outbreaks and acts of terror-

ism. In 2010, 70% of all deaths were related to chronic disease

(CDC, 2016). In 2012 approximately half of all adults had one

or more chronic conditions, with arthritis being the most com-

mon cause of disability (CDC, 2016). There is some concern

that certain chronic diseases may be caused or intensiied by

infectious disease processes. Often, complications occur as a

result of infectious disease, such as with human immunodei-

ciency virus/acquired immunodeiciency syndrome (HIV/

AIDS) and tuberculosis, which can result in chronic lung dis-

ease and certain types of cancer, because of the compromised

immune system. Health behaviors and economics related to

poverty are also continuing to build the path to acute and

chronic health problems (e.g., the global obesity epidemic)

(Chaufan et al, 2015). Although some people choose to ignore

behavioral factors related to obesity, such as physical activity

and eating, those with insuficient income choose foods high in

fat and sugar because those are the cheaper foods to obtain. The

chronic disease burden is concentrated among the poor. Poor

people are more vulnerable for several reasons, including in-

creased exposure to risks and decreased access to health ser-

vices. Chronic diseases can cause poverty in individuals and

families and draw them into a downward spiral of worsening

disease and poverty.

134 PART 2 Inluences on Health Care Delivery and Nursing

Investment in chronic disease prevention programs is going

to be essential for many low- and middle-income countries

struggling to reduce poverty. For the United States, this issue is

addressed in the new health care reform program of 2010.

Health promotion and protection, disease surveillance, emer-

gency preparedness, new laboratory and epidemiological meth-

ods, continued antimicrobial and vaccine development, and

environmental health research are continuing challenges for

this century. The role of technology has also intensiied during

this century. Technology is now deined as the application of

science to develop solutions to health problems or issues such

as the prevention or delay of onset of diseases or the promotion

and monitoring of good health. The labor force is changing to

include radiology oncologists, geneticists, and surgical subspe-

cialists, as well as allied and support professions such as medical

sonographers, radiation technologists, and laboratory techni-

cians. These have all been created to support the use of speciic

types of technology.

The infrastructure necessary to support more complex tech-

nologies is also considered to be a part of health care technol-

ogy. Use of electronic medical records and electronic prescrib-

ing are methods for coordinating the increasingly complex

array of services provided, as well as allowing for electronic

checks of quality to reduce medical errors for things such as

drug interactions. Because technologies have become a part of

standard medical practice, there are concerns about whether

they are consistently being used properly and about the quality

of the information provided by tests, imaging, and other tech-

nological outputs (Kvedar et al, 2014).

In addition to the labor force changes just described, physi-

cians are increasingly moving away from solo practice to group

practices, selling primary-care practices to hospitals, working as

hospital or corporation employees. The emerging role of hospi-

tal intensivists is growing, with hospitals employing physicians

and sometimes nurse practitioners to be in house and available

to patients and to their community physicians to cover nonur-

gent, urgent, and emergent care while the patient is hospital-

ized. More nurse practitioners and physician assistants can be

found working side by side with the physician in the commu-

nity as a member of the ofice or clinic team.

Public health nurses are more involved with population-

centered care, assessment of community needs, and the devel-

opment or implementation of programs that meet the needs of

certain populations. A move is underway to provide more care

to clients in the home, such as the programs to provide care to

new mothers and babies who are deined as being at risk. Public

health nurses play key roles in developing and implementing

plans for bioterrorism and natural disasters in the community.

Nursing education is seeing a dramatic change in this cen-

tury. There is a recommendation to move all advanced practice

nursing to the level of the new doctoral program, begun in 2000,

titled the Doctorate of Nursing Practice. This has the potential

for closing specialists masters programs in nursing. This means

the new bachelor of science in nursing (BSN) graduate, for ex-

ample, can go into a doctoral program at graduation and be-

come an advanced public health nurse or a nurse practitioner

working in the community. The health care industry is one of

the largest employers in the United States and, despite the eco-

nomic downturn in 2008, has continued to grow. In addition,

the largest number of employees in the health care industry are

registered nurses (RNs) (BLS, 2016; Lockard and Wolf, 2012).

Along with other changes in health care delivery and health

insurance plans, the ACA (US Law, 2010) proposed an empha-

sis on prevention and wellness by establishing the National

Prevention, Health Promotion, and Public Health Council to

coordinate health promotion and public health activities, as

well as the creation of a prevention and public health fund to

expand and sustain these activities. The council was established

in the Ofice of the US Surgeon General, and every year, the

council submits a report describing national progress in meet-

ing speciic prevention, health promotion, and public health

goals deined in the National Prevention Strategy to the presi-

dent and the relevant committees of Congress. The National

Prevention Strategy developed through the council “aims to

guide our nation in the most effective and achievable means for

improving health and well-being. This Strategy envisions a

prevention-oriented society where all sectors recognize the

value of health for individuals, families, and society and work

together to achieve better health for all Americans” (USDHHS,

2016b). The council activities were to assist in the development

FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES

Teamwork and Collaboration

Both teamwork and collaboration refer to the ability to function effectively with

nursing and interprofessional teams and to foster communication, mutual re-

spect, and shared decision making to provide quality client care.

• Knowledge: Identify system barriers and facilitators of effective team func-

tioning.

• Skill: Participate in designing systems that support effective teamwork.

• Attitudes: Values the inluences of systems solutions in achieving effective

functioning.

Teamwork and Collaboration Question

As a strategy set forth by the Affordable Care Act, a fund was established to

support prevention and wellness activities within states to reduce risks. Among

the options for spending the funds was the establishment of programs and pro-

cesses to reduce the rate of chronic disease.

Monies have been distributed to states to promote prevention and wellness.

Find out through your state government how the money is to be used.

The Quad Council public health nursing competency “community dimensions of

practice” indicates that beginning public health nurses will collaborate with

community partners to promote the health of their clients.

Have public health nurse at the state level or locally in your state been in-

volved in collaborations to determine how chronic disease rates might be re-

duced in your area? If yes, how? If not, can you suggest how they might be?

Also, the public health nursing competency that addresses inancial manage-

ment and planning suggests that public health nurses may provide input into the

iscal planning and narrative components of proposals submitted for external

funding. Determine what the process will be for obtaining local funds for chronic

disease and whether public health nurses have had or will have the opportunity

to provide input into the proposals.

135CHAPTER 8 Economic Inluences

of the national strategy to improve health, reduce chronic dis-

ease rates, and address health disparities. With these develop-

ments, it seems that we are moving toward a ifth developmen-

tal phase in health care delivery.

TRENDS IN HEALTH CARE SPENDING

Much has been written in the popular and scientiic literature

about the costs of US health care and how society makes deci-

sions about using available and scarce resources. Given that

economics in general and health care economics in particular

are concerned with resource use and decision making, any dis-

cussion of the economics of health care must consider past and

current health care spending. The trends shown here relect

public and private decisions about health care and health care

delivery in the past. Spending from that time relects past deci-

sion making; likewise, past decisions relect the values and be-

liefs held by society and policymakers that underlie policymak-

ing at any given point in time.

According to the NCHS (2016), national health expenditures

reached $3 trillion in 2014. This is in contrast to the $700 billion

spent on health care in 1990 (NCHS, 2016). The increase in

health spending, from $1.6 trillion in 2001 to $1.8 trillion in

2002, was the largest single-year jump in US history (Centers for

Medicare [CMS], 2014a). The CMS (2014b) predicts total US

health spending in 2024 will be $5.4 trillion. Health spending

has outpaced increases in the gross domestic product (GDP),

accounting for 17.5% of the GDP by 2014 (NCHS, 2016). This

means that $17.50 of every $100 spent in 2014 was for health

care. The CMS (2015a) relates the spending growth to major

coverage expansions under the ACA, particularly for Medicaid

and private health insurance. The effect of this economic growth

represents a large increase in contrast to the approximately 13%

GDP spent on health care between 1992 and 2001.

Fig. 8.3 shows a breakdown of the distribution of health care

expenses for 2014, and Table 8.1 shows the growth in US health

care expenditures between 1960 and 2014 (NCHS, 2016).

Spending for health care increased from approximately $27 bil-

lion in 1960 to over $3 trillion in 2014. These numbers relect

per-person spending amounts of $143 in 1960 and over $9000

in 2014. In 2014 approximately $248 was spent per person for

public health activities (NCHS, 2016).

Calendar Year

Total Health Expenditures

(in billions of dollars)

Total Health Expenditures per

Capita per Person (in dollars)

Percent of Gross

Domestic Product

1960 $26.7 $146 5.0

1970 $74.6 $355 6.9

1980 $255.3 $1108 8.9

1990 $721.4 $2843 12.1

2000 $1369.7 $4857 13.3

2009 $2496.4 $8147 17.3

2012 $2799.0 $8927 17.3

2013 $2879.9 $9115 17.3

2014 $3031.3 $9523 17.5

TABLE 8.1 Health Care Expenditures: 1960 to 2014

Data from National Center for Health Statistics: Health, United States, 2015, with special feature on racial and ethnic health disparities, Hyattsville,

MD, 2016, US Government Printing Ofice. Table 93, p. 293-294.

Physician and clinical services, 20%

Hospital care, 32%Other personal care, 5%

Net cost of health insurance, 6%

Public health, 3% Investment (research, equipment, etc.), 5%

Administration, 1%

Dental services, 4% Other professional services, 3%

Home health care, 3%

Nursing care facilities, 5%

Retail outlet sales

of medical products, 13%

FIG. 8.3 Distribution of US health care expenditures, 2014. (Data from National Center for

Health Statistics: Health, United States, 2015, with special feature on racial and ethnic health

disparities, Hyattsville, MD, 2016, US Government Printing Ofice. Table 94, p. 295.)

136 PART 2 Inluences on Health Care Delivery and Nursing

The largest portions of health care expenses were for hospi-

tal care and physician/clinical services, respectively, in 2014

(NCHS, 2016). Only a small fraction of total health care dollars

was spent on home health, public health, and research and con-

struction in 2014. The trends over time indicate that this is an

ongoing pattern of spending.

FACTORS INFLUENCING HEALTH CARE COSTS

Health economists, providers, payers, and politicians have ex-

plored a variety of explanations for the rapid rate of increase in

health expenses in contrast to population growth. That indi-

viduals have, over time, consumed more health care is not an

adequate explanation. The following factors are frequently cited

as having caused the increases in total and per capita health care

spending since 1960: inlation, changes in population demo-

graphics, technology and intensity of services, and increased

health coverage for individuals from the ACA (CMS, 2015b;

NCHS, 2012).

DEMOGRAPHICS AFFECTING HEALTH CARE

A major demographic change under way in the United States is

the aging of the population. Population changes are also af-

fected by illnesses such as acquired immunodeiciency syn-

drome and by chemical dependency epidemics. These changes

have implications for providers’ health services, and they affect

the overall costs of health care. Because the majority of older

adults and other special populations receive services through

publicly funded programs, the growing health needs among

these populations have a great impact on costs, payments, and

providers associated with Medicaid and Medicare programs. As

the population ages and the Baby Boom generation ages and

retires, federal expenses for Social Security will increase

(Congressional Budget Ofice [CBO], 2015). At 78 million

strong, the oldest of the Boomers—born between 1946 and

1964—are already making unsustainable demands on federal

entitlement programs such as Medicare and Medicaid.

In its Long-Term Outlook for Major Federal Health Care Pro-

grams, the CBO reports that spending for those programs will

account for about 8% each of GDP in 2040 (CBO, 2015).

By 2035, in the absence of change, spending for Medicare

alone (which is more likely to be affected by aging Boomers)

will have more than doubled to 8%, and by 2080 it will have

grown to 15% unless changes are implemented.

The aging population is expected to affect health services more

than any other demographic factor. In 1950 more than half of the

US population was under 30 years of age; in 1994, half of the

population was 34 years of age or older. In 1990 individuals 65 and

older made up 4.1% of the population; in 2011, they accounted for

13.3% of the population, or more than 1 in 8 Americans. By 2050,

it is estimated that they will account for up to 20% of the popula-

tion. In addition, the number of individuals 85 and older is ex-

pected to double between 1990 and 2050 because the population is

living longer, healthier lives (USDHHS, 2012).

Although many older adults are independent and active,

they are likely to experience multiple chronic conditions that

may become disabling. They are admitted to hospitals three

times more often than the general population, and their average

length of stay is more than 3 days longer than the overall aver-

age. They visit physicians more often and make up a larger

percentage of nursing home residents than the general popula-

tion (CDC, 2013; NCHS, 2012).

Life expectancy and health status have been increasing in the

United States. However, older adults continue to consume a

large portion of inancial resources. Health care providers are

concerned about the growth in the older adult population be-

cause public funding sources, such as Medicare, have not been

increasing their reimbursement rates suficiently to cover inla-

tion, and thus, providers collect a smaller amount for visits by

older adult clients each year.

The aging of the population also spurs concerns about fund-

ing their health care because of changes in the proportion of

employed individuals to retired individuals. Persons in the

workforce pay the majority of income taxes and all Social Secu-

rity payroll taxes. The funding base for Medicare decreases as

the population ages, as retirement rates increase, and as the

numbers in the workforce decrease. As a result, some policy-

makers believe that Medicare and system reforms are needed to

ensure adequate inancing and delivery of health care services

to an aging population (US Law, 2010).

Health policy reform options being considered include in-

creased age limits to become eligible for Medicare, means testing

(i.e., determining a lack of inancial resources) for Medicare eligibil-

ity, increased coverage for long-term care insurance, increased

incentives for prevention, and less expensive and more eficient

delivery arrangements and care settings (e.g., managed care ar-

rangements). Meanwhile, the debate continues over how to best

handle the future funding of the growing Medicare program. One

example of a policy change to reduce the Medicare program burden

is the prescription plan (Medicare D) passed by Congress in 2005

and effective in January 2006. This plan, although complicated, re-

quires most Medicare recipients to provide a copayment for pre-

scription medications. Although controversial, the plan is thought

to provide a positive impact for the elderly who could not afford to

pay for their prescriptions while reducing the cost burden for those

who had to pay full price for prescriptions (US Law, 2003).

TECHNOLOGY AND INTENSITY

The introduction of new technology enhances the delivery of

care, but it also has the potential to increase the costs of care. As

new and more complex technology is introduced into the sys-

tem, the cost is typically high. However, clients often demand

access to the technology, and providers want to use it. In an ef-

fort to keep health care costs down, however, payers have at-

tempted to restrict the use of certain technologies. For example,

the drug Viagra, developed for the treatment of impotence by

Pizer Pharmaceuticals, is an example of a controversial techno-

logical advance that, as soon as it was available to the public,

was in high demand and prescribed by providers. Initially, use

137CHAPTER 8 Economic Inluences

was restricted by payers because of cost. It is now covered by

health insurance plans.

The adoption of new technology demands investment in

personnel, equipment, and facilities. Furthermore, new tech-

nology adds to administrative costs, especially if the federal

government provides inancial coverage for the service or is

involved in regulating the technology. Table 8.2 outlines federal

policy that has had an impact on technology and the cost of

health care over time.

CHRONIC ILLNESS

Chronic illness is a new factor affecting health care spending.

Chronic disease accounted for 70% of deaths in 2010 (CDC,

2016). Using Medical Expenditure Panel Survey (MEPS)

data, chronic medical conditions are identified by those

costing the most, the number of bed days, work-loss days,

and activity impairments. The most chronic medical condi-

tion was stroke.

Year Federal Regulation

1906 Prescription drug regulation (PL 59-384): Pure Food and Drugs Act , now the Food, Drug, and Cosmetic Act

1935 Social Security Act (PL 74-271): Provides grants-in-aid to states for maternal and child care, aid to dependent and crippled children, and aid to the

blind and aged

1938 Food, Drug, and Cosmetic Act (PL 75-540): Establishes federal FDA protections for drug safety and protections for misbranded goods, drugs, and

cosmetics

1946 Hill-Burton Act (PL 79-725): Enacts Hospital Survey and Construction Act, providing national direct support for community hospitals; establishes

rudimentary standards for construction and planning; establishes community service obligation

1954 Hill-Burton Act amended (PL 83-482): Expands the scope of the program for nursing homes, rehabilitation facilities, chronic disease hospitals, and

diagnostic or treatment centers

1963 Community Mental Health and Mental Retardation Center Construction Act (PL 88-164)

1965 Medicare Title 18; Medicaid Title 19 (PL 89-97): Amendments to Social Security Act provide Medicare and Medicaid to support health care services

for certain groups

1966 Comprehensive Health Planning Act (PL 89-749): For health services, personnel, and facilities in federal, state, and local partnerships

1971 President Nixon introduces the concept of health maintenance organizations (HMOs) as the cornerstone of his administration’s national health

insurance proposal

1972 Social Security Act amendments (PL 92-603): Extend coverage to include new treatment technologies for end-stage renal disease; provide for

professional standards review organizations to review the appropriateness of hospital care for Medicare and Medicaid recipients

1973 Health Maintenance Organization Act (PL 93-222): Provides assistance and expansion for HMOs

1975 National Health Planning and Resources Development Act (PL 93-641): Designates local health system areas and establishes a national

certiicate-of-need (CON) program to limit major health care expansion at local and state levels

1978 Medicare End-Stage Renal Disease Amendment: Provides payment for home dialysis and kidney transplantation; Health Services Research, Health

Statistics, and Health Care Technology Act establishes a national council on health care technology to develop standards for use

1981 Omnibus Budget Reconciliation Act of 1981 (PL 97-351): Consolidates 26 health programs into four block grants (preventives, health services,

primary care, and maternal and child health)

1982 Tax Equity and Fiscal Responsibilities Act (PL 97-248): Seeks to control costs by limiting hospital costs per discharge adjusted to hospital case mix

1983 Amended Social Security Act (PL 98-21): Establishes a new Medicare hospital prospective payment system based on diagnosis-related groups

(DRGs)

1986 1974 Health Planning and Resource Development Act (PL 93-641): Moves CON program to states

1989 Omnibus Reconciliation Act of 1989 (PL 101-239): Creates a physician resource-based fee schedule to be implemented by 1992, with emphasis on

high-tech specialties of surgery; creates the Agency for Health Care Policy and Research to research the effectiveness of medical and nursing

services, interventions, and technologies

1990 Ryan White Care Act (PL 101-381): Authorizes formula-based and competitive supplemental grants to cities and states for HIV-related outpatient

medical services

1990 Safe Medical Devices Act (PL 101-629): Gives the FDA authority to regulate medical devices and diagnostic products

1993 Omnibus Budget Reconciliation Act (OBRA 93) (PL 103-66): Cuts Medicare funding and reduces payments to skilled nursing facilities; provides

support for immunizations for children on Medicaid

1996 Health Insurance Portability and Accountability Act: Protects health insurance coverage for laid-off or displaced workers

1997 Balanced Budget Act of 1997: Creates a new program for states to offer health insurance to children in low-income and uninsured families

1998 PL 105-33: Authorizes third-party reimbursement for Medicare Part B services for nurse practitioners and clinical nurse specialists

2003 Medicaid Nursing Incentive Act (HR 2295): Expands direct reimbursement to all nurse practitioners and clinical nurse specialists and recognizes

specialized services offered by advanced practice registered nurses, such as primary-care case management, pain management, and mental

health services

2006 Medicare Part D: Provides a plan for prescription payments

2010 Patient Protection and Affordable Care Act passed and signed into law on March 23, 2010

TABLE 8.2 Federal Regulations Contributing to Technology and Cost Controls

138 PART 2 Inluences on Health Care Delivery and Nursing

FINANCING OF HEALTH CARE

Against the backdrop of today’s chronic conditions, it must be

appreciated that inancing for health care has evolved through

the 20th century from a system supported primarily by con-

sumers to a system inanced by third-party payers (public and

private). From 1960 to 2014, the percentage of third-party pub-

lic insurance payments increased, and the percentage of out-of-

pocket payments declined (NCHS, 2016). Combined state and

federal governments paid the most in 2014 (NCHS, 2016).

PUBLIC SUPPORT

The US federal government became involved in health care

inancing for population groups early in its history. In 1798

the federal government created the Marine Hospital Service

to provide medical care for sick and disabled sailors and pro-

tect the nation’s borders against the importing of disease

through seaports. The Marine Hospital Service is considered

the irst national health insurance plan in the United States.

The National Health Board was established in 1879 and was

later renamed the US Public Health Service (PHS). Within

the PHS, the federal government developed a public health

liaison with state and local health departments for the pur-

pose of controlling communicable diseases and improving

sanitation. Additional health programs were also developed

to meet obligations to federal workers and their families

within the PHS, the Department of Defense, and the Veterans

Administration.

Medicare and Medicaid, two federal programs adminis-

tered by the CMS, account for the majority of public health

care spending. Table 8.3 compares these programs. The CMS

is the federal regulatory agency within the USDHHS that is

responsible for overseeing and monitoring Medicare and

Medicaid spending. This agency routinely collects and re-

ports actual health care use and spending and projects

future spending trends. Through these programs, the federal

government purchases health care services for population

groups through independent health care systems, such as

managed care organizations, private practice physicians, and

hospitals.

Medicare The Medicare program, established in Title XVIII of the Social

Security Act of 1965, provides hospital insurance and medical

insurance to persons aged 65 years and older, to permanently

disabled persons, and to persons with end-stage renal disease—

altogether approximately 46 million people in 2013 (CMS,

2014b). Medicare has two parts: Part A (hospital insurance)

covers hospital care, home care, and skilled nursing care (lim-

ited); Part B (noninstitutional care insurance) covers “medically

necessary” services, such as health care provider services, outpa-

tient care, home health, and other medical services, such as di-

agnostic services and physiotherapy. In 1999 a program titled

Medicare Advantage was added to the program (Part C). This is

an option that can be chosen for additional coverage. This op-

tion includes both Part A and Part B services. The Part C plans

are coordinated care plans that include health maintenance

organizations (HMOs), private fee-for-service plans, and medi-

cal savings accounts (MSAs). Part C provides for all health care

coverage costs after a high deductible (CMS, 2014b). Medicare

Part D was added to the program in 2006 to provide prescrip-

tion drug coverage.

Medicare Part A is primarily inanced by a federal payroll tax

that is paid by employers and employees. The proceeds from

this tax go to the Hospital Insurance Trust Fund, which is man-

aged by the CMS. Part A coverage is available to all persons who

are eligible to receive Medicare. Older adults account for the

majority of individuals eligible. There is concern about the fu-

ture of the Medicare Trust Fund, because projected expenses

may be more than the resources of the trust fund. Payments to

hospitals for covered services have been and continue to be

Feature Medicare Medicaid

Where to obtain information Local Social Security Administration ofice State welfare ofice

Recipients Client is 65 years of age or older, is disabled, or has

end-stage renal disease

Speciied low-income and needy, children, aged, blind, and/or

disabled; those eligible to receive federally assisted income

Type of program Insurance Insurance

Government afiliation Federal All states

Availability All states All states

Financing of hospital insurance Medicare Trust Fund, mandatory payroll deduction,

recipient deductibles, trust fund interest

Federal and state governments

Financing of medical insurance Recipient premium payments; general revenue,

US Treasury

Federal and state governments

Types of coverage Inpatient and outpatient hospital services, skilled nursing

facilities (SNFs), limited home health services

Inpatient and outpatient hospital services; prenatal care;

vaccines for children; physician, dental, nurse practitioner, and

nurse-midwife services; SNF services for persons 21 years of

age or older; family services; rural health clinic

TABLE 8.3 Comparison of Medicare and Medicaid Program Features

From US Department of Health and Human Services, Centers for Medicare and Medicaid Services: Medicare and you, Baltimore, MD, 2016,

USDHHS.

139CHAPTER 8 Economic Inluences

higher than fund growth. Thus the Medicare reimbursement

policy has been changing in an attempt to control increasing

hospital costs. Part A requires a deductible from recipients for

the irst 60 days of services with a reduced deductible for 61 to

90 days of service, based on a rate equal to a 1-day stay in the

hospital. The deductible has increased as daily hospital costs

have increased. For skilled nursing facility care, persons pay

nothing for the irst 20 days and a cost per day for days 21

through 100. After 100 days, persons must pay the total cost for

care (CMS, n.d.a). The person pays zero for hospice care and

home health.

The medical insurance package, Part B, is a supplemental

(voluntary) program available to all Medicare-eligible persons

for a monthly premium ($104.90 minimum in 2016) (CMS,

n.d.b). The majority of Medicare-covered persons elect this

coverage. Part B provides coverage for services (other than hos-

pital, physician care, outpatient hospital care, outpatient physi-

cal therapy, and home health care) that are not covered by

Part A, such as laboratory services, ambulance transportation,

prostheses, equipment, and some supplies. After a deductible,

up to 80% of reasonable charges are paid for these services. For

mental health services, generally, 80% of the costs are paid

(CMS, n.d.b). Part B resembles the major medical insurance

coverage of private insurance carriers. Fig. 8.4 shows the total

expenses of the Medicare program from 1970 to 2014.

Since the passing of the Medicare amendments to the Social

Security Act in 1965, the cost of Medicare has increased dra-

matically. Hospital care continues to be the major factor con-

tributing to Medicare costs. However, because of shorter hospi-

tal stays, home health and nursing home costs have increased

dramatically. As a result of rising health costs, Congress passed a

law in 1983 that radically changed Medicare’s method of pay-

ment for hospital services. In 1983 federal legislation (PL 98-21)

mandated an end to cost-plus reimbursement by Medicare and

instituted a 3-year transition to a prospective payment system

(PPS) for inpatient hospital services. The purpose of the new

hospital payment scheme was to shift the cost incentives away

from provision of more care and toward more eficient services.

The basis for prospective reimbursement is the 468 diagnosis-

related groups (DRGs). Also, the Balanced Budget Act of 1997

determined that payments to Medicare skilled nursing facili-

ties would be made on the basis of the PPS, effective July 1,

1998. The PPS payment rates cover skilled nursing facility

services, including routine, ancillary, and capital-related costs

(CMS, 2013). In 2001 CMS developed PPS DRGs for home

health with Health Insurance Prospective Payment System

(HIPPS) codes.

In 2010 the average out-of-pocket amount spent for ser-

vices for Medicare beneiciaries was approximately $4700 (KFF,

2014). The average out-of-pocket spending is skewed to bene-

iciaries who are older or have declining health. This is because

of the limits in Medicare coverage, including certain preventive

care, and the limited number of physicians and agencies that

accept Medicare and Medicaid payment. Older adults who do

not have supplemental insurance must cover the difference

between the Medicare payment and the additional costs for

services.

Medicaid The Medicaid program, Title XIX of the Social Security Act of

1965, provides inancial assistance to states and counties to pay

for medical services for poor older adults, the blind, the dis-

abled, and families with dependent children. The Medicaid

program is jointly sponsored and inanced with matching funds

from the federal and state governments. In 2015 more than 58

million people were enrolled in Medicaid (CMS, 2016a). Med-

icaid expenditures from 1987 to 2014 are shown in Fig. 8.5.

Since the institution of Medicaid, full payment has been pro-

vided for ive types of services (NCHS, 2016):

1. Inpatient and outpatient hospital care

2. Laboratory and radiology services

3. Physician services

4. Skilled nursing care at home or in a nursing home for people

older than 21 years of age

5. Early periodic screening, diagnosis, and treatment (EPS-DT)

for people younger than 21 years of age

600

500

400

300

200

100

B il li o n s o

f d o ll a rs

1970 1980 1990 2000 2009 2014

7.3 36.3

107.3

215.3

470.3

580.7

Year

FIG. 8.4 Medicare expenditures for selected years from

1970 to 2014. (Data from National Center for Health Statistics:

Health, United States, 2015, with special feature on racial and

ethnic health disparities, Hyattsville, MD, 2016, US Government

Printing Ofice. Table 95, p. 297.)

B il li o n s o

f d o ll a rs

Year

Total

Federal

State and

local

State and local

1980

24.7

13.7

1990

69.7

40.3

29.4

2000

186.9

109.3

77.6

2009

346.2

230.6

115.6

2014

444.9

273.6

171.3

500

450

400

350

300

250

200

150

100

FIG. 8.5 Medicaid expenditures for selected years from

1980 to 2014. (Data from National Center for Health Statistics:

Health, United States, 2015, with special feature on racial and

ethnic health disparities, Hyattsville, MD, 2016, US Government

Printing Ofice. Table 95, p. 297.)

140 PART 2 Inluences on Health Care Delivery and Nursing

The 1972 Social Security amendments added family plan-

ning to the list of full-pay services. States can choose to add

prescriptions, dental services, eyeglasses, intermediate care fa-

cilities, and coverage for the medically indigent as program

options. By law, the medically indigent are required to pay a

monthly premium.

Any state participating in the Medicaid program is re-

quired to provide the six basic services to persons who are

below state poverty income levels. Optional programs are

provided at the discretion of each state. In 1989 changes in

Medicaid required states to provide care for children younger

than 6 years of age and to pregnant women under 133% of the

poverty level. For example, if the poverty level were $12,000, a

pregnant woman could have a household income as high as

$16,000 and still be eligible to receive care under Medicaid.

These changes also provided for pediatric and family nurse

practitioner reimbursement. In the 1990s, states were allowed

to petition the federal government for a waiver. If the waiver

was approved, the states could use their Medicaid monies for

programs other than the six basic services. The irst waiver to

be approved was given to Oregon for their health care reform

plan. Other states have received waivers to develop Medicaid-

managed care programs for special populations. The 2010

health care reform plan provides for new approaches to offer-

ing Medicaid services and incentives for states to offer Medic-

aid services rather than through the waiver option as de-

scribed previously (US Law, 2010).

The major expense categories for the Medicaid program

have historically been long-term care and acute care. When

combined, these two categories account today for 96% of all

costs to the program (KFF, 2015b).

PUBLIC HEALTH

Most public government agencies operate on an annual bud-

get, and they plan for costs by estimating salaries, expenses,

and costs of services for a year. Public health agencies, such as

health departments and the Special Supplemental Nutrition

Program for Women, Infants, and Children (WIC), receive

primary funding from taxes, with additional money for select

goods and services through private third-party payers. Se-

lected public health programs receive reimbursement for ser-

vices through grants given by the federal government to states

for prenatal and child health; through Medicare and Medicaid

for home health, nursing homes, WIC programs, and EPS-DT;

and through collecting of fees on a sliding scale for select cli-

ent services, such as immunizations (Trust for America’s

Health, 2014).

In 2014, only 3% of all health care–related federal funds were

expended for federal health programs such as WIC, in contrast

to 97% for other types of health and illness care (such as hospi-

tal and physician services) (NCHS, 2016). In addition to this

3% allotment, public health funds also come through states and

territorial health agencies. State and local governments contrib-

uted 31% to public and general assistance, maternal and child

health, public health activities, and other related services in

2013 (Pew Charitable Trust, 2015).

OTHER PUBLIC SUPPORT

The federal government inances health services for military

persons and dependents through TRICARE, the Veterans Ad-

ministration, and the Indian Health Service (IHS). These pro-

grams are very important in providing needed health care ser-

vices to these populations (see additional information in

Chapters 3 and 7). TRICARE is the Department of Defense’s

health care program for members of the uniformed services,

their families, and their survivors. TRICARE also offers health

care programs for retired service members, including TRICARE

Pharmacy, TRICARE Dental (United Concordia), and TRI-

CARE for Life.

EVIDENCE-BASED PRACTICE

This retrospective study examined the incidence, costs, and factors associated

with potentially avoidable hospitalizations (PAHs) in dually eligible Medicare

and Medicaid beneiciaries. This population was selected due to their complex

clinical needs and high costs of care. PAHs were deined by an expert panel

that identiied conditions and associated diagnostic related groups (DRGs) that

can often be prevented or safely and effectively managed in a skilled nursing

facility or home- and community-based services. Seventy-eight percent of the

PAHs resulted from ive conditions: pneumonia, congestive heart failure, uri-

nary tract infections, dehydration, and chronic obstructive pulmonary disease.

The total costs of these hospitalizations were $3 billion for Medicare benei-

ciaries and $463 million for Medicaid beneiciaries. A sensitivity analysis

found that between 77,000 and 260,000 hospitalizations and between $625

million and $1.9 billion in expenditures could be avoided each year in this

population.

Nurse Use

Community health nursing initiatives, such as health education and case man-

agement, could signiicantly reduce the number of hospital admissions in this

population. Such interventions could greatly reduce the negative health effects

and quality of life for this population, as well as reduce the high health care

costs for this group.

Modiied from Walsh EG, Wiener JM, Haber S, et al: Potentially avoid-

able hospitalizations of dually eligible Medicare and Medicaid benei-

ciaries from nursing facility and home- and community-based services

waiver program. J Am Geriatr Soc 60:821–829, 2012.

PRIVATE SUPPORT

Private health care payer sources include insurance, employers,

managed care, and individuals. Although insurance and con-

sumers have been prominent health care payment sources for

some time, the role of employers, managed care, and consumers

became increasingly prominent and powerful during the irst

decade of the 21st century, particularly as concerns grew about

the use and changing nature of health insurance.

Evolution of Health Insurance Insurance for health care was irst offered for the private sector

in 1847 by a commercial insurance company. The purpose of

the insurance was to provide security and protection when

health care services were needed by individuals. The idea be-

hind insurance was that it provided security, guaranteeing

(within certain limits) monies to pay for health care services to

141CHAPTER 8 Economic Inluences

offset potential inancial losses from unexpected illness or in-

jury related to accidents, catastrophic communicable diseases

(such as smallpox and scarlet fever), and recurring (but unex-

pected) chronic illnesses.

The economic depression of the 1930s, rising medical costs,

and the need to spread inancial risk across communities

spurred the development of the third-party payment system.

The system began as a major industry in the 1930s with the Blue

Cross system, which initially provided prepayment for hospital

care. In 1939 Blue Shield created plans to provide physician

payment. The Blue Cross plans began as tax-free, nonproit

organizations established under special enabling legislation in

various states.

In the 1940s and 1950s, hospital and medical-surgical cover-

age increased. Employee group coverage appeared, and proit-

making commercial insurance underwriters began offering

health insurance packages with competitive premiums. Pre-

mium competition, the offering of health insurance as a fringe

beneit, and the use of health insurance as a negotiable collec-

tive bargaining item led to an increase in covered beneits, irst-

dollar coverage for medical care expenses, and increased em-

ployer-paid premiums. In turn, these factors pushed up

insurance premium costs and health care costs and enabled

insurance plans to cover high-cost segments of the population

(the aged, poor, or disabled).

The health needs of high-risk populations led to the passage

of Medicare and Medicaid legislation. These and other national

health programs targeted health care coverage for speciic

population groups. Because these programs directed additional

money into the health care system to subsidize care, there were

inancial incentives to encourage the provision of services (i.e.,

the more services that were ordered, the greater the amount of

money that would be received). Other incentives were related to

the use of services by clients (i.e., the more available the pay-

ment was for services that might otherwise have gone unused,

the more services that were requested).

Employers Since the beginning of Blue Cross and Blue Shield, health insur-

ance has been tied to employment and the business sector. This

tie was strengthened during World War II to compensate, at-

tract, and retain employees. Since that time, employers have

played the major role in determining health insurance beneits.

However, with the economic downturn in 2008, employers be-

gan to reduce their health insurance beneits or return the cost

of insurance premiums to the employee.

Before the growth of insurance (i.e., before 1930 and the

beginning of Blue Cross), the health care consumer had more

inluence over health care costs because payment was out of

pocket. Consumers made decisions about how they would

spend their money, making certain tradeoffs—for example,

about the type of health care they were willing to buy and how

much they would pay. Entering the system was restricted in

large part to those who could afford to pay for care or who

could ind care inanced through charitable and philanthropic

organizations. With the beginning of the insurance (or third-

party payer) system, health care costs were set by payers, and

they determined the type of care or service that would be of-

fered and its price. This began to change somewhat in the 1980s

with the increased use of managed care.

As the cost of health insurance has increased, some em-

ployers, in an effort to bypass the costs established by insurers,

have found it less costly to self-insure. The employer does this

by contracting directly with providers to obtain health care

services for employees rather than going through health in-

surance companies. Some large businesses directly employ

onsite providers for care delivery or offer onsite wellness pro-

grams. These programs within the private sector offer oppor-

tunities for nurses to provide wellness programs and health

assessments to screen and monitor employees and their fami-

lies. This move to self-insure has resulted in savings to compa-

nies and has reduced overall sick care costs (Knickman and

Kovner, 2015).

Individuals In 2014, individuals paid only approximately 13% of total

health expenditures out of pocket (NCHS, 2016). However,

these igures do not relect the amount of money the consumer

pays in taxes to inance government-supported programs such

as Medicare and Medicaid, insurance premiums, and money

paid for supplemental insurance to cover the gaps in a primary

health insurance policy or Medicare.

The average monthly cost for private health insurance has

increased greatly through the years. Premiums relect a shift of

the health care cost burden from employers to employees as the

percent of employer contributions to health care declines. The

decrease in employer contribution to health insurance premi-

ums parallels the economic downturn of 2008, the move away

from traditional insurance plans, and the move toward man-

aged care plans or self-insurance plans by both small and large

employers or toward dropping health insurance as a beneit. In

2008, 2 million people lost employer health insurance coverage

(KFF, 2009).

Managed Care Arrangements Managed care is the term used for a variety of health care

arrangements that integrate the financing and the delivery

of health care. Managed care offers an array of services

to purchasers, such as employers or Medicare, for a set fee.

This fee, in turn, is used to pay providers through preset

arrangements for services delivered to individuals who are

covered (NCHS, 2016). The concept of managed care is

based on the notion that the use of costly care could be re-

duced if consumers had access to care and services that would

prevent illness through consumer education and health

maintenance. Therefore managed care uses disease preven-

tion, health promotion, wellness, and consumer education

(Knickman and Kovner, 2015).

Two common types of managed care organizations are

health maintenance organizations (HMOs) and preferred

provider organizations (PPOs). Box 8.1 provides an overview

of HMOs and PPOs. Although they seem relatively new

to many clients of care, HMOs have actually been around

since the 1940s. The Health Maintenance Organization Act

142 PART 2 Inluences on Health Care Delivery and Nursing

was enacted in 1972, and since that time the number of indi-

viduals receiving care through HMOs and other types of man-

aged care organizations has increased considerably. Managed

care is based, in part, on the principles of managed competi-

tion. Managed competition was introduced in health care in

the late 1980s and early 1990s to address the increasing costs

of health care and to introduce quality into the forefront of

discussions. Managed competition simply means that clients

make decisions and choose the health care services they want

on the basis of the quality or reputation of the service. To

make decisions, they use knowledge and information about

health care problems, care, and providers, and they look at the

costs of care. However, health care is a complex market and

not one in which information about health care, health prob-

lems, and the costs of care is easy to obtain.

Medical Savings Accounts Another insurance reform discussion at the political level

concerns MSAs. MSAs are touted as a way of turning health

care decision-making control over to the individuals receiving

care. MSAs are tax-exempt accounts available to individuals

who work for small companies, usually established through a

bank or insurance company, that enable the individuals to

save money for future medical needs and expenses (Internal

Revenue Service, 2016). Money is contributed to an MSA by

the employer, and the initial money put into an MSA does not

come out of taxable income. Also, interest earned in MSAs is

tax-free, and unused MSA money can be held in the account

from year to year until the money is used. MSAs, in theory,

would allow individuals to make tradeoffs between cost and

quality and would require that individuals become knowl-

edgeable about health care, become involved in health care

decision making, and take responsibility for the decisions

made. Providers, in turn, must be willing to provide and dis-

close information to individuals and give up control of health

care decision making. The Health Insurance and Portability

and Accountability Act (HIPAA) and MSAs are examples of

health insurance reform efforts, and these efforts will very

likely remain at the forefront of political discussions for some

time to come.

HEALTH CARE PAYMENT SYSTEMS

Several methods have been used by public and private sources

to pay health care providers for health care services. These in-

clude retrospective reimbursement and prospective reimburse-

ment for paying health care organizations and fee-for-service

and capitation for paying health care practitioners (Knickman

and Kovner, 2015).

PAYING HEALTH CARE ORGANIZATIONS

Retrospective reimbursement is the traditional reimburse-

ment method. Fees for the delivery of health care services in an

organization are set after services are delivered (Knickman and

Kovner, 2015).

Prospective reimbursement, or payment, is a more recent

method of paying an organization, in which the third-party

payer establishes the amount of money that will be paid for

the delivery of a particular service before offering the services

to the client (Knickman and Kovner, 2015). Since the estab-

lishment of prospective payment in Medicare in 1983, private

insurance has followed by requiring preapprovals before cli-

ents can receive certain services, such as hospital admission

or mammograms, more than once per year (Knickman and

Kovner, 2015).

Similarly, ambulatory care services received by Medicare re-

cipients are classiied into ambulatory payment classes, which

relect the type of ambulatory clinical services received and re-

sources required (CMS, 2016b). Prospective payment to skilled

nursing facilities is also adjusted for case mix and geographic

variations (CMS, 2013).

Growth in contracting, or competitive bidding, for health

care services, intended to create incentives for providers to

compete on price, has occurred as managed care has increased

in health care markets. For example, contracting has been used

by states to provide Medicaid services to eligible persons. Hos-

pitals and other health care providers who do not have a con-

tract with the state to provide services are not eligible to receive

Medicaid payments for client care. Managed care organizations

BOX 8.1 Types of Managed Care Organizations

Health Maintenance Organization (HMO)

An HMO is a provider arrangement whereby comprehensive care is provided

to plan members for a ixed, “per member per month” fee. Common features

include the following:

• Capitation

• Use of designated providers

• Point-of-service care, or receiving care from nondesignated plan providers

• One of the following models:

• Staff model, in which physicians are HMO employees

• Group model, in which a physician group practice contracts with the

HMO to provide care

• Individual practice association (IPA), in which the HMO contracts with

physicians in solo, small group practices, or physician networks to pro-

vide care

• Mixed model, in which the HMO uses a combination group or IPA

arrangement

Preferred Provider Organization (PPO)

A PPO is a provider arrangement in which predetermined rates are established

for services to be delivered to members. Common features include the following:

• Hospital and physician providers

• Discounted rate setting

• Financial incentives to encourage plan members to select PPO providers

• Expedited claims payment to providers

From Folland S, Goodman AC, Stano M: The economics of health and

health care: Pearson International Edition, New York, 2016, Routledge;

and National Center for Health Statistics: Health, United States, 2015,

with special feature on racial and ethnic health disparities, Hyattsville,

MD, 2016, US Government Printing Ofice.

143CHAPTER 8 Economic Inluences

also use this approach to negotiate with health care organiza-

tions, such as hospitals, for coverage of services to be provided

to covered enrollees, often called covered lives.

PAYING HEALTH CARE PRACTITIONERS

The traditional method of paying health care practitioners is

known as fee-for-service payment (Knickman and Kovner,

2015) and is like the retrospective method just described. The

practitioner determines the costs of providing a service, delivers

the service to a client, submits a bill for the delivered service to

a third-party payer, and is paid by the third-party payer. His-

torically, Medicare, Medicaid, and private insurance companies

have used this method of reimbursing physicians.

Capitation is similar to prospective reimbursement for

health care organizations. Speciically, third-party payers de-

termine the amount that practitioners will be paid for a unit

of care, such as a client visit, before the delivery of the service,

thereby placing a limit on the amount of reimbursement re-

ceived per patient (Knickman and Kovner, 2015). In contrast

to a fee-for-service arrangement, in which the practitioner

determines both the services that will be provided to clients

and the charges for those services, practitioners being paid

through capitation are given the rate they will be paid for a

client’s care, regardless of speciic services provided. There-

fore, for example, physicians and nurse practitioners are

aware, in advance, of the payment they will receive to perform

a routine, uncomplicated physical examination or a more

complex, detailed physical examination, diagnosis, and treat-

ment (Knickman and Kovner, 2015).

In capitated arrangements, physicians and other practitio-

ners are paid a set amount to provide care to a given client or

group of clients for a set period and amount of money. This

arrangement, typically used by managed care organizations, is

one in which the practitioner contracts with the managed care

organization to provide health care services to plan members

for a preset and negotiated fee. The agreed-on fee is negoti-

ated between the practitioner and the managed care organiza-

tion before the delivery of services and is set at a discounted

rate, and the practitioner and managed care organization

come to a legal agreement, or contract, for the delivery and

payment of services. The managed care organization pays the

predetermined fee to the practitioner, often before the deliv-

ery of services, to provide care to plan members for a set pe-

riod (Knickman and Kovner, 2015).

Reimbursement for Nursing Services Historically, practitioners eligible to receive reimbursement for

health care services included physicians only. However, nurses

who function in certain capacities, such as NPs, CNSs, and

midwives, also provide primary care to clients and receive reim-

bursement for their services. Being recognized as primary-care

providers and eligible to receive reimbursement has not been an

easy achievement.

Hospital nursing care costs have traditionally been included

as part of the overall patient room charge and reimbursed as

such. Other agencies, such as home health care agencies, in-

clude nursing care costs with administrative costs, supplies, and

equipment costs. Nursing organizations, such as the American

Nurses Association, have long advocated that nursing care

should become a separate budget item in all organizations so

that cost studies can show the eficiency and effectiveness of

the nursing profession.

Spurred by efforts to control the costs of medical care,

effective January 1, 1998, NPs and CNSs were granted third-

party reimbursement for Medicare Part B services only, un-

der Public Law 105-33 (American Nurses Association [ANA],

1999). This new law set reimbursement for NPs and CNSs at

85% of physician rates for the same service, an extension of

previous legislation that allowed the same reimbursement

rate to NPs and CNSs practicing in rural areas (Buppert,

1999). This law was passed after years of work in this area,

including research documenting NP and CNS contributions

to health care delivery and client outcomes, and after active

lobbying efforts by professional nursing organizations. Re-

imbursement for these nurses has not changed to any extent

since the 1990s.

In addition, data about the cost/benefit ratio, efficiency,

and effectiveness of nursing care in general have been col-

lected. In about 2012, more than 250 nurse-managed clinics

provide health care services to individuals in the United

States who might not otherwise have access to health

care, such as older adults, the homeless, and schoolchildren

(Esperat et al, 2012).

All of these events have moved the discipline toward more

autonomy in nursing practice and are serving as a means for

evaluating and documenting nurses’ contributions to health

care delivery. In 2014 it was reported that the number of nurse-

managed clinics had grown to 500, largely due to the passing of

the ACA (Toner, 2014).

ECONOMICS AND THE FUTURE OF NURSING PRACTICE

Nurses must plan for future changes in health care financ-

ing by becoming aware of the costs of nursing services,

identifying aspects of care in which cost savings can be

safely achieved, and developing knowledge on how nursing

practice affects and is affected by the principles of econom-

ics. Nursing must continue to focus on improving the over-

all health of the nation, deining its contribution to the health

of the nation, deriving the value of nursing care, and ensur-

ing its economic viability within the health care marketplace.

Nurses must effect changes in the health care system by pro-

viding leadership in developing new models of care delivery

that provide effective, high-quality care and by assuming a

greater role in evaluating client care and nurse performance.

It is through their leadership that nurses will contribute to

improved decision making about allocating scarce health

care resources and will promote primary prevention as an

answer to improve many of the current population-level

health outcomes.

144 PART 2 Inluences on Health Care Delivery and Nursing

APPLYING CONTENT TO PRACTICE

This chapter focuses on examining the balance of interest within society and

health care, which will continue to shift toward a focus on quality, safety, and

elimination of health disparities through public- and private-sector partnerships.

Health care system concerns of the 21st century are expected to focus on examin-

ing the quality of health care relative to the costs of care delivered, reduction in

disparities, access to care, and health care reform. These changes will result from

continued efforts of both the public and private sectors to reform the US health

care system. The current era of health care delivery will be noted as a time of vast

changes in all sectors of health care delivery.

Nurses will want to plan for future changes in health care inancing by becom-

ing aware of the costs of nursing services and identifying aspects of care where

cost savings can be safely achieved. Nursing must continue to focus on improv-

ing the overall health of the nation, deining its contribution to the health of the

nation, deriving the value of nursing care, and ensuring its economic viability

within the health care marketplace. Nurses must effect changes in the health

care system by providing leadership in developing new models of care delivery

that provide effective, high-quality care and by assuming a greater role in evalu-

ating client care and nurse performance. This chapter will assist the reader in

identifying how, through their leadership, nurses will contribute to improved

decision making about allocating scarce health care resources and promoting

primary prevention as an answer to improve many of the current population-level

health outcomes.

P R A C T I C E A P P L I C A T I O N

R E M E M B E R T H I S !

Connie, a nursing student, has identiied a caseload of ive

families in a chronic disease program offered by the local public

health department. She is interested in assessing the costs of care

to her clients and to the agency. Connie approaches the public

health nurse administrator and asks the following questions:

A. How is the agency reimbursed for chronic disease management?

• From 1800 to the 1980s, the US health care delivery system

experienced three developmental stages, with different em-

phases on health care economics. In 1985 the health care

delivery system entered a fourth developmental stage.

• Four basic components provide the framework for the devel-

opment of the delivery of health care services: service needs

and intensity, facilities, technology, and labor (workforce).

• Three major factors have been associated with the growth of the

health care delivery system: price inlation, changes in popula-

tion demographics, and technology and service intensity.

• Chronic disease is becoming a major health factor affecting

health care spending.

• Health care inancing has evolved through the 20th century

from a system inanced primarily by the consumer to a

system inanced primarily by third-party payers. In the

21st century, the consumer is being asked to pay more.

• To solve the problems of rising health care costs, various

plans for future payment of health care are being considered;

all include some form of rationing.

• Excessive and ineficient use of goods and services in health

care delivery has been viewed as the major cause of rising

health care costs.

• Economics is concerned with the use of resources, including

money, to fulill society’s needs and wants.

• Health economics is concerned with the problems of produc-

ing services and programs and distributing them to clients.

• The goal of public health economics is maximum beneits

from services of public health providers, leading to health

and wellness of the population.

B. Does the client have a responsibility to pay for services?

C. Are nursing care costs known?

D. Are services rationed to clients?

E. What effect will the chronic disease management program

have on the community population?

Answers can be found on the Evolve website.

• The goal of public health is providing the most good for the

most people.

• Nurses need to understand basic economic principles to

avoid contributing to rising health care costs.

• The gross domestic product (GDP) relects the market value

of goods and services produced by the United States.

• The GDP relects the market value of the output of labor

and property located in the United States.

• Social issues, economic issues, and communicable disease

epidemics mark the problems of the 21st century.

• Medicare and Medicaid are two government-funded pro-

grams that help meet the needs of high-risk populations in

the United States.

• A majority of the US population has health insurance. The

remaining uninsured segment represents millions of people,

mostly the working poor, older adults, and children.

• Poverty has a detrimental effect on health.

• Health care rationing has always been a part of the US health

care system.

• Nurses are cost-effective providers and must be an integral

part of health care delivery.

• Healthy People 2020 is a document that has established US

health objectives.

• Human life is valued in health economics, as is money. An

emphasis on changing lifestyles and preventive care will re-

duce the unnecessary years of life lost to early and prevent-

able death.

145CHAPTER 8 Economic Inluences

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147

Epidemiological Applications

DeAnne K. Hilfinger Messias and Swan Arp Adams

C H A P T E R

PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

After reading this chapter, the student should be able to:

1. Deine epidemiology and describe how it has developed

over time.

2. Describe the essential elements of epidemiology and an

epidemiological approach.

3. Discuss the steps in the epidemiological process.

4. Explain the basic epidemiological concepts of population

at risk, natural history of disease, levels of prevention,

O B J E C T I V E S

host-agent-environment relationships, and the web-of-

causation model.

5. Differentiate between descriptive and analytic epidemiology.

6. Explain how nurses use epidemiology in public health

practice.

Deinitions

History

How Nurses Use Epidemiology

Basic Concepts in Epidemiology

Measures of Morbidity and Mortality

Epidemiologic Triangle: Agent, Host, and

Environment

Levels of Preventive Interventions

Screening

Reliability and Validity

Basic Methods in Epidemiology

Sources of Data

Rate Adjustment

Comparison Groups

Descriptive Epidemiology

Person

C H A P T E R O U T L I N E

Place

Time

Analytic Epidemiology

Cohort Studies

Prospective Cohort Studies

Case-Control Studies

Cross-Sectional Studies

Ecological Studies

Experimental Studies

Clinical Trials

Community Trials

Causality

Statistical Associations

Bias

Assessing for Causality

Applications of Epidemiology in Nursing

agent, 155

analytic epidemiology, 148

attack rate, 153

bias, 166

case-control study, 164

case fatality rate (CFR), 154

causal inference, 167

cohort study, 163

confounding, 166

cross-sectional study, 165

descriptive epidemiology, 148

determinants, 148

distribution, 148

ecological fallacy, 165

ecological model, 156

environment, 155

epidemic, 152

epidemiology, 148

host, 155

incidence proportion, 152

incidence rate, 152

levels of prevention, 156

natural history of disease, 156

negative predictive value, 159

point epidemic, 161

positive predictive value, 159

prevalence proportion, 152

K E Y T E R M S

Continued

148 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

The term epidemiology comes from the Greek terms logos

(“study”), demos (“people”), and epi (“upon”). Literally this

would be “the study of what is upon the people.” Epidemiology

is the study of the distribution and determinants of disease in

populations. For example, you would use epidemiology to see if

a disease is more common among men or women or if the dis-

ease is seen more in older versus younger people. The term

originally referred to the spread of infectious epidemics such as

cholera or tuberculosis (TB). Now the term is more inclusive

and involves infectious diseases and chronic diseases, such as

cancer and cardiovascular disease, as well as mental health and

other health-related events, such as intentional injuries (acci-

dents), violence, occupational and environmental exposures

and their effects, and positive health states. The public health

science of epidemiology has made major contributions to

(1) the understanding of factors that contribute to health and

disease, (2) the development of health promotion and disease-

prevention measures, (3) the detection and characterization of

emerging infectious agents, (4) the evaluation of health services

and policies, and (5) the practice of nursing in public health.

DEFINITIONS

Epidemiology investigates the distribution or the patterns of

health events in populations and the determinants or the fac-

tors that inluence those patterns. When using descriptive epi-

demiology, health outcomes are considered in terms of what,

who, where, and when. That is: What is the outcome? Who is

affected? Where are they? When do events occur? Descriptive

epidemiology discusses a disease in terms of person, place, and

time. The how and why, or determinants of health events, are

those factors, exposures, characteristics, behaviors, and contexts

that determine (or inluence) the patterns: How does it occur?

Why are some people affected more than others? Determinants

may be individual, relational or social, communal, or environ-

mental. This focus on investigation of causes and associations is

called analytic epidemiology.

Epidemiology, like both the research process and nursing

process, consists of a set of steps. The irst step is to answer the

“what” question by deining the outcome. The health outcome

can be a disease, or it can refer to injuries, accidents, or even

wellness (Koepsell and Weiss, 2003). The aim in epidemiology

is to describe the distribution (i.e., determine how, where, and

when the disease occurs) and to look for factors that explain the

pattern of the disease or the risk for occurrence (i.e., answer the

questions of why and how the disease occurs).

Like nursing, epidemiology builds on and draws from

other disciplines and methods, including clinical medicine and

laboratory sciences, social sciences, quantitative methods (espe-

cially biostatistics), and public health policy and goals. Epidemi-

ology focuses on populations, whereas clinical medicine focuses

on the diagnosis and treatment of disease in individuals. Epide-

miology studies populations to determine the causes of health

and disease in communities and to investigate and evaluate in-

terventions that will prevent disease and maintain health. Epide-

miological methods are used extensively to determine to what

extent the goals of Healthy People 2020 (US Department of

Health and Human Services, 2010) have been met and to moni-

tor the progress of those objectives not fully met at present.

Epidemiology is true detective work. For example, consider

a man who visited a country other than where he lived. Within

3 days, he was experiencing nausea and diarrhea. The epide-

miological process could help determine what action should be

taken. Speciically, what did he eat or drink? Did others eat or

drink the same things? Are other people with him experiencing

the same symptoms? After a thorough review of the “what, who,

where, and when,” he realizes that the only thing he did differ-

ently from others with him was use water from the bathroom

faucet to brush his teeth. Others in his group had used bottled

water. Although he knew that people often react negatively to

water that is different from their own, he was so accustomed to

using tap water to brush his teeth that he did so in this new

location without thinking about the effects it might have for

him. Similarly, three women shared a meal, and all ate every-

thing, except for one person who did not eat any green peppers.

Thirty minutes after eating, the two women who ate the green

peppers had painful gastrointestinal symptoms. The only thing

different in what they had to eat and drink that day was the

peppers. One can conclude that the peppers may not have been

washed carefully or had some other way of having bacteria

attached to them.

primary prevention, 156

proportionate mortality ratio

(PMR), 155

reliability, 158

risk, 151

screening, 157

secondary prevention, 157

secular trends, 161

sensitivity, 158

speciicity, 158

surveillance, 159

tertiary prevention, 157

validity, 158

web of causality, 156

K E Y T E R M S—cont’d

• AH-2: Increase the percentage of adolescents who participate in extracur-

ricular and out-of-school activities.

• AOCBC-4: Reduce the proportion of adults with doctor-diagnosed arthritis

who ind it “very dificult” to perform speciic joint-related activities.

• D-16: Increase prevention behaviors in persons at high risk for diabetes

with prediabetes.

• HAI-2: Reduce invasive methicillin-resistant Staphylococcus aureus

(MRSA) infections.

From US Department of Health and Human Services: Healthy People

2020, Washington, DC, 2010, US Government Printing Ofice.

HEALTHY PEOPLE 2020

Examples of Epidemiologic Objectives in Healthy

People 2020

149CHAPTER 9 Epidemiological Applications

HISTORY

Hippocrates, in the 4th century bce, was one of the irst people to

use the ideas that are now part of epidemiology (Merrill and

Timmreck, 2006). He examined health and disease in a commu-

nity by looking at geography, climate, the seasons of the year, the

food and water consumed, and the habits and behaviors of the

people. His approach, like descriptive epidemiology, looked at how

health is inluenced by personal characteristics, place, and time.

In the 18th and 19th centuries, comparison groups began to

be used to measure change or the effects of some action or treat-

ment on an experimental group. Also at this time, quantitative

methods (i.e., numeric measurements or counts) were begin-

ning to be used. One of the most famous studies using a com-

parison group is the mid-19th-century investigation of cholera

by John Snow, whom some call the “father of epidemiology”

(Merrill and Timmreck, 2006). By mapping cases that clustered

around one public water pump during a London cholera out-

break, Snow was able to show how the water supply and cholera

were associated. He observed that cholera rates were higher

among households supplied by water companies whose water

came from downstream than among households whose water

came from farther upstream, where it was subject to less con-

tamination. Snow conducted a “natural experiment,” as seen in

Table 9.1, and documented that foul water was the vehicle for

transmission of the agent that caused cholera (Rothman, 2012).

In nursing, Florence Nightingale contributed to the develop-

ment of epidemiology in her work with British soldiers during

the Crimean War (1854 to 1856). At this time, sick soldiers were

cared for in cramped quarters that had poor sanitation, were

overrun with lice and rats, and had insuficient food and medi-

cal supplies. She looked at the relationship between the condi-

tions of the environment and the recovery of the soldiers. Using

simple epidemiological measures of rates of illness per 1000

soldiers, she was able to show that improving environmental

conditions and adding nursing care decreased the mortality

rates of the soldiers (Cohen, 1984; Palmer, 1983). These same

principles can be applied today in the many countries that ex-

perience war leading to poor food, water, and sanitary condi-

tions. That is, if the environment could be improved and better

care provided, the rate of illnesses and death would be reduced.

During the 20th century, several changes in society inluenced

the further development of epidemiology. Some of these were the

Great Depression of the 1920s in the United States; World War II;

a rising standard of living for many but poverty for others; im-

proved nutrition; better sanitation; the development of antibiot-

ics, vaccines, and cancer chemotherapies; decreased birth rates in

some countries; and decreases in infant and child mortality in

many nations. People began to live longer, and the rates of several

chronic diseases such as coronary heart disease (CHD), stroke,

cancer, and senile dementia increased. In 1900 the leading causes

of death were (1) pneumonia and inluenza, followed by (2) tu-

berculosis and (3) gastritis, enteritis, and colitis; then came

(4) heart diseases, (5) symptoms of senility, (6) vascular lesions

affecting the central nervous system (CNS), (7) chronic nephritis

and renal sclerosis, (8) unintentional injuries, (9) malignant neo-

plasms, and (10) diphtheria. That contrasts with the changes in

patterns that were seen in the 1950s and continue today, with the

following leading causes of death in 2013:

1. Diseases of the heart (heart disease)

2. Malignant neoplasms (cancer)

3. Chronic lower respiratory diseases

4. Accidents (unintentional injuries)

5. Cerebrovascular disease (stroke)

6. Alzheimer’s disease

7. Diabetes mellitus

8. Inluenza and pneumonia

9. Nephritis, nephrotic syndrome, and nephrosis (kidney disease)

10. Intentional self-harm (suicide)

These were followed by septicemia, chronic liver disease and

cirrhosis, essential hypertension and hypertensive renal disease,

Parkinson’s disease, and pneumonitis due to solids and liquids

(Xu et al, 2016).

During the 20th century a shift occurred from looking for

single agents, such as the infectious agent that causes cholera, to

determining the multifactorial etiology or the many factors or

combinations of factors that contribute to disease. An example

of multifactorial etiology can be found in the complex number

and type of factors that cause cardiovascular disease. People

began to realize that not all of the diseases of older people were

the result of the degenerative processes of aging. Rather, it be-

came clear that many behavioral and environmental factors

supported or encouraged the development of diseases. This

information led to the belief that some diseases could be pre-

vented and other diseases could at least be delayed.

In addition, the development of genetic and molecular tech-

niques increased the ability of the epidemiologist to classify persons

in terms of exposures or inherent susceptibility to disease. Examples

included the identiication of genetic traits that indicated an in-

creased risk for breast cancer and markers that identiied exposures

to environmental toxins such as lead or pesticides. These develop-

ments are of particular interest to nurses who work with people in

their living and work environments and understand the interaction

of the environment(s) on health and well-being. Furthermore,

nurses in the community can assess a broad range of health out-

comes, as well as factors that contribute to wellness and illness.

Company Number of Houses Deaths from Cholera Deaths per 10,000 Households

Southwark and Vauxhall 40,046 1263 315

Lambeth 26,107 98 37

TABLE 9.1 Household Cholera Death Rates by Source of Water Supply in John Snow’s 1853 Investigation

From Snow J: On the mode of communication of cholera. In Snow on cholera, New York, 1855, The Commonwealth Fund.

150 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

Unfortunately, in recent years new infectious diseases (e.g.,

Ebola, the Zika virus, Lyme disease, methicillin-resistant Staph-

ylococcus aureus [MRSA], the H1N1 and H3N2 viruses) and

new forms of old diseases (e.g., drug-resistant strains of tuber-

culosis [TB], new forms of Escherichia coli) have emphasized

the dangers that can occur with these diseases. Also, potential

threats from terrorist use of infectious agents (e.g., anthrax,

smallpox) have once again placed the epidemiology of infec-

tious diseases in the spotlight. Epidemiological methods also

have been applied to a broader spectrum of health-related out-

comes, including accidents, injuries and violence, occupational

and environmental exposures, psychiatric and sociological phe-

nomena, health-related behaviors, and health services research.

HOW NURSES USE EPIDEMIOLOGY

Nurses play a key role in the community’s interdisciplinary

team looking at health, disease causation, and how to both pre-

vent and treat illness. Nurses use epidemiology in the commu-

nity to examine factors that affect the individual, family, and

population group because it is more dificult to control these

factors in the community than in the hospital. Speciically, it is

dificult to control the environment, including water and food

supplies; air quality conditions, including pollutants; disposal

of garbage and trash; insects and animals that carry infectious

diseases; quality of paint used to ensure it contains no lead; or

what comes in the mail. Therefore community residents are

often exposed to many factors affecting their health.

GENETICS IN PRACTICE

A 40-year-old woman returns from a cancer center after learning that she has

an ATM gene mutation and that this may cause her to have a higher risk of

developing certain types of cancers. There is a likely increased risk for breast,

ovarian, and pancreatic cancer. One of her options is a prophylactic mastec-

tomy, which has been shown to signiicantly reduce the risk of breast cancer.

That will be a dificult decision for her to make. However, the other dificult

decision will be whether she will inform members of her family of this informa-

tion because they could also be affected. .Consider the following questions:

1. Would you do nothing until she decides whether she will have the mastec-

tomy or not and learns more about the ATM gene?

2. Would you suggest that she think carefully about whether she should tell

her siblings and other family members who may also be at increased risk?

3. If she decides to tell her family, should she encourage them to have genetic

testing?

4. Would you recommend that she meet with a genetic counselor before she

tells her family members?

5. How can you be assured that she is aware of the Genetic Information Non-

discrimination Act (GINA), which prohibits health insurers and most employ-

ers from discriminating against individuals based on genetic information

(including the results of genetic tests and family history information)?

6. You might encourage her to visit http://www.ginahelp.org; what other steps

would you take to advise and counsel her effectively?

Mary Miles is the nurse epidemiologist for the Warren County Health Depart-

ment. A local church contacted Ms. Miles when several church members became

sick after the annual church picnic. Of the 200 people who attended the picnic,

100 were ill with diarrhea, nausea, or vomiting. Ten people required emergency

CASE STUDY

Church Picnic

Nurses work in an interdisciplinary team to solve epidemio-

Nurses are involved in the surveillance and monitoring of

disease trends. In settings such as homes, schools, workplaces,

clinics, and health care organizations, nurses can identify pat-

terns of disease in a group. For example, if several children in a

school become sick with abdominal problems within a short

period (e.g., a 24-hour period), the nurse would try to deter-

mine what these children had in common. For instance, did

they eat the same food, drink from the same source of water, or

swim in the same pool? Likewise, if workers in a plant displayed

a similar pattern of symptoms, the nurse would look for factors

in the workplace to locate the cause. The reason for looking at

the workplace irst is that it is the setting the individuals have in

common.

Care of clients, families, and population groups in the commu-

nity uses the following steps of the nursing process: (1) assessment,

(2) diagnosis, (3) planning, (4) implementation, and (5) evalua-

tion. When using the nursing process, epidemiology provides

baseline information for assessing needs, identifying problems,

designing appropriate strategies to evaluate the problems, setting

priorities to develop a plan of care, and evaluating how effective the

care was. The information learned from the Human Genome Proj-

ect completed in 2003 will continue to be the basis of new discover-

ies about the consequences of genetic variations and the outcomes

of the interaction between genes and the environment. Nurses,

in their focus on health, can use the information that is now avail-

able and will increasingly become available as a result of further

research. The “Essential Nursing Competencies and Curricula

Guidelines for Genetics” will help nurses care for individuals,

families, communities, and populations by including genetic and

genomic information in their practice. For example, this informa-

tion could assist a nurse to recognize whether a newborn is at

risk for morbidity or mortality resulting from errors in genetic

metabolism and when there is a history of a genetic mutation in

the family (American Nurses Association, 2006).

The sections that follow discuss the “tools of epidemiology”

that are needed by nurses who work in community settings.

http://www.ginahelp.org

151CHAPTER 9 Epidemiological Applications

BASIC CONCEPTS IN EPIDEMIOLOGY

MEASURES OF MORBIDITY AND MORTALITY

Rates, Proportions, and Risk Epidemiology looks at the distribution of health states and

events. Because people differ in their probability or risk for

disease, the primary concern is how they differ. Today epide-

miologists use tools such as geographic information systems

to study health-related events to identify disease distribution

patterns, similar to how John Snow mapped cases of cholera

in one area of London. However, mapping of cases is limited

in what it can reveal. A larger number of cases may simply be

the result of a larger population with more potential cases or

the result of a longer period of observation. Any description

of disease patterns should take into account the size of the

population at risk for the disease. That is, we should look not

only at the numerator (the number of cases) but also at the

denominator (the number of people in the population at

risk) and at the amount of time each was observed. For ex-

ample, 50 cases of inluenza might be seen as a serious epi-

demic in a population of 250 but would be a low rate in a

population of 250,000. Using rates and proportions instead

of simple counts of cases takes the size of the population at

risk into account.

Epidemiological studies rely on rates and proportions. A

proportion is a type of ratio in which the denominator in-

cludes the numerator. For example, if there were 2,426,264

deaths recorded in the United States, of which 631,636 were

reported to have been caused by heart disease, the proportion

of deaths attributed to heart disease at a given time was

631,636/2,426,264 5 0.260, or 26.0. Because the numerator

must be included in the denominator, proportions can range

from 0 to 1. Proportions are often multiplied by 100 and ex-

pressed as a percent, literally meaning “per 100.” In public

health statistics, however, if the proportion is very small, we

use a larger multiplier to avoid small fractions, so the propor-

tion may be expressed as a number per 1000 or per 100,000.

A rate is a measure of the frequency of a health event in

different populations at certain periods (Porta, 2008). A rate

is a ratio, but it is not a proportion because the denominator

is a function of both the population size and the dimension

of time, whereas the numerator is the number of events. Fur-

thermore, depending on the units of time and the frequency

of events, a rate may exceed 1. As its name suggests, a rate is

a measure of how quickly something is happening: how rap-

idly a disease is developing in a population or how rapidly

people are dying. Rates deal with change: moving from one

state of being to another, from well to ill, from alive to dead,

or from ill to cured. Because they deal with events (i.e., mov-

ing from one state of being to another), time is involved.

We must follow a population over time to observe the

changes in state, and we typically exclude from the population

being followed those persons who have already experienced

the event.

Risk refers to the probability that an event will occur within

a speciied period. A population at risk is the population of

medical treatment or hospitalization. Incubation periods ranged from 1.5 to

30 hours, with a mean of 6 hours and a median of 3.5 hours. Duration of illness

ranged from 1 to 80 hours, with a mean of 30 hours and a median of 15 hours.

The annual church picnic is a potluck lunch buffet. The menu included

macaroni casserole (brought by the Joneses), turkey with gravy and stufing

(brought by the Smiths), potato salad (brought by the Changs), green bean

casserole (brought by the Champs), chili (brought by the Turners), homemade

bread (brought by Granny Ivy), chocolate cake (brought by the Bushes),

and cookies (brought by the Beckmans). Ms. Miles interviewed the church

members who were ill and found that three food items were signiicantly

associated with illness: turkey, gravy, and stufing.

Ms. Miles interviewed the Smiths, who brought the turkey, gravy, and stufing

to the picnic. Review of food-handling procedures indicated that the turkey had

cooled for 4 hours at room temperature after cooking—a time and temperature

suficient for bacterial growth and toxin production. Furthermore, the same

utensils were used for both the turkey and other foods before and after cooking.

Ms. Miles talked with the Smiths about proper food-handling practices,

emphasizing hand washing, proper cooling and preserving methods, and better

equipment and utensil sanitation. Ms. Miles also offered a similar class to the

church congregation.

1. For the nurse to evaluate why people at the picnic became sick, what ques-

tions should she ask the people who brought the food?

A. Cooking time and how they cooked the food

B. Hygiene of their equipment

C. Sources of the water used in cooking the food

D. All of the above

2. Identify the agent, host, and environment in this.

3. Is Ms. Miles performing descriptive epidemiology or analytic epidemiology?

4. Which level of prevention is Ms. Miles exemplifying?

A. Primary prevention

B. Secondary prevention

C. Tertiary prevention

D. Combination of the above

E. None of the above

CASE STUDY—cont’d

Church Picnic

Answers can be found on the Evolve website.

APPLYING CONTENT TO PRACTICE

It is important that nurses understand the relationship between population

health concepts and clinical practice. Within the ield of epidemiology, the

deinition of population is not necessarily conined to large groups of people,

such as a population of the United States. Population health concepts also

apply to other types of groups, such as the collective group of clients at one

clinical practice site. In this case, the clinical epidemiologic application of

population health concepts is evident in questions such as: What are the fac-

tors that contribute to the health and illness of issues among clients that I see

in my clinic? Why do some of my clients fare better than others with the same

disease conditions? Are there alternative clinical practices that might help my

clients? All of these clinical questions incorporate epidemiologic concepts of

describing the burden of disease in a population, identifying and understand-

ing determinants of health, and examining possible root causes of health out-

comes. Two important documents highlight ways in which epidemiologic

knowledge and skills are essential in nursing practice. The Council on Linkages

between Academia and Public Health Practice (2010) outlined essential analytic/

assessment and public health science skills, and the Quad Council of Public

Health Nursing Competencies (Swider et al, 2013) provided details and examples

of ways to implement these skill sets in nursing practice.

152 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

persons for whom there is some inite probability (even if

small) of that event occurring. For example, although the risk

for breast cancer in men is small, a few men do develop breast

cancer and therefore are part of the population at risk. There

are some outcomes for which certain people would never be at

risk (e.g., men cannot be at risk for ovarian cancer, nor can

women be at risk of testicular cancer). A high-risk population,

on the other hand, would include those persons who, because

of exposure, lifestyle, family history, or other factors, are at

greater risk for disease than the population at large. For ex-

ample, although everyone in the population is at risk for hu-

man immunodeiciency virus (HIV) infection and acquired

immunodeiciency syndrome (AIDS), persons who have mul-

tiple sexual partners without adequate protection or who

use intravenous drugs are in the high-risk population for

HIV infection. However, others may unknowingly be at high

risk, such as women who think they are in monogamous rela-

tionships and do not know that their partners have sexual rela-

tions with other women or men. Genetic testing is becoming

more common, but most tests for disease indicate only suscep-

tibility to disease, not certainty. Similarly, screening tests are

never perfect, so there is always some probability of misclassi-

fying a person.

Epidemiologists and other health professionals examine

measures of morbidity, especially incidence proportions, inci-

dence rates, and prevalence proportions, to learn about the risk

for disease, the rate of disease development, and the levels of

existing disease in a population, respectively.

Measures of Incidence Measures of incidence relect the number of new cases or

events in a population at risk during a speciied time. An inci-

dence rate quantiies the rate of development of new cases in

a population at risk, whereas an incidence proportion indi-

cates the proportion of the population at risk that experiences

the event over some period of time (Rothman, 2012). The

population at risk is considered to be persons without the

event or outcome of interest but who are at risk for experienc-

ing it. People who already have the disease or outcome of in-

terest are excluded from the population at risk for this calcula-

tion because they already have the condition and are no longer

at risk for developing it. The incidence proportion is also re-

ferred to as the cumulative incidence rate because it relects the

cumulative effect of the incidence rate over the time period.

The risk for disease is a function of both the rate of new dis-

ease development and the length of time the population is at

risk. The interpretation can be for an individual (i.e., the

probability that the person will become ill) or for a popula-

tion (i.e., the proportion of a population expected to become

ill over that period). In epidemiology, we often calculate pro-

portions on the basis of population frequencies. These fre-

quencies are then translated into personal risk statements for

people representative of the population on which the esti-

mates are based.

For example, suppose a health department and hospital

partner want to develop an intensive, broad-based screening

program in an area with overcrowded housing, limited access to

services, and underuse of preventive health practices. They

might include physical examinations; tuberculin skin tests with

follow-up chest radiography where indicated; cardiovascular,

glaucoma, and diabetes screening; and mammography for

women and prostate screening for men older than 45 years of

age. Of the 8000 women screened, 35 were previously diag-

nosed with breast cancer; by screening and follow-up, 20 with

no history of breast cancer were found to have cancer of the

breast. We could follow the 7945 women in whom no breast

cancer was detected and note the number of new cases of breast

cancer detected over the following 5 years. Assuming no losses

to follow-up (i.e., moved away or died from other causes), if 44

women were diagnosed over the 5-year period, the 5-year inci-

dence proportion of breast cancer in this population would be

as follows:

7945 0.005538, or 553.8 per 100,0005

Note the multiplication by 100,000, so that the number of

cases is expressed as per 100,000 women. A cumulative inci-

dence rate estimates the risk for developing the disease in that

population during that time. Also, as a proportion, each event

in the numerator must be represented in the denominator, and

only those persons at risk for the event counted in the numera-

tor may be included in the denominator.

A ratio can be used as an approximation of a risk. For ex-

ample, the infant mortality “rate” is the number of infant deaths

(infants are deined as being younger than 1 year of age) in a

given year divided by the number of live births in that same

year. It approximates the risk for death in the irst year of life for

live-born infants in a speciic year. Some of the infants who die

that year were born in the previous year, and some of the in-

fants born that year may die in the following year before their

irst birthday. However, because about two-thirds of infant

deaths occur within the irst 28 days of life, the number of in-

fants in the numerator (i.e., deaths in a given year) but not in

the denominator (i.e., live births in that same year) will be

small. It can be assumed that current year’s deaths from the

previous year’s cohort approximately equal the deaths from the

current year’s cohort occurring in the following year. Although

technically a ratio, this is an approximation to the true propor-

tion and, therefore, an estimate of the risk.

An epidemic occurs when the rate of disease, injury, or other

condition exceeds the usual (i.e., endemic) level of that condi-

tion. No speciic threshold of incidence indicates that an epi-

demic exists. Because smallpox has been eradicated, any occur-

rence of smallpox might be considered an epidemic by this

deinition. In contrast, given the high rates of ischemic heart

disease in the United States, an increase of many cases would be

needed before an epidemic was noted, although some might

argue that the current high rates in contrast to earlier periods

already indicate an epidemic.

Prevalence Proportion The prevalence proportion is a measure of existing disease in a

population at a particular time (i.e., the number of existing

153CHAPTER 9 Epidemiological Applications

cases divided by the current population). It is also possible to

calculate the prevalence of a speciic risk factor or exposure. In

the breast cancer example given earlier, the screening program

discovered 35 of the 8000 women screened had previously been

diagnosed with breast cancer and 20 women with no history of

breast cancer were diagnosed as a result of the screening. The

prevalence proportion of current and past breast cancer events

in this population of women would be as follows:

8000 0.006875, or 687.5 per 100,0005

A prevalence proportion is not an estimate of the risk for

developing disease because it is a function of both the rate at

which new cases of the disease develop and how long those

cases remain in the population. In this example, the prevalence

of breast cancer in this population of women is a function of

how many new cases develop and how long women live after

the diagnosis of breast cancer. A fairly constant prevalence

might be seen, for example, if improved survival after diagnosis

were offset by an increasing incidence rate. The duration of a

disease is affected by case fatality and cure. (For simplicity, in

this example, women with a history of the disease are counted

in the prevalence proportion even though they may have been

cured.) A disease with a short duration (e.g., an intestinal virus)

may not have a high prevalence proportion even if the rate of

new cases is high because cases do not accumulate (see the dis-

cussion of point epidemic). A disease with a long course will

have a higher prevalence proportion than a rapidly fatal disease

that has the same rate of new cases.

Incidence and Prevalence Compared The prevalence proportion measures existing cases of disease.

The prevalence odds (P[1 2 P]) are roughly proportional to

the incidence rate multiplied by the average duration of dis-

ease. The prevalence proportion is therefore affected by fac-

tors that inluence risk (i.e., incidence) and factors that inlu-

ence survival or recovery (i.e., duration). For that reason,

prevalence measures are less useful when looking for factors

related to disease etiology. Because prevalence proportions

relect duration in addition to the risk for getting the disease,

it is dificult to sort out what factors are related to risk and

what factors are related to survival or recovery. In mathemat-

ical notation,

p P I/ ( ) ,

( . )

or, when , the

� �

�

� D

P is small 0 1 P � I D� ,

where P 5 prevalence, I 5 incidence rate, and D 5 average

duration.

For example, the 5-year survival rate for breast cancer is ap-

proximately 85%, but the 5-year survival rate for lung cancer in

women is only about 15%. Even if the incidence rates of breast

and lung cancer were the same in women (and they are not), the

prevalence proportions would differ because, on average,

women live longer with breast cancer (i.e., it has a longer dura-

tion). Incidence rates and incidence proportions, on the other

Attack Rate One inal measure of morbidity, often used in infectious disease

investigations, is the attack rate, or the proportion of persons

who are exposed to an agent and develop the disease. Attack

rates are often speciic to an exposure; food-speciic attack rates,

for example, are the proportion of persons becoming ill after

eating a speciic food item.

Mortality Rates Several key mortality rates are shown in Table 9.2. Many com-

monly used mortality rates are not true rates but are propor-

tions, because the population changes throughout the year.

Although measures of mortality relect serious health problems

and changing patterns of disease, they have limited usefulness.

They provide information only about fatal diseases and do not

provide direct information about either the level of existing

disease in the population or the risk for getting a particular

disease. Also, a person may have one disease (e.g., prostate

cancer) yet die of a different cause (e.g., stroke).

Note than many commonly used mortality rates listed in

Table 9.2 are in fact proportions, not true rates (Rothman, 2012;

Gordis, 2013). Because the population changes during the

course of a year, we typically take an estimate of the population

at mid-year as the denominator for annual rates because the

mid-year populations approximate the amount of person-time

contributed by the population during a given year.

HOW TO Determine If a Health Problem Exists in the Community Planning for resources and personnel often requires quantifying the level of

a problem in a community. For example, to know how different districts

compare in the rates of infants with very low birth weight, you would calcu-

late the prevalence of births of infants with very low birth weight in each

district:

1. Determine the number of live births in each district from birth certiicate

data obtained from the vital records division of the health department.

2. Use the birth weight information from the birth certiicate data to determine

the number of infants born weighing less than 1500 g in each district.

3. Calculate the prevalence of births of infants with very low birth weight by

district as the number of infants weighing less than 1500 g at birth divided

by the total number of live births.

4. If the number of births of infants with very low birth weight in each district

is small, use several recent years of data to obtain a more stable estimate.

hand, are the measure of choice to study etiology because

incidence is affected only by factors related to the risk for devel-

oping disease and not to survival or cure. Prevalence is useful in

planning health care services because it is an indication of the

level of disease existing in the population and therefore of the

size of the population in need of services. In the previous ex-

ample about screening, the health department would want to

know both the existing level of TB in the area (the prevalence),

to plan services and direct prevention and control measures,

and the rate at which new cases are developing (the incidence),

to study risk factors and evaluate the effectiveness of prevention

and control programs (see the “How To” box).

154 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

The crude annual mortality rate is an estimate of the risk for

death for a person in a given population for that year. These

rates are multiplied by a scaling factor, usually 100,000, to avoid

small fractions. The result is then expressed as the number of

deaths per 100,000 persons. Although a crude mortality rate is

calculated easily and represents the actual death rate for the

total population, it has certain limitations. It does not reveal

speciic causes of death, which change in relative importance

over time. Also, the mortality rate is affected by the population’s

age distribution, because older people are at much greater risk

for death than younger people.

Mortality rates are also calculated for speciic groups (e.g.,

age-speciic, gender-speciic, race-speciic rates). In these in-

stances, the number of deaths occurring in the speciied group is

divided by the population at risk, now restricted to the number

of persons in that group. This rate is then viewed as the risk for

death for persons in the speciied group during the period of

observation.

The cause-speciic mortality rate is an estimate of the risk for

death from some speciic disease in a population. It is the num-

ber of deaths from a speciic cause divided by the total popula-

tion at risk, usually multiplied by 100,000. Two related mea-

sures should be distinguished from the cause-speciic mortality

rate. The case fatality rate (CFR) is the proportion of persons

diagnosed with a particular disorder (i.e., cases) who die within

a speciied period. It is considered an estimate of the risk for

death within that period for a person newly diagnosed with the

disease (e.g., the proportion of persons with a disease who die

during the natural history of the disease). Because the CFR is

the proportion of diagnosed persons who die within the period,

Rate/Ratio Deinition and Example*

Crude mortality (death) rate Number of deaths from any cause during time interval

Estimated mid interval populat- iion (mid - year population)

Example: In 2010 there were 2,465,932 deaths in a total population of 275,264,999, or 873.1 per 100,000.

Age-speciic rate Number of deaths among persons of agiven age group per mid ear population o-y ff that age group

Estimated population iin that age group at mid interval rate

� per 100, 000

17, 744

18, 484, 615 96 per 100, 000 persons� ages 20 to 24 years

Cause-speciic rate Number of deaths from a specific cause per mid year population

Estimated mid i

- nnterval populaiton rate per 100, 000�

97, 900 accidental deaths

275, 264, 999 mid - yyear population 35.6 per 100, 000�

Case fatality rate Number of deaths from a specific disease inagiven period

Number of persons diaagnosed

Example: If 87 of every 100 persons diagnosed with lung cancer die within 5 years, the 5-year case fatality rate is 87%; the

5-year survival rate is 13%.

Proportionate mortality ratio Number of deaths from a speciic disease per total number of deaths in the same period

Example: If there were 710,760 deaths from diseases of the heart and 2,403,351 deaths from all causes:

710, 760

2, 403, 351 0.296 or 29.6%of all� ddeaths were due to heart disease

Infant mortality ratio Number of deaths of infants under 1 year of age in a year per number of live births in the same year

Example: If there were 28,035 infant deaths and 4,058,814 live births:

28, 035

4, 058, 814 0.0069 or 6.9 per 10000 live births

Neonatal mortality rate Number of deaths of infants under 28 days of age in a year per number of live births in the same year

Example: If there were 18,776 neonatal deaths and 4,058,814 live births:

18, 776

4, 058, 814 4.63 per 1000 live bir� tths

Postneonatal mortality rate Number of deaths of infants from 28 days to 1 year of age in a year per number of live births in the same year

Example: If there were 9259 postneonatal deaths and 4,058,814 live births:

9296

4, 058, 814 2.28 per 1000 live birth� ss

TABLE 9.2 Common Mortality Rates

See Murphy SL, Xu JQ, Kochanek KD: Deaths: preliminary data for 2010, Natl Vital Stat Rep 60; 2012 for actual 2010 data. Time interval used for

the denominator is usually mid-year data.

155CHAPTER 9 Epidemiological Applications

1 minus the CFR yields the survival rate. For example, if the

5-year CFR for lung cancer is 86%, then the 5-year survival rate

is only 14% (Remington et al, 2010).

The second measure to be distinguished from the cause-

speciic mortality rate is the proportionate mortality ratio

(PMR), the proportion of all deaths resulting from a speciic

cause. Some sources, especially those used in occupational

health, say it is the proportion of all deaths resulting from a

speciic cause divided by the same proportion in a standard

population. The denominator is not the population at risk for

death, but the total number of deaths in the population; there-

fore the PMR is not a rate, nor does it estimate the risk for death.

The magnitude of the PMR is a function of both the number of

deaths from the cause of interest and the number of deaths

from other causes. If deaths from certain causes decline over

time, deaths from other causes that remain fairly constant may

have increasing PMRs. For example, the leading cause of death

for individuals between the ages of 1 and 44 years was uninten-

tional accidents, with the relative burden of mortality being

greater at young ages, accounting for 31.7% of all deaths in the

age group of 19 years and under; 39.5% of deaths for persons

10 to 24 years of age, and 27.4% for those in the age group of

25 to 44 years (Heron, 2016). In contrast, for those between 45

and 64 years of age, cancer was the leading cause of death, ac-

counting for 30.9% of deaths. For the population over 65 years

of age, heart disease was the leading cause of death (21.4%).

Infant mortality is used around the world as an indicator of

overall health and availability of health care services. The most

common measure, the infant mortality rate, is the number of

deaths to infants in the irst year of life divided by the total

number of live births. Because the risk for death declines con-

siderably during the irst year of life, neonatal (i.e., newborn),

and postneonatal mortality rates are also of interest.

EPIDEMIOLOGIC TRIANGLE: AGENT, HOST, AND ENVIRONMENT

Epidemiologists understand that disease results from complex

relationships among causal agents, susceptible persons, and

environmental factors. These three elements—agent, host, and

environment—are called the epidemiologic triangle (Fig. 9.1A).

Changes in one of the elements of the triangle can inluence the

occurrence of disease by increasing or decreasing a person’s risk

for disease. Fig. 9.1B shows that agent and host, as well as their

interaction, are inluenced by the environment in which they

exist. They also may inluence the environment. Speciically,

these elements or variables are deined as follows:

• Agent: An animate or inanimate factor that must be present

or lacking for a disease or condition to develop

• Host: A living species (human or animal) capable of being

infected or affected by an agent

• Environment: All that is internal or external to a given host

or agent and that is inluenced and inluences the host and/

or agent

Examples of these three components are listed in Box 9.1.

Causal relationships (one thing or event causes another) are

often more complex than the epidemiological triangle conveys.

Environment

Agent Host

Environment

Host

Agent

Env ironment

E n v ir

o n m

e n

E n v iro

n m

e n

FIG. 9.1 (A and B) Two models of the agent-host-environment

interaction (the epidemiologic triangle).

BOX 9.1 Examples of Agent, Host, and Environmental Factors in the Epidemiologic Triangle

Agent

• Infectious agents (bacteria, viruses, fungi, parasites)

• Chemical agents (heavy metals, toxic chemicals, pesticides)

• Physical agents (radiation, heat, cold, machinery)

Host

• Genetic susceptibility

• Immutable characteristics (age, sex)

• Acquired characteristics (immunological status)

• Lifestyle factors (diet, exercise)

Environment

• Climate (temperature, rainfall)

• Plant and animal life (agents, reservoirs or habitats for agents)

• Human population distribution (crowding, social support)

• Socioeconomic factors (education, resources, access to care)

• Working conditions (levels of stress, noise, satisfaction)

156 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

The term web of causality recognizes the complex interrela-

tionships of many factors interacting, sometimes in subtle ways,

to increase (or decrease) the risk for disease. Also, associations

are sometimes mutual, with lines of causality going in both di-

rections. Recently, some researchers advocated for a new para-

digm that goes beyond the two-dimensional causal web and

considers multiple levels of factors that affect health and disease

(Macintyre and Ellaway, 2000). This is consistent with the eco-

logical model for population health supported by the 2002 re-

port of the Institute of Medicine (IOM) that expands epide-

miological studies both upward to broader contexts such as

neighborhood characteristics and social context and downward

to the genetic and molecular level. The ecological model treats

the multiple determinants of health as interrelated and acting

synergistically (or antagonistically), rather than as discrete fac-

tors. This model encompasses determinants at many levels: bio-

logical, mental, behavioral, social, and environmental factors,

including policy, culture, and economic environments, and in-

cludes a life span perspective. The IOM’s vision of “healthy

people in healthy communities” requires a model that recog-

nizes that healthy communities are more than a collection of

healthy individuals and that the characteristics of communities

affect the health of people who live in them (IOM, 2002).

LEVELS OF PREVENTIVE INTERVENTIONS

The goal of epidemiology is to identify and understand the

causal factors and mechanisms of disease, disability, and inju-

ries so that effective interventions can be implemented to pre-

vent the occurrence of these adverse processes before they begin

or before they progress. The natural history of disease is the

course of the disease process from onset to resolution (Porta

et al, 2008). The three levels of prevention—primary, secondary,

and tertiary—provide a framework often used in public health

practice. See the Levels of Prevention box later in the chapter.

Primary prevention refers to interventions that promote

health and prevent the occurrence of disease, injury, Or disabil-

ity. Primary prevention is aimed at individuals and groups who

are susceptible to disease but have no discernible pathological

process (i.e., they are in a state of pre-pathogenesis). An exam-

ple of primary prevention is when a nurse provides health edu-

cation and training for daycare workers about issues of health

and hygiene, such as proper hand hygiene, diapering, and food

preparation and storage. Immunizations are another example

of primary prevention, as are teaching about the importance of

wearing seat belts and about taking folic acid supplementation

at preconception to prevent neural tube defects, luoridation of

water supplies to prevent dental caries, and actions taken to

reduce human exposure to agents that may cause cancer.

Immunizations are an integral part of primary prevention.

served. Image #147673258).

EVIDENCE-BASED PRACTICE

Sexual health and well-being affect people of all cultures regardless of race,

social class, education, age, or country of origin. Also, sexually transmitted

infections (STIs) can affect people of all ages, even though the rates are high-

est among people under 25 years of age. Wiehe et al (2015) sought to estimate

the rates of STIs among criminal offenders in the irst year after arrest or re-

lease from incarceration. They conducted a retrospective study of risk for

having a positive STI (chlamydia, gonorrhea, or syphilis) or positive HIV test in

the irst year following arrest or incarceration in Marion County, Indiana. They

had 247,211 individuals with arrests or incarceration in jail, juvenile detention,

or prison in a 5-year period. What they found were that rates of STI and HIV in

the year after arrest or incarceration were higher among their sample than for

nonoffenders, but rates varied by demographic characteristics and type of de-

tention facility. Speciically, rates were highest for chlamydia and gonorrhea

and lower for syphilis and HIV. The rates were 1.5–2.8 times higher among

women than men and 2.7–6.9 times higher among blacks than whites. The

highest rates of chlamydia and gonorrhea were among persons between ages

15 and 19 years, and syphilis was highest among those ages 45–54 years. HIV

was highest among the 20- to 44-year-olds.

Nurse Use

It is important that public health nurses who work with individuals in the com-

munity who have been arrested or incarcerated work closely with the local jus-

tice system. These individuals need health education and follow-up in locales

that are convenient and economical for them. Follow-up can be via appointments

at community clinics or telemedicine using texts or e-mail messages to stay in

touch and encourage safe sex and immediate follow-up if signs of an STI appear.

Data from Wiehe SE, Rosenman MC, Aalsma MC, Scanlon ML,

Fortenberry JD: Epidemiology of sexually transmitted infections

among offenders following arrest or incarceration, American Journal of

Public Health 105(12):26-33, 2015.

CASE STUDY

Inmates at the Local Jail

An infection preventionist (IP) at a local hospital contacted the nurse epide-

miologist at the local health department to report that the hospital had re-

ceived three laboratory reports of Acinetobacter baumannii infection from

inmates at the local jail. The IP stated that the jail typically sends all of its

laboratory specimens to the hospital for processing. The IP stated that the

specimens were obtained from wounds and collected within a 2-month

period.

1. The nurse epidemiologist suspects an outbreak and launches an investigation

for which reason?

A. This is an unusual problem

157CHAPTER 9 Epidemiological Applications

Secondary prevention refers to interventions designed to

increase the probability that a person with a disease will have

that condition diagnosed early enough that treatment is likely

to result in a cure. Health screenings are at the core of second-

ary prevention. Early and periodic screenings are critical for

diseases, such as breast cancer, for which there are few speciic

primary prevention strategies. Screening programs are dis-

cussed in the section on screening that follows.

Interventions at the secondary level of prevention often take

place in community settings. For example, a nurse may teach an

asthmatic client to recognize and avoid exposure to asthma

triggers and assist the family to implement speciic protection

strategies such as replacing carpets, keeping air systems clean

and free of mold, staying inside when the pollution level is high,

and avoiding pets. A nurse also might ask a family about their

history of cancer, heart disease, diabetes, and mental illness as

part of a client’s health history and then follow up with educa-

tion about appropriate screening procedures. Other secondary

prevention interventions include mammography to detect

breast cancer, Papanicolaou (Pap) smears to detect cervical

cancer, colonoscopy for early detection of colon cancer, and

prenatal screening of pregnant women to screen for gestational

diabetes. In developing countries, oral rehydrating therapy

(ORT) is an excellent example of secondary prevention. If safe

water is available, ORT can be used to treat infant diarrheal

disease. To do so you would prepare a homemade ORT solution

of water, sugar, and salt to give to infants.

Tertiary prevention includes interventions aimed at limit-

ing disability and interventions that enhance rehabilitation

from disease, injury, or disability. Interventions for tertiary pre-

vention occur most often at secondary and tertiary levels of care

(e.g., specialized clinics, hospitals, rehabilitation centers) but

also may occur in community and primary care settings. Ex-

amples of tertiary prevention are medical treatment, physical

and occupational therapy, and rehabilitation. With the emer-

gence of new drug-resistant strains of TB, nurses now face the

challenge of designing and implementing programs to increase

long-term compliance and provide aftercare for clients in a va-

riety of community settings. An example of tertiary prevention

for persons diagnosed with active TB is directly observed ther-

apy (DOT) discussed in Chapter 27.

SCREENING

Screening, a key component of many secondary prevention in-

terventions, involves the testing of groups of individuals who are

at risk for a speciic condition but do not have symptoms. The

goal is to determine the likelihood that these individuals will

develop the disease. From a clinical perspective, the aim of

screening is early detection and treatment when these result in a

more favorable prognosis. From a public health perspective, the

objective is to sort out eficiently and effectively those who prob-

ably have the disease from those who probably do not, again to

detect early cases for treatment or begin public health prevention

and control programs. A screening test is not a diagnostic test.

Effective screening programs must include referrals for diagnos-

tic evaluation for those who have positive indings on screening,

to determine if they actually have the disease and need treatment.

Nurses must stay current about screening guidelines because

these are regularly reviewed and revised on the basis of epide-

miological research results. For example, the US Preventive

Services Task Force (USPSTF) recommends screening for high

blood pressure in adults 18 years and older (Siu, 2015). “The

USPSTF found good evidence that screening for and treatment

of high blood pressure in adults substantially reduces the inci-

dence of cardiovascular events” (Siu, 2015, p 779), and that

there are few harms associated with the screening. In terms

of risk assessment, the USPSTF reported that “Persons at in-

creased risk for high blood pressure are those who have high-

normal blood pressure (130–139/85–89 Hg), those who are

overweight or obese, and African Americans” (Siu, 2015, p. 779).

The net beneit of screening is substantial and outweighs the

cost. Adults over age 40 years and those at increased risk should

be screened annually, whereas adults from ages 18 to 39 years

should be screened every 3 to 5 years (Siu, 2015).

As community health advocates and educators, nurses plan

and implement screening and prevention programs for high-

risk populations, such as prostate-screening programs among

Case prepared by Mary Beth White-Comstock, MSN, RN, CIC.

CASE STUDY—cont’d

Inmates at the Local Jail

B. There is a potential risk to the public

C. There is a casual pathway

D. All the above

2. The nurse epidemiologist decided to visit the jail. Based on what she knows

about the transmission of A. baumannii, she should collect which of the fol-

lowing information?

A. Underlying infections and chronic diseases of inmates

B. Medical procedures performed in the jail

C. The number of air exchanges in the jail

D. All of the above

E. A and B only

3. The nurse epidemiologist discovers that all of the infected inmates have their

wound dressings changed on the same day of the week in the same treatment

room. She notices there is no sink or evidence of hand sanitizer in the treat-

ment room. She recommends all of the following strategies except:

A. Installing hand-hygiene stations in convenient locations in treatment

rooms

B. Cleaning and disinfecting examination tables after each inmate is seen

C. Educating staff on proper wound care and hand hygiene

D. Antibiotics for all inmates and staff

4. The nurse epidemiologist decides to educate all staff about the organism,

including how it is transmitted and prevention strategies. This level of

prevention is

A. Primary

B. Secondary

C. Tertiary

Answers can be found on the Evolve website.

158 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

African American men. Examples of recent screening recom-

mendations include the following:

• Abnormal blood glucose and Type 2 diabetes mellitus

screening was recommended in 2015 for adults between the

ages of 40 and 70 years.

• Breast cancer screening with mammography was recom-

mended in 2015 for women between 50 and 74 years of age

every 2 years.

• Autism spectrum disorder screening was not recommended

routinely due to the lack of scientiic evidence to support

this practice.

See http://www.uspreventiveservicestaskforce.org for details

on recommendations, the year the recommendation was pub-

lished, and analyses still in progress.

Occupational health nurses and nurses in community health

may work together to target populations on the basis of occu-

pational risk. Men with questionable prostate-speciic antigen

(PSA) levels need to be referred, especially if they have in-

creased risk factors for prostate cancer, such as African Ameri-

can heritage or a family history of prostate cancer. Successful

screening programs have several characteristics that depend

on the tests and on the population screened (Box 9.2). Criteria

for evaluating the usefulness of a screening test include cost-

effectiveness, ease and safety of administration, availability of

treatment, ethics of administration, or widespread implemen-

tation, sensitivity, speciicity, validity, and reliability (Gordis,

2013; McKeown and Learner, 2009).

RELIABILITY AND VALIDITY

Reliability It is important to pay attention to the precision, or reliability,

of the measure (i.e., its consistency or repeatability) and

the accuracy of the measure, its validity (i.e., whether it is

really measuring what we think it is and how exactly). Sup-

pose you want to screen for blood pressure in a community.

You will take blood pressure readings on a large number of

people, perhaps following up with repeated measures for

individuals with higher pressures. If the readings of the

sphygmomanometer used for the screening vary so that two

consecutive readings are not the same for the same person,

the sphygmomanometer lacks reliability. The instrument

would be unreliable even if the overall mean of repeated

measurements were close to the true overall mean for the

persons measured. The problem would be that the readings

would not be reliable for any individual, which is what a

screening program requires.

On the other hand, suppose the readings are reliably repro-

ducible, but, unknown to you, they tend to be about 10 mm Hg

too high. This instrument is producing precise readings, but

the uncorrected (or uncalibrated) instrument lacks accuracy.

In short, a measure can be consistent without producing valid

results.

The following three major sources of error can affect the

reliability of tests:

1. Variation inherent in the trait being measured (e.g., blood

pressure changes with time of day, activity, level of stress,

and other factors)

2. Observer variation, which can be divided into intraobserver

reliability (i.e., consistency by the same observer) and in-

terobserver reliability (i.e., level of consistency from one

observer to another)

3. Consistency in the instrument, which includes the level of

internal consistency of the instrument (e.g., whether all

items in a questionnaire measure the same thing) and the

stability (i.e., or test-retest reliability) of the instrument

over time

Validity: Sensitivity and Speciicity Validity in a screening test is typically measured by sensitivity

and speciicity. Sensitivity quantiies how accurately the test

identiies those with the condition or trait. Sensitivity repre-

sents the proportion of persons with the disease whom the test

correctly identiies as positive (true positives). High sensitivity

is needed when early treatment is important and when identi-

ication of every case is important.

Speciicity indicates how accurately the test identiies those

without the condition or trait (i.e., the proportion of persons

whom the test correctly identiies as negative for the disease

[true negatives]). High speciicity is needed when rescreening is

impractical and when it is important to reduce false-positive

results. The sensitivity and speciicity of a test are determined

by comparing the test results with results from a deinitive di-

agnostic procedure (sometimes called the gold standard). For

example, the Pap smear is used frequently to screen for cervical

dysplasia and carcinoma. The deinitive diagnosis of cervical

cancer requires a biopsy with histological conirmation of ma-

lignant cells.

The ideal for a screening test is 100% sensitivity and 100%

speciicity. That is, the test is positive for 100% of those who

actually have the disease, and it is negative for all those who

do not have the disease. In practice, sensitivity and speciicity

are often inversely related. That is, if the test results are such

that it is possible to choose some point beyond which a person

is considered positive (a “cutpoint”), as in a blood pressure

reading to screen for hypertension or a serum glucose reading

to screen for diabetes, then moving that critical point to im-

prove the sensitivity of the test will result in a decrease in

1. Valid (accurate): A high probability of correct classiication of persons

tested

2. Reliable (precise): Results are consistent from place to place, time to

time, and person to person

3. Capable of large group administration:

a. Fast in both the administration of the test and the obtaining of results

b. Inexpensive in both personnel required and the materials and proce-

dures used

4. Innocuous: Few if any side effects, and the test is minimally invasive

5. High yield: Able to detect enough new cases to warrant the effort and

expense (yield deined as the amount of previously unrecognized disease

that is diagnosed and treated as a result of screening)

BOX 9.2 Characteristics of A Successful Screening Program

http://www.uspreventiveservicestaskforce.org

159CHAPTER 9 Epidemiological Applications

speciicity, or an improvement in speciicity can be made only

at the expense of sensitivity.

A third measure associated with sensitivity and speciicity is

the predictive value of the test. The positive predictive value

(also called predictive value positive) is the proportion of per-

sons with a positive test who actually have the disease, inter-

preted as the probability that an individual with a positive test

has the disease. The negative predictive value (or predictive

value negative) is the proportion of persons with a negative test

who are actually disease-free.

Two or more tests can be combined, in series or in parallel,

to enhance sensitivity or speciicity. In series testing, the inal

result is considered positive only if all tests in the series were

positive, and it is considered negative if any test was negative.

For example, if a blood sample were screened for HIV, a positive

enzyme-linked immunosorbent assay (ELISA) might be fol-

lowed with a Western blot test, and the sample would be con-

sidered positive only if both tests were positive. Series testing

enhances speciicity, producing fewer false positives, but sensi-

tivity will be lower. In series testing, sequence is important; a

very sensitive test is often used irst to pick up all cases, includ-

ing false positives, and then a second, very speciic test is used

to eliminate the false positives. In parallel testing, the inal result

is considered positive if any test was positive and is considered

negative only if all tests were negative. To return to the example

of a blood sample being tested for HIV, a blood bank might

consider a sample positive if a positive result was found on ei-

ther the ELISA or the Western blot. Parallel testing enhances

sensitivity, leaving fewer false negatives, but speciicity will be

lower.

BASIC METHODS IN EPIDEMIOLOGY

SOURCES OF DATA

It is important to know early in any epidemiological study how

the data will be obtained (Gordis, 2013; Koepsell and Weiss,

2003). The following three major categories of data sources are

commonly used in epidemiological investigations:

1. Routinely collected data: census data, vital records (i.e., birth

and death certiicates), and surveillance data (i.e., system-

atic collection of data concerning disease occurrence) as

carried out by the Centers for Disease Control and Preven-

tion (CDC)

2. Data collected for other purposes but useful for epidemio-

logical research: medical, health department, and insurance

records

3. Original data collected for speciic epidemiological studies

Routinely Collected Data The US census is conducted every 10 years and provides popu-

lation data, including demographic distribution (i.e., age, race,

sex), geographic distribution, and additional information about

economic status, housing, and education. These data provide

denominators for various rates. The American Community

Survey is an ongoing survey conducted by the US Census

Bureau. Data from these surveys provide information about the

status of the population and for public health planning and

evaluation.

Vital records are the primary source of birth and mortality

statistics. Registration of births and deaths is mandated in

most countries and provides one of the most complete sources

of health-related data. However, the quality of speciic infor-

mation varies. For example, on birth certiicates, sex and date

of birth are fairly reliable, whereas reports of gestational age,

level of prenatal care, and smoking habits of the mother

during pregnancy are less reliable. On death certiicates, the

quality of the cause-of-death information varies over time

and from place to place, depending on diagnostic capabilities

and custom. Vital records are readily available in most areas;

they are inexpensive and convenient and allow study of long-

term trends. Mortality data, however, are informative only for

fatal diseases.

Data Collected for Other Purposes Hospital, physician, health department, and insurance records

provide information on morbidity, as do surveillance systems,

such as cancer registries and health department reporting

systems, which solicit reports of all cases of a particular dis-

ease within a geographic region. Other information, such

as occupational exposures, may be available from employer

records.

Epidemiological Data The National Center for Health Statistics sponsors periodic

health surveys and examinations in carefully drawn samples

of the US population. Examples are the National Health and

Nutrition Examination Survey (NHANES), the National

Health Interview Survey (NHIS), and the National Hospital

Discharge Survey (NHDS). The CDC also conducts or con-

tracts for conduct of surveys such as the survey for the Youth

Risk Behavior Surveillance System (YRBSS), Pregnancy Risk

Assessment Monitoring System (PRAMS), and the Behavioral

Risk Factor Surveillance System (BRFSS). These surveys pro-

vide information on the health status and behaviors of the

population. For many studies, however, the only way to obtain

the needed information is to collect the required data in a

study speciically designed to investigate a particular question.

The design of such studies is discussed later. Global position-

ing system and geographic information system technology

can be used to examine health issues such as access to prenatal

care, mapping the distribution of health exposures or out-

comes, linking data with geo-coded addresses of individuals

to sources of potentially toxic exposures (McLafferty and

Grady, 2005).

RATE ADJUSTMENT

Rates, which are essential in epidemiological studies, can be

misleading when compared across different populations.

For example, the risk for death increases considerably after

40 years of age, so a higher crude death rate is expected in a

population of older people in contrast to a population of

younger people (Gordis, 2013; Koepsell and Weiss, 2003;

160 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

Rothman, 2012). Comparing the overall mortality rate in

an area with a large population of older adults with the

rate in a younger population would be misleading. Methods

that adjust for differences in populations can be used to com-

pare death rates. Age adjustment is based on the assumption

that a population’s overall mortality rate is a function of

the age distribution of the population and the age-speciic

mortality rates.

Age adjustment can be performed by direct or indirect

methods. Both methods require a standard population, which

can be an external population, such as the US population for a

given year, a combined population of the groups under study,

or some other standard chosen for relevance or convenience.

COMPARISON GROUPS

Comparison groups are often used in epidemiology. To decide

if the rate of disease is the result of a suspected risk factor, the

exposed group should be compared with a group of compara-

ble unexposed persons. For example, you might investigate the

effect of smoking during pregnancy on the rate of low-birth-

weight infants by calculating the rate of low-birth-weight in-

fants born to women who smoked during their pregnancy.

However, the hypothesis that smoking during pregnancy is a

risk factor for low birth weight is supported only when the low-

birth-weight rate among smoking women is compared with the

(lower) rate of low-birth-weight infants born to nonsmoking

women.

Ideally you want to compare one group of people who all

have a certain characteristic, exposure, or behavior with a group

of people exactly like them except they all lack that characteris-

tic, exposure, or behavior. In the absence of that ideal, you can

either randomize people to exposure or treatment groups in

experimental studies or select comparison groups that are com-

parable in observational studies. It is especially important in

observational studies to control for confounding variables or

factors.

DESCRIPTIVE EPIDEMIOLOGY

Descriptive epidemiology describes the distribution of dis-

ease, death, and other health outcomes in the population ac-

cording to person, place, and time. This type of epidemiology

provides a picture of how things are or have been and de-

scribes who, where, and when of disease patterns. In contrast,

analytic epidemiology looks for the determinants of the pat-

terns observed—the how and why. That is, epidemiological

concepts and methods are used to identify what factors, char-

acteristics, exposures, or behaviors might account for differ-

ences in the observed patterns of disease occurrence. Descrip-

tive and analytic studies are observational. In these studies the

investigator observes events as they are or have been and does

not intervene to change anything or to introduce a new factor.

Experimental or intervention studies, however, include inter-

ventions to test preventive or treatment measures, techniques,

materials, policies, or drugs.

PERSON

Personal characteristics of interest in epidemiology include

race, sex, age, education, occupation, income (and related

socioeconomic status), and marital status. Age is the most

important predictor of overall mortality. The mortality curve

by age drops sharply during and after the irst year of life to a

low point in childhood, then begins to increase through ado-

lescence and young adulthood, and after that increases

sharply through middle and older ages (Gordis, 2013). Mor-

tality and morbidity differ by sex. Of the 10 leading causes

of death, as listed earlier in the chapter, males and females

diverged in the ranking in unintentional injuries (3rd for

males and 6th for females). Chronic lower respiratory disease

HOW TO Assess Health Problems in a Community

1. Examine local epidemiologic data (e.g., incidence, morbidity, mortality

rates) to identify major health problems.

2. Examine local health services data to identify major causes of hospitaliza-

tions and emergency department visits. Consult with key community lead-

ers (e.g., political, religious, business, educational, health, cultural) about

their perceptions of identiied community health problems.

3. Mobilize community groups to elicit discussions and identify perceived

health priorities within the community (e.g., focus groups, neighborhood or

community-wide forums).

4. Analyze community environmental health hazards and pollutants (e.g.,

water, sewage, air, toxic waste).

5. Examine indicators of community knowledge and practices of preventive

health behaviors (e.g., use of infant car seats, safe playgrounds, lighted

streets, seat-belt use, designated driver programs).

6. Identify cultural priorities and beliefs about health among different social,

cultural, racial, or national origin groups.

7. Assess community members’ interpretation of and degree of trust in federal,

state, and local assistance programs.

8. Engage community members in conducting surveys to assess speciic health

problems.

A direct adjusted rate applies the age-speciic death rates

from the study population to the age distribution of the stan-

dard population. The result is the (hypothetical) death rate of

the study population if it had the same age distribution as the

standard population.

The indirect method, as the name suggests, is more compli-

cated. The age-speciic death rates of the standard population

applied to the study population’s age distribution result in an

index rate that is used with the crude rates of both the study

and standard populations to produce the inal indirect adjusted

rate, which is also hypothetical. The indirect method may be

required when the age-speciic death rates for the study popula-

tion are unknown or unstable (e.g., based on relatively small

numbers).

Often, instead of an indirect adjusted rate, a standardized

mortality ratio (SMR) is calculated. This is the number of ob-

served deaths in the study population divided by the number of

deaths expected on the basis of the age-speciic rates in the

standard population and the age distribution of the study

population (Gordis, 2013; Szklo and Nieto, 2012).

161CHAPTER 9 Epidemiological Applications

ranked 4th for males and 3rd for females, and stroke ranked

5th for males and 4th for females. Diabetes ranked 6th for

males and 7th for females, and Alzheimer’s disease ranked

9th for males and 5th for females. For rheumatoid arthritis,

the prevalence among women is greater than among men

(Remington et al, 2010).

There are also mortality differences by age. Speciically,

in 2013, the leading cause of death among people ages 1 to

44 years was unintentional injuries, whereas the leading cause

for the population aged 45 to 64 years was cancer, and for the

population aged 65 years and over, heart disease was the leading

cause of death. For the younger age groups, external causes

accounted for more deaths than other causes, whereas for

the older age groups, chronic illnesses were more prevalent

(Heron, 2016).

Data are collected by race and Hispanic origin. The race

categories are white, black, American Indian or Alaska Native

(AIAN), and Asian or Paciic Islander (API). In the 2013 collec-

tion of data, the four groups shared seven of the leading causes

of death but had different relative disease burden. For example,

heart disease ranked irst among white, black, and AIAN per-

sons but second among the API population.

The leading cause of infant death in 2013 was congenital

malformations, and the second leading cause was disorders

related to short gestation and low birth weight. There

were differences in the leading cause of death in the neonatal

period (under 28 days after birth), which was disorders

related to short gestation and low birth weight, and in the

postneonatal period, which was sudden infant death syn-

drome (Heron, 2016)

smaller babies. Other diseases relect distinctive geographic

patterns. For example, Lyme disease is transmitted from ani-

mal reservoirs to humans by a tick vector. Disease is more

likely to be found in areas in which there are animals carrying

the disease, a large tick population for transmission to hu-

mans, and contact between the human population and the

tick vectors (Heymann, 2014). Geographic variations can be

caused by the following:

• Differences in the chemical, physical, or biological envi-

ronment

• Differences in population densities, customary patterns of

behavior and lifestyle, or other personal characteristics

Geographic variations might occur because of high concen-

trations of a religious, cultural, or ethnic group that practices

certain health-related behaviors. The high rates of stroke

found in the southeastern United States are likely to be the

result of social and personal factors that have little to do with

geographic features per se. Other neighborhood-level variables

include the unemployment and crime rate, education levels,

racial segregation, social cohesion, and access to important

services (Bradman et al, 2005; Fuller et al, 2005; McLafferty

and Grady, 2005).

TIME

Time is the third component of descriptive epidemiology. In

relation to time, epidemiologists ask these questions: Is there an

increase or decrease in the frequency of the disease over time?

Are other temporal (and spatial) patterns evident? Temporal

patterns could include secular trends, point epidemic, cyclical

patterns and event-related clusters.

Secular Changes Long-term patterns of morbidity or mortality rates (i.e., over

years or decades) are called secular trends. Secular trends

may relect changes in social behavior or practices. For

example, increased lung cancer mortality rates in recent

years relect a delayed effect of the increased smoking in

prior years. Also, the decline in cervical cancer deaths is pri-

marily the result of widespread screening with the Pap test

(Remington et al, 2010).

Some secular trends may result from increased diagnostic

ability or changes in survival (or case fatality) rather than in

incidence. For example, case fatality from breast cancer has

decreased in recent years, although the incidence of breast

cancer has increased. Some, though not all, of the increased

incidence is the result of improved diagnostic capability.

These two trends result in a breast cancer mortality curve

that is latter than the incidence curve (Remington et al,

2010). Relying on mortality data alone does not accurately

relect the true situation. Secular trends also are affected

by changes in case deinition or revisions in the coding of

a disease according to the International Classiication of Dis-

eases (ICD).

A point epidemic is a time-and-space–related pattern that is

important in infectious disease investigations and as an indica-

tor for toxic exposures. A point epidemic is most clearly seen

HOW TO Assess Health Problems in an Individual 1. Obtain a history of physical and mental health problems.

2. Ask the individual to identify major health problems. Always start inter-

ventions with what the individual views as important.

3. Obtain a family history of diseases. Identify a possible genetic link based

on early age of onset of a disease or multiple family members with a

disease.

4. Do a clinical examination, including laboratory work.

5. Evaluate health risk based on lifestyle. Include smoking status, dietary

patterns of iber and fat, exercise patterns, stress factors, and risk-taking

behaviors.

6. Identify immediate and long-range safety concerns.

7. Assess the individual’s cultural beliefs about health.

8. Assess social support.

9. Examine the knowledge and practice of preventive health care.

10. Provide appropriate age-based screening (e.g., cancer screening, hyper-

tension screening).

PLACE

When looking at the distribution of a disease, examine geo-

graphic patterns. Does the rate of disease differ from place

to place (e.g., with local environment)? If geography had no

effect on disease occurrence, random geographic patterns

might be seen, but that is often not the case. For example, at

high altitudes, oxygen tension is lower, which might result in

162 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

when the frequency of cases is graphed against time. The sharp

peak characteristic of such graphs indicates a concentration of

cases over a short interval of time. The peak often indicates the

population’s response to a common source of infection or con-

tamination to which they were all simultaneously exposed.

Knowledge of the incubation or latency period (i.e., the time

between exposure and development of signs and symptoms)

for the speciic disease entity can help determine the probable

time of exposure. A common example of a point epidemic is an

outbreak of gastrointestinal illness from a food-borne patho-

gen. Nurses who are alert to a sudden increase in the number of

cases of a disease can chart the outbreak, determine the proba-

ble time of exposure, and, by careful investigation, isolate the

probable source of the agent.

In addition to secular trends and point epidemics, there

are also cyclical time patterns of disease. Seasonal luctuation

is a common type of cyclical variation in some infectious ill-

nesses. Seasonal changes may be inluenced by changes in the

agent itself, changes in population densities or behaviors of

animal reservoirs or vectors, or changes in human behaviors

resulting in changing exposures (e.g., being outdoors in

warmer weather and indoors in colder months). Also, calen-

dar events may create artiicial seasons, such as holidays and

tax-iling deadlines, that are associated with patterns of

stress-related illness. Patterns of accidents and injuries also

may be seasonal, relecting differing employment and recre-

ational patterns. Some disease cycles, such as inluenza, have

patterns of smaller epidemics every few years, depending on

strain, with major pandemics occurring at longer intervals

(Heymann, 2014). Public health workers need to pay atten-

tion to cyclical patterns so that they are prepared to meet

possible increased demands for service.

A third type of temporal pattern is nonsimultaneous, event-

related clusters. These are patterns in which time is not mea-

sured from ixed dates on the calendar but from the point of

some exposure, event, or experience presumably held in com-

mon by affected persons, though not occurring at the same

time. An example of this pattern would be vaccine reactions

during an immunization program. Clearly, if vaccinations are

being given on a regular basis, nonspeciic symptoms, such as

fever, headaches, or rashes, might be seen fairly consistently

over time, making identiication of a cluster related to the vac-

cinations dificult. If, however, the occurrence of symptoms is

plotted against the amount of time since vaccination, the num-

ber of vaccine reactions is likely to peak at some period after the

immunization.

CHECK YOUR PRACTICE?

The Dean of the School of Nursing held an open house on August 26 to welcome

new and returning nursing students. Approximately 50 nursing students and

professors attended. Light appetizers and cider were served. On the morning of

August 28, two nursing students reported to the student health clinic with nau-

sea and vomiting. Later that day, three other students reported to the clinic with

headache, nausea, and vomiting. Two of the ive students reported that their

symptoms began the evening of August 27, and the other three reported symp-

tom onset the morning of August 28. Two nursing professors called in sick with

nausea and diarrhea on August 28. Both attended the dean’s open house and a

reception earlier in the week.

Check Your Practice:

The student health nurse notiied the nurse epidemiologist at the local health

department that she has seen ive nursing students with gastrointestinal symp-

toms. She reports their names, dates of birth, and dates and times of onset of

symptoms.

1. The nurse epidemiologist at the health department develops a line list to or-

ganize the data. The line list includes the information reported by the student

health nurse. What is the term used to describe the type of epidemiology

associated with time, place, and person?

A. Descriptive

B. Analytic

C. Scientiic

D. Environmental

2. The nurse epidemiologist notes that the infections are clustered in time,

place, and person. She interviews all of the ill nursing students and learns

that all of them attended the open house at the dean’s home. What should

the nurse do next?

A. Close the nursing school

B. Arrange to collect stool specimens

C. Contact the dean

D. Quarantine all of the open house attendees

3. The nurse epidemiologist notiies the student health nurse that all of the

stool specimens were positive for norovirus. Based on the incubation period

for norovirus (12–48 hours) and the dates of onset of symptoms, the nurse

epidemiologist suspects the students were exposed to the virus at or around

the same time. She hypothesizes that the nurses contracted norovirus

from a contaminated item consumed at the open house event. She makes

arrangements to meet with the dean to discuss the situation and gather

additional information. What information would be useful to the nurse

epidemiologist?

A. A list of items served at the event

B. A list of persons who prepared and served the refreshments

C. A list of students, faculty, and staff who attended the event

D. A list of faculty and student absences

E. All of the above

4. The nurse epidemiologist decides to interview everyone (ill and well) who

attended the open house. This type of study is called a:

A. Case-control study

B. Cohort study

C. Longitudinal study

D. Case study

5. Based on the data analysis, the nurse epidemiologist determined that the

fresh vegetable tray is associated with illness. She also learned that two of

the food handlers were not feeling well during the event. What measures

should she take at this point to control the outbreak?

A. Try to obtain stool specimens from the catering staff

B. Educate catering and serving staff about safe food preparation

C. Encourage food service staff not to prepare or serve food when they are

ill with gastrointestinal symptoms

D. Call the Better Business Bureau

Case prepared by Mary Beth White-Comstock, MSN, RN, CIC.

163CHAPTER 9 Epidemiological Applications

ANALYTIC EPIDEMIOLOGY

Descriptive epidemiology deals with the distribution of health

outcomes. The goal of analytic epidemiology is to discover the

determinants of outcomes—the how and the why. Analytic epi-

demiology deals with the factors that inluence the observed

patterns of health and disease and increase or decrease the risk

for adverse outcomes. This section discusses analytic study de-

signs and the related measures of association derived from

them. Table 9.3 summarizes the advantages and disadvantages

of each design.

COHORT STUDIES

The cohort study is the standard for observational epidemiologi-

cal studies. It comes closest to the idea of a natural experiment

(Rothman, 2012). The term cohort is used in epidemiology to

describe a group of persons who are born at about the same time.

In analytic studies, cohort refers to a group of persons generally

sharing some characteristic of interest. They are enrolled in a

study and followed over time to observe some health outcome

(Porta, 2008). Because of this ability to observe the development

of new cases of disease, cohort study designs allow for calculation

of incidence rates and therefore estimates of risk for disease.

Cohort studies may be prospective or retrospective (Gordis,

2013; Rothman, 2012).

PROSPECTIVE COHORT STUDIES

In a prospective cohort study (also called a longitudinal or

follow-up study), subjects who do not have the Outcome under

investigation are classiied on the basis of the exposure of

Study Design Advantages Disadvantages

Ecologic Quick, easy, inexpensive irst study

Uses readily available existing data

May prompt further investigation or suggest other or new

hypotheses

May provide information about contextual factors not accounted

for by individual characteristics

Ecologic fallacy: The associations observed may not hold true

for individuals

Problems in interpreting temporal sequence (cause and effect)

More dificult to control for confounding and “mixed” models

(ecologic and individual data); more complex statistically

Cross-sectional

(correlational)

Gives general description of the scope of problem; provides

prevalence estimates

Often based on population (or community) sample, not just who

sought care

Useful in health service evaluation and planning

Data obtained at once; less expense and quicker than cohort

because of no follow-up

Baseline for prospective study or to identify cases and controls

for case-control study

No calculation of risk; prevalence, not incidence

Temporal sequence unclear

Not good for rare disease or rare exposure unless there is a

large sample size or stratiied sampling

Selective survival can be a major source of selection bias; sur-

viving subjects may differ from those who are not included

(e.g., death, institutionalization)

Selective recall or lack of past exposure information can create

bias

Case-control (retrospective,

case comparison)

Less expensive than cohort; smaller sample required

Quicker than cohort; no follow-up

Can investigate more than one exposure

Best design for rare diseases

If well designed, it can be an important tool for etiologic

investigation

Best suited to a disease with a relatively clear onset (timing

of onset can be established so that incident cases can be

included)

Greater susceptibility than cohort studies to various types of

bias (selective survival, recall bias, selection bias in choice

of both cases and controls)

Information on other risk factors may not be available,

resulting in confounding

Antecedent-consequence (temporal sequence) not as certain as

in cohort

Not well suited to rare exposures

Gives only an indirect estimate of risk

Generally limited to a single outcome because of sampling

effect on disease status

Prospective cohort

(concurrent cohort,

longitudinal, follow-up)

Best estimate of disease incidence

Best estimate of risk

Fewer problems with selective survival and selective recall

Temporal sequence more clearly established

Broader range of options for exposure assessment

Expensive in terms of time and money

More dificult organizationally

Not good for rare diseases

Attrition of participants can bias the estimate

Latency period may be very long; may miss cases

May be dificult to examine several exposures

Retrospective cohort

(nonconcurrent cohort)

Combines advantages of both prospective cohort and case-

control

Shorter time (even if follow-up into the future) than prospective

cohort

Less expensive than prospective cohort because it relies on

existing data

Temporal sequence may be clearer than case-control

Shares some disadvantages with both prospective cohort and

case-control

Subject to attrition (loss to follow-up)

Relies on existing records that may result in misclassiication

of both exposure and outcome

May have to rely on a surrogate measure of exposure (e.g., job

title) and vital records information on cause of death

TABLE 9.3 Comparison of Major Epidemiologic Study Designs

164 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

interest at the beginning of the follow-up period. The subjects

are then followed for some period of time to determine the oc-

currence of disease in each group. The question is, “Do persons

with the factor (or exposure) of interest develop (or avoid) the

outcome more frequently than those without the factor (or

exposure)?”

For example, a cohort of subjects could be recruited who

would be classiied as physically active (“exposed”) or sedentary

(“not exposed”). If you had adequate information you could

quantify the amount of the “exposure.” You could then follow

these subjects over time to determine the development of CHD.

This study design avoids the problem of selective survival seen

in other designs. The cohort study also has the advantage of

allowing estimation of the risk for acquiring disease for those

who are exposed compared with those who are unexposed (or

less exposed). This ratio of cumulative incidence rates is called

the relative risk.

Suppose 1000 physically active and 1000 sedentary middle-

aged men and women were enrolled in a prospective cohort

study. All were free of CHD at enrollment. Over a 5-year follow-

up period, regular examinations detect CHD in 120 of the

sedentary men and women and in 48 of the active men and

women. Assuming no other deaths or losses to follow-up, the

data could be presented as shown in Fig. 9.2.

The incidence of CHD in the active group is (a/[a 1 b]) 5

48/1000, and the incidence of CHD in the sedentary group is

(c/[c 1 d]) 5 120/1000. The relative risk is:

(48/1000) (120 /1000) 0.4 .� �

Because physical activity is protective for CHD, the

relative risk is less than 1. In this example over a 5-year

period, the risk for CHD in persons who are physically active

compared with the risk among sedentary persons was 0.4. In

the cohort study design, subjects are enrolled before disease

onset, and this allows the researcher to study more than one

outcome, calculate incidence rates and estimate risk, and

establish the temporal sequence of exposure and outcome

with greater clarity and certainty. The researcher may need

a large sample to ensure that enough cases are observed to

provide statistical power to detect meaningful differences

between groups and may have to wait a long time for some

diseases to develop.

Retrospective Cohort Studies Retrospective cohort studies combine some of the advantages

and disadvantages of case-control studies and prospective co-

hort studies. These studies rely on existing records, such as em-

ployment, insurance, or hospital records, to deine a cohort that

is classiied as having been exposed or unexposed at some time

in the past. The cohort is followed over time using the records to

determine if the outcome occurred. Retrospective cohort (also

called historical cohort) studies may be conducted entirely using

past records or may include current assessment or additional

follow-up time after study initiation. This approach saves time;

however, its accuracy relies on existing historical records.

CASE-CONTROL STUDIES

In the case-control study, subjects are enrolled because they

are known to have the outcome of interest (these are the cases) or

they are known not to have the outcome of interest (these are the

controls). Case-control status is veriied using a clear case deini-

tion and some previously determined method or protocol (e.g.,

by an examination, laboratory test, or medical chart review). In-

formation is then collected on the exposures or characteristics of

interest, frequently from existing sources, subject interview, or

questionnaire (Rothman, 2012; Szklo and Nieto, 2012). The

question in a case-control study is “Do persons with the outcome

of interest (cases) have the exposure characteristic (or a history of

the exposure) more frequently than those without the outcome

(controls)?”

Because of the method of subject selection in case-control

studies, neither incidence nor prevalence can be calculated di-

rectly. In a case-control study, an odds ratio tells us how much

more (or less) likely the exposure is to be found among cases

than among controls. The odds of exposure among cases (a and

c in the table that follows) are compared with the odds of expo-

sure among controls (b and d). The ratio of these two odds

provides us with an estimate of the relative risk.

Suppose a research group wanted to study risk factors for

suicide attempts among adolescents. To do so they would enroll

100 adolescents who had attempted suicide, and select 200 ado-

lescents from the same community with no history of a suicide

attempt. The research group’s goal is to determine if the adoles-

cents had a history of substance abuse (SA). Through a ques-

tionnaire and use of medical records they learned that 68 of the

100 adolescents who had attempted suicide had a history of

substance abuse. They also found that 36 of the 200 adolescents

with no suicide attempt had a history of substance abuse. The

information could be presented as follows:

History Suicide Attempt

No Attempt

History of substance abuse 68 36

(a) (b)

No history of substance abuse 32 164

The odds of a history of substance abuse among suicide at-

tempters are a/c or 68/32, whereas the odds of substance abuse

Physically

active

CHD CHD

48 952

120 880

1000

a b

c d

Sedentary

FIG. 9.2 Cohort study.

165CHAPTER 9 Epidemiological Applications

among controls are b/d or 36/164. The odds ratio (equivalent to

ad/bc) is the following:

68 164

36 32 9.68

�

� �

This would be interpreted to mean that adolescents who at-

tempted suicide are almost 10 times more likely to have a history

of substance abuse than are adolescents who have not attempted

suicide. Note that an odds ratio of 1 is indicative of no association

(i.e., the odds of exposure are similar for cases and controls). An

odds ratio less than 1 suggests a protective association, that is,

cases are less likely to have been exposed than controls. Because

case-control studies know the number of cases involved, they do

not require a large sample or take a long follow-up time. They

may have biases. Bias is a systematic deviation from the truth.

Because these studies begin with existing diseases, differential

survival can produce biased results. The use of recently diagnosed

(or “incident”) cases may reduce this bias. Because exposure in-

formation is obtained from subject recall or past records, there

may be errors in exposure assessment or misclassiication.

CROSS-SECTIONAL STUDIES

The cross-sectional study provides a snapshot, or cross section, of

a population or group (Gordis, 2013). Information is collected on

current health status, personal characteristics, and potential risk

factors or exposures all at once. In the cross-sectional study there

is a simultaneous collection of information necessary for the clas-

siication of exposure. Historical information can also be collected

(e.g., past diet, history of radiation exposures).

One way cross-sectional studies evaluate the association of a

factor with a health problem is to compare the prevalence of the

disease in those with the factor (or exposure) with the preva-

lence of the disease in the unexposed. The ratio of the two

prevalence rates is an indication of the association between the

factor and the outcome. If the prevalence of CHD in smokers

were twice as high as the prevalence among nonsmokers, the

prevalence ratio would be 2. If a factor is unrelated to the preva-

lence of a disease, the prevalence ratio will be close to 1. A value

less than 1 may suggest a protective association. For example, the

prevalence of CHD is lower among physically active people than

among sedentary persons. Thus the prevalence ratio for the

association between physical activity and CHD should be less

than 1. Use caution in interpreting prevalence ratios because the

prevalence measure is affected by cure, survival, and migration

and does not estimate the risk for getting the disease.

Cross-sectional studies are subject to bias resulting from selec-

tive survival. That is, persons with existing cases who have sur-

vived to be in the study may be different from those diagnosed at

about the same time who died and are unavailable for inclusion.

Suppose physical activity not only reduced the risk for heart dis-

ease but also improved survival among those with heart disease.

Sedentary persons with heart disease would then have higher fa-

tality rates than physically active persons who developed heart

disease. Higher rates of physical activity might be observed in a

group of heart disease survivors than in a general population

without heart disease. This might occur because of the survival

advantage and also because of the participation of the survivors in

cardiac rehabilitation programs. It might, however, erroneously

appear that physical activity was a risk factor for heart disease.

ECOLOGICAL STUDIES

An ecological study is a study that is a bridge between descrip-

tive and analytic epidemiology. The descriptive component

looks at variations in disease rates by person, place, or time. The

analytic component tries to determine if there is a relation of

disease rates to variations in rates for possible risk (or protec-

tive) factors or characteristics. The identifying characteristic of

ecological studies is that only aggregate data, such as population

rates, are used, rather than data on individuals’ exposures, char-

acteristics, and outcomes. Examples include the following:

1. Examination of information on per capita cigarette con-

sumption in relation to lung cancer mortality rates in several

countries, several groups of people, or the same population

at different times

2. Comparisons of rates of breastfeeding and of breast cancer

3. Average dietary fat content and rates of CHD

4. Unemployment rates and level of psychiatric disorder

Ecological studies often use existing, readily available rates

and are therefore quick and inexpensive to conduct. They are

subject, however, to ecologic fallacy (i.e., associations observed at

the group level may not hold true for the individuals who make

up the groups, or associations that actually exist may be masked

in the grouped data). This can occur when other factors operate

in these populations for which the ecological correlations do not

account. For that reason, ecological studies may suggest possible

answers, but they require conirmation in studies that use indi-

vidual data (Gordis, 2013; Koepsell and Weiss, 2003).

EXPERIMENTAL STUDIES

The study designs discussed so far are called observational studies

because the investigator observes the association between expo-

sures and outcomes as they exist but does not intervene to alter

the presence or level of any exposure or behavior. In contrast, in

experimental or intervention studies, the investigator initiates a

treatment or intervention to inluence the risk for or course of

disease. These studies test whether interventions can prevent

disease or improve health. Both observational and experimental

studies generally use comparison (or control) groups. In experi-

mental studies, persons can be randomly assigned to a particular

group; an intervention (i.e., a treatment or exposure) is applied,

and the effects of the intervention are measured. The two types

of intervention studies are clinical trials and community trials.

CLINICAL TRIALS

The goal of a clinical trial is generally to evaluate the effective-

ness of an intervention, such as a medical treatment for disease,

a new drug or existing drug used in a new or a different way, a

surgical technique, or other treatment. In clinical trials, subjects

should be randomly assigned to groups. In randomization,

166 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

treatments are assigned to patients (subjects) so that all possible

treatment assignments have a predetermined probability, but

neither subject nor investigator determines the actual assign-

ment of any participant. Randomization avoids the bias that

may result if subjects choose to be in one group or the other or

if the investigator or clinician chooses subjects for each group.

Masking or “blinding” treatment assignments is a second

aspect of treatment allocation. Generally it is best to use a

double-blinded study in which neither subject nor investigator

knows who is getting which treatment. Clinical trials usually are

the best way to show causality because of the objective way in

which subjects are assigned and the greater control over other

factors that could inluence outcome. Like cohort studies, they

are prospective and provide the clearest evidence of correct

temporal sequence.

They do tend to be conducted in a contrived (versus natural)

situation, under controlled conditions, and with patient popu-

lations. That means that treatment may not be as effective when

applied under more realistic clinical or community conditions

in a more diverse patient population. There are also more ethi-

cal considerations involved in experimental studies than in

observational studies. For example, is it fair to withhold a treat-

ment, if the treatment truly appears to have the potential to

alleviate a disease, to evaluate this treatment systematically us-

ing both an experimental and a control group? Finally, clinical

trials are expensive in terms of time, personnel, facilities, and,

in some cases, supplies.

COMMUNITY TRIALS

Community trials are similar to clinical trials in that an investi-

gator determines what the exposure or intervention will be.

However, community trials often deal with health promotion

and disease prevention rather than treatment of existing dis-

ease. The intervention is usually undertaken on a large scale,

and the unit of treatment is a community, region, or group

rather than individuals. Although a pharmaceutical product

such as luoridation of water or mass immunizations may be

involved in a community trial, these trials often involve educa-

tional, programmatic, or policy interventions. Examples of

community interventions would be measuring the rates of dia-

betes or cardiovascular disease in a community in which the

availability of exercise programs and facilities was increased or

in which a much larger supply of healthful fresh foods was

made available.

Although community trials provide the best means of test-

ing whether changes in knowledge or behavior, policy, pro-

grams, or other mass interventions are effective, they do present

some problems. For many interventions, it may take years for

the effectiveness to be evident, for example, the effect of chang-

ing the availability of exercise and healthful food on the rates of

either diabetes or heart disease. While the study is being carried

out over time, other factors can inluence the outcome either

positively (i.e., making the intervention look more effective

than it really is) or negatively (i.e., making the intervention look

less effective than it really is). Comparable community popula-

tions without similar interventions for comparative analysis are

often dificult to ind. Even when comparable comparison com-

munities are available—especially when the intervention is

improved knowledge or changed behavior—it is dificult and

unethical to prevent the control communities from making use

of generally available information, effectively making them less

different from the intervention communities. Finally, because

community trials are often undertaken on a large scale and over

long periods, they can be expensive, require a large staff, have

complicated logistics, and need extensive communication about

the study.

CAUSALITY

STATISTICAL ASSOCIATIONS

Sample size, strength of association, and variance of measures

can all affect statistical signiicance. For example, to determine

if eating habits affect the onset of hypertension, a statistical

association between the factor (diet) and the health outcome

(hypertension) would need to be established. If the probability

of disease seems unaffected by the presence or level of the fac-

tor, no association is apparent. If, on the other hand, the prob-

ability of disease does vary according to whether the factor is

present, there is a statistical association. The earlier discussion

of null values is pertinent at this point. When an observed mea-

sure of association (e.g., a risk ratio) does not differ from the

null value, there is no evidence of an association between the

factor and the outcome being studied. To say a result is statisti-

cally signiicant means that the observed result is unlikely to be

due to chance. Sample size affects statistical signiicance.

BIAS

A statistically signiicant result may also be observed because of

bias, a systematic error as a result of the study design, the way

it is conducted, or a confounding factor. For example, if there

were a gumball machine with colors randomly mixed and three

red ones in a row came out, that would be due to chance. If,

however, the person loading the gumball machine had poured

in a bag of red ones irst, then green ones, then yellow ones, it

would not be surprising to get three red ones in a row because

of the way the machine was loaded. In epidemiological studies,

results are sometimes biased because of the way the study was

“loaded” (i.e., the way the study was designed or the way sub-

jects were selected, information was collected, and subjects were

classiied). Although the types of bias are numerous, there are

three general categories of bias (Rothman, 2012). Bias can be

attributed to the following:

1. Selection or the way subjects enter a study: Selection bias

has to do with selection procedures and the population from

which subjects are drawn, and it may involve self-selection

factors. Example: Are teenagers who agree to complete a

questionnaire on alcohol, tobacco, and other drug use repre-

sentative of the total teenage population?

2. Misclassiication of subjects once they are in the study:

This is information, or classiication (or misclassiication),

bias. It is related to how information is collected, including

167CHAPTER 9 Epidemiological Applications

Primary Prevention

Discuss a low-fat diet and the need for regular physical exercise with clients.

Secondary Prevention

Implement blood pressure and cholesterol screening; give a treadmill

stress test.

Tertiary Prevention

Provide cardiac rehabilitation, medication, and surgery.

the information that subjects supply or how subjects are

classiied.

3. Confounding or bias resulting from the relationship be-

tween the outcome and study factor and some third factor

not accounted for. Example: There is a well-known associa-

tion between maternal smoking during pregnancy and low-

birth-weight babies. There is also an association between

alcohol consumption and smoking that is not due to chance,

nor is it causal (i.e., drinking alcohol does not cause a person

to smoke, nor does smoking cause a person to drink alco-

hol). If we were to investigate the association between alco-

hol consumption and low birth weight, smoking would be a

confounder because it is related to both alcohol consump-

tion and low birth weight. Failure to account for smoking in

the analysis would bias the observed association between

alcohol use and low birth weight. In practice, we can often

identify potentially confounding variables and adjust for

them in the analysis.

ASSESSING FOR CAUSALITY

The existence of a statistical association does not necessarily

mean that a causal relationship exists or that causality is

present. As just discussed, the observed association may be a

random event (due to chance) or may be the result of bias from

confounding or from some aspect of the study design or execu-

tion. Statistical associations, although necessary to an argument

for causal inference, are not adequate proof. Some epidemiolo-

gists refer to guidelines, a term originally established to evaluate

the link between an infectious agent and a disease but revised

and elaborated to apply also to other outcomes. Although vari-

ous lists of guidelines have been proposed, the seven guidelines

listed in Box 9.3 are often used (Gordis, 2013; Koepsell and

Weiss, 2003).

APPLICATIONS OF EPIDEMIOLOGY IN NURSING

Nurses need to know and be able to use epidemiology. Nurses

regularly collect, report, analyze, interpret, and communicate

epidemiological data in many of the areas in which they work.

Nurses involved in the care of persons with communicable dis-

eases use epidemiology daily as they identify, report, treat, and

provide follow-up on cases and contacts of TB, gonorrhea, and

gastroenteritis. School nurses also function as epidemiologists,

collecting data on the incidence and prevalence of accidents,

injuries, and illnesses in the school population. They are also

key players in the detection and control of local epidemics, such

as outbreaks of lice. As described earlier in this chapter, nurses

across practice settings are actively involved in activities related

to primary, secondary, and tertiary prevention (see the discus-

sion of levels of prevention and the Levels of Prevention box).

LEVELS OF PREVENTION

Related to Cardiovascular Disease

BOX 9.3 Guidelines for Causal Inference

1. Strength of association: A strong association between a potential risk

factor and an outcome supports a causal hypothesis (i.e., a relative risk of

7 provides stronger evidence of a causal association than a relative

risk of 1.5).

2. Consistency of indings: Repeated indings of an association with

different study designs and in different populations strengthen a causal

inference.

3. Biological plausibility: Demonstration of a physiological mechanism by

which the risk factor acts to cause disease enhances the causal hypothesis.

Conversely, an association that does not initially seem biologically defen-

sible may later be discovered to be so.

4. Demonstration of correct temporal sequence: For a risk factor to cause

an outcome, it must precede the onset of the outcome.

5. Dose-response relationship: The risk for developing an outcome should

increase with increasing exposure (either in duration or quantity) to the

risk factor of interest. For example, studies have shown that the more a

woman smokes during pregnancy, the greater is the risk for delivering a

low-birth-weight infant.

6. Speciicity of the association: The presence of a one-to-one relationship

between an agent and a disease (i.e., the idea that a disease is caused by

only one agent and that agent results in only one disease lends support to

a causal hypothesis, but its absence does not rule out causality). This crite-

rion grows out of the infectious disease model in which it is more often

though not always satisied and is less applicable in chronic diseases.

7. Experimental evidence: Experimental designs provide the strongest epi-

demiologic evidence for causal associations, but they are not feasible or

ethical to conduct for many risk factor–disease associations.

Some nursing jobs are speciically based in epidemiological

practice. These include nurse epidemiologists and environmen-

tal risk communicators employed by local health departments,

as well as hospital infection control nurses. Nurses are key

members of local fetal and infant mortality review boards,

which examine cases of newborn deaths for identiiable risk

factors and quality of care measures. Members of these review

boards may include public health and maternal and child

nurses, as well as representatives from hospital labor and deliv-

ery and neonatal intensive care units. Nurses play a key role in

disaster preparedness in their communities, and this work in-

cludes knowledge of epidemiology.

Nursing documentation on patient charts and records is an

important source of data for epidemiological reviews. Patient

demographics and health histories are often collected or veri-

ied by nurses. As nurses collect and document patient infor-

mation, they might not be thinking about the epidemiological

connection. However, the reliability and validity of such data

can be key factors in the quality of future epidemiological

studies.

168 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES

Targeted Competency: Informatics—Use information and technology

to communicate, manage knowledge, mitigate error, and support decision

making.

Important aspects of informatics include:

• Knowledge: Identify essential information that must be available in a

common database to support client care.

• Skills: Use information management tools to monitor outcomes of care

processes.

• Attitudes: Value nurses’ involvement in design, selection, implementation

and evaluation of information technologies to support client care.

Informatics Question

Determine If a Health Problem Exists in the Community

Nurses are involved in the surveillance and monitoring of health phenomena.

Planning for resources and personnel often requires quantifying the level

of a problem in the community. For example, to know how different districts

compare in the rates of infants with very low birth weight, you would

calculate the prevalence of infants with very low birth weight in each

district:

1. Determine the number of live births in each district from birth certiicate data

obtained from the vital records division of the health department.

2. Use the birth-weight information from the birth certificate data to deter-

mine the number of infants born weighing less than 1500 g in each

district.

3. Calculate the prevalence of births of infants with very low birth weights by

district as the number of infants weighing less than 1500 g at birth divided

by the total number of live births.

4. If the number of births of infants with very low birth weights in each district

is small, use several years of data to obtain a more stable estimate.

Prepared by Gail Armstrong, PhD, DNP, ACNS-BC, CNE, Associate Professor, University of Colorado College of Nursing.

P R A C T I C E A P P L I C A T I O N

R E M E M B E R T H I S !

You are a nurse at a local health department where Rob Jones, a

46-year-old African American, comes for a routine blood pres-

sure check. He mentions that his father recently died of prostate

cancer and that he is worried about himself. Further assessment

reveals that his father was diagnosed with prostate cancer when

he was 52 years old and that Mr. Jones’s uncle, who is 56,

was recently diagnosed with prostate cancer. You know from

Mr. Jones’s health history that he smokes a pack of cigarettes

per day and eats fried food frequently.

Which action would be your best choice?

A. Give Mr. Jones a digital rectal examination and prostate-speciic

antigen (PSA) test immediately to screen for prostate cancer.

• Epidemiology is the study of the distribution and determi-

nants of health-related events in human populations and the

application of this knowledge to improving the health of

communities.

• Epidemiology is a multidisciplinary science that recognizes

the complex interrelationships of factors that inluence dis-

ease and health at both the individual and the community

level; it provides the basic tools for the study of health and

disease in communities.

• Epidemiological methods are used to describe health and

disease and to investigate the factors that promote health or

inluence the risk for, or distribution of, disease. This knowl-

edge can be useful in planning and evaluating programs,

policies, and services and in clinical decision making.

• Basic epidemiological concepts include the interrelationships

among the agent, host, and environment (the epidemiologic

triangle); the interactions of factors, exposures, and charac-

teristics in a causal web affecting the risk for disease; and the

levels of prevention corresponding to stages in the natural

history of disease.

B. Do not discuss or provide prostate cancer screening with

him, because he is younger than 50 years.

C. Advise Mr. Jones to be tested immediately for the prostate

cancer gene, because of his family history.

D. Inform him of the risks and beneits of prostate cancer test-

ing and of his increased personal risk for prostate cancer

because of his family history, smoking, and dietary habits.

Involve him in the decision-making process about prostate

cancer screening.

Answers can be found on the Evolve website.

• Primary prevention involves interventions to reduce the

incidence of disease by promoting health and preventing

disease processes from developing.

• Secondary prevention includes programs (e.g., screening)

designed to detect disease in the early stages, before signs

and symptoms are clinically evident, to intervene with early

diagnosis and treatment.

• Tertiary prevention provides treatments and other interven-

tions directed toward persons with clinically apparent disease,

with the aim of lessening the course of the disease, reducing

disability, or rehabilitating the client.

• Epidemiological methods are also used in the planning and

design of screening (secondary prevention) and community

health intervention (primary prevention) strategies and in

the evaluation of their effectiveness.

• Basic epidemiological methods include the use of exist-

ing data sources to study health outcomes and related

factors and the use of comparison groups to assess

the association between exposures or characteristics and

health outcomes.

169CHAPTER 9 Epidemiological Applications

• Epidemiologists use rates and proportions to quantify levels

of morbidity and mortality.

• Prevalence proportions provide a picture of the level of ex-

isting cases in a population at a given time.

• Incidence rates and proportions measure the rate of new

case development in a population and provide an estimate

of the risk for disease.

• Descriptive epidemiological studies provide information on

the distribution of disease and health states according to

personal characteristics, geographic region, and time. This

epidemiology, ed 2, New York, 2009, Oxford University Press,

pp 147–181.

McLafferty S, Grady S: Immigration and geographic access to prena-

tal clinics in Brooklyn, NY: a geographic information systems

analysis, Am J Public Health 95:638–640, 2005.

Merrill RM, Timmreck TC: Introduction to epidemiology, ed 4, Sudbury,

Mass, 2006, Jones & Bartlett.

Murphy SL, Xu JQ, Kochanek KD: Deaths: preliminary data for 2010,

Natl Vital Stat Rep 60; 2012 for actual 2010 data.

Palmer IS: Florence Nightingale and the irst organized delivery of

nursing services, Washington, DC, 1983, American Association of

Colleges of Nursing.

Porta M: A dictionary of epidemiology, ed 5, New York, 2008, Oxford

University Press.

Remington PL, Brownson RC, Wegman MV: Chronic disease epidemi-

ology and control, ed 3, Washington DC, 2010, American Public

Health Association.

Rothman KJ: Epidemiology: an introduction, ed 2, New York, 2012,

Oxford University Press.

Siu AL: Screening for high blood pressure in adults: US Preventive

Services Task Force recommendation statement, Annals of Internal

Medicine 163(10):778–786, 2015.

Snow J: On the mode of communication of cholera. In Snow on cholera,

New York, 1855, The Commonwealth Fund.

Swider SM, Krothe J, Reyes D, Cravetz M: The Quad Council practice

competencies for public health nursing, Public Health Nursing

30(6):519–536, 2013.

Szklo M, Nieto FJ: Epidemiology beyond the basics, ed 3, Boston, 2012,

Jones & Bartlett.

US Department of Health and Human Services: Healthy People 2020,

Washington, DC, 2010, US Government Printing Ofice.

Wiehe SE, Rosenman MC, Aalsma MC, Scanlon ML, Fortenberry JD:

Epidemiology of sexually transmitted infections among offenders

following arrest or incarceration, American Journal of Public

Health 105(12):26–33, 2015.

Xu JQ, Murphy SL, Kochanek KD, Bastian BA: Deaths: Final data for

2013, National Vital Statistics Reports 64(2):1–119, Hyattsville MD,

2016, National Center for Health Statistics.

REFERENCES

American Nurses Association: Essential nursing competencies and curricula

guidelines for genetics and genomics, Silver Spring, MD, 2006, ANA.

Bradman A, Chevier J, Tager I, et al: Association of housing disrepair

indicators with cockroach and rodent infestations in a cohort

of pregnant Latina women and their children, Environ Health

Perspect 113:1795–1801, 2005.

Cohen IB: Florence Nightingale, Sci Am 250:128–137, 1984.

Council on Linkages between Academic and Public Health Practice:

Core competencies for public health professionals, Washington DC,

2010, Public Health Foundation/Health Resources and

Services Administration.

Fuller CM, Borrell LN, Latkin CA, et al: Effects of race, neighbor-

hood, and social network on age at initiation of injection drug

use, Am J Public Health 95:689–695, 2005.

Gordis L: Epidemiology, ed 5, Philadelphia, 2013, Saunders.

Heron M: Deaths: leading causes for 2013, Natl Vital Stat Rep 65(2):1–14,

Hyattsville, MD, 2016, National Center for Health Statistics.

Heymann DL, editor: Control of communicable diseases manual, ed 20,

Washington, DC, 2014, American Public Health Association.

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Washington, DC, 2002, National Academies Press. Retrieved May

2012 from http://www.iom.edu/Reports.

Koepsell TD, Weiss NS: Epidemiologic methods: studying the occur-

rence of illness, New York, 2003, Oxford University Press.

Macintyre S, Ellaway A: Ecological approaches: rediscovering the role

of the physical and social environment. In Berkman LF, Kawachi I,

editors: Social epidemiology, New York, 2000, Oxford University

Press, pp 332–348.

McKeown RE, Learner RM: Ethics in public health practice.

In Coughlin S, Beauchamp T, Weed T, editors: Ethics and

knowledge enables practitioners to target programs and al-

locate resources more effectively and provides a basis for

further study.

• Analytic epidemiological studies investigate associations be-

tween exposures or characteristics and health or disease

outcomes, with the goal of understanding the etiology of

disease. Analytic studies provide the foundation for under-

standing disease causality and for developing effective inter-

vention strategies aimed at primary, secondary, and tertiary

prevention.

EVOLVE WEBSITE

http://evolve.elsevier.com/Stanhope/foundations

• Case Study, with Questions and Answers

• NCLEX® Review Questions

• Practice Application Answers

http://www.iom.edu/Reports

http://library.umassmed.edu/ebpph/

170

Emphasis on evidence-based practice (EBP) is a recent devel-

opment in health care delivery in the United States. It is a

relevant approach to providing the highest quality of health

care in all settings, which will result in improved health

outcomes. EBP is important for all professionals who work

in social and health care environments, regardless of the

client or the setting with which professionals are dealing,

including public health nurses who work with populations.

Emphasis on EBP has resulted from increased expectations

of consumers, changes in health care economics, increased

expectations of accountability, advancements in technology,

the knowledge explosion fueled by the Internet, and the

growing number of lawsuits occurring when there is injury

or harm as a result of practice decisions that are not based

on the best available evidence (Makic et al, 2014). Nurses at

all levels have an opportunity to improve the practice of

nursing and client outcomes. The Institute of Medicine

(IOM) 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. An even greater concern in public health is that the ield

is lagging behind in developing evidence-based guidelines

for the community setting. It is important to recognize that

regardless of the level of education, undergraduate or gradu-

ate, nurses can be involved in the development, implementa-

tion, and evaluation of the effects of EBP (Florin et al,

2012; Gerrish and Cooke, 2013; Mattila et al, 2013; Merrill

et al, 2013; Sprayberry, 2014).

Evidence-Based Practice

Marcia Stanhope

10 C H A P T E R

After reading this chapter, the student should be able to:

1. Deine evidence-based practice.

2. Understand the history of evidence-based practice in

health care.

3. Assess the relationship between evidence-based practice

and the practice of nursing in the community.

O B J E C T I V E S

4. Provide examples of evidence-based practice in the

community.

5. Identify barriers to evidence-based practice.

6. Apply resources for evidence-based practice.

Deinition of Evidence-Based Practice

History of Evidence-Based Practice

Types of Evidence

Factors Leading to Change or Barriers to Evidence-Based

Practice

Steps in the Evidence-Based Practice Process

Approaches to Finding Evidence

Approaches to Evaluating Evidence

Approaches to Implementing Evidence-Based

Practice

C H A P T E R O U T L I N E

Current Perspectives

Cost versus Quality

Individual Differences

Appropriate Evidence-Based Practice Methods for

Community-Oriented Nursing Practice

Healthy People 2020 Objectives

Example of Application of Evidence-Based Practice to Public

Health Nursing

evidence-based medicine, 171

evidence-based nursing, 171

evidence-based practice, 171

evidence-based public health, 171

grading the strength of evidence, 176

integrative review, 174

meta-analysis, 174

narrative review, 174

randomized controlled trial (RCT),

172

research utilization, 171

systematic review, 174

K E Y T E R M S

The authors acknowledge the contribution of Sharon E. Lock to the

content of this chapter.

171CHAPTER 10 Evidence-Based Practice

DEFINITION OF EVIDENCE-BASED PRACTICE

The deinition of evidence-based medicine by Sackett et al

(1996) became the industry standard. Sackett et al (2000) de-

ined evidence-based medicine as “the conscientious, explicit,

and judicious use of current best evidence in making decisions

about the care of individual clients” (p 71). Adapting the deini-

tion by Sackett et al (1996), Rychetnik et al (2003) deined

evidence-based public health as “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” (p 538).

Brownson et al (2009) recently expanded the deinition of

evidence-based public health to include “making decisions on

the basis of the best available evidence, using data and informa-

tion systems, applying program planning frameworks, engaging

the community in decision making, conducting evaluations,

and disseminating what has been learned” (p 175).

In a position statement on evidence-based practice, the

Honor Society of Nursing, Sigma Theta Tau International, de-

ined evidence-based nursing as “an integration of the best

evidence available, nursing expertise, and the values and prefer-

ences of the individuals, families, and communities who are

served” (Honor Society of Nursing, Sigma Theta Tau Interna-

tional, 2005). The deinition continues to be broadened in

scope and now includes a life-long problem-solving approach

to clinical practice, integrating both external and internal evi-

dence to answer clinical questions and to achieve desired client

outcomes (Melnyk and Fineout-Overholt, 2015). External evi-

dence includes research and other evidence, whereas internal

evidence includes the nurse’s clinical experiences and the client’s

preferences.

Applied to nursing, evidence-based practice includes the

best available evidence from a variety of sources, including

research studies, evidence from nursing experience and exper-

tise, and evidence from community leaders. Culturally and

inancially appropriate interventions need to be identiied when

working with communities. The use of evidence to determine

the appropriate use of interventions that are culturally sensitive

and cost-effective is a must.

From Joseph DA, Redwood D, DeGroff A, Butler EL: Use of evidence-based interventions to address disparities in colorectal cancer screening,

MMWR, 65(1): 21-28, 2016.

EVIDENCE-BASED PRACTICE

The second leading cause of cancer deaths among cancers that affect both men

and women is colorectal cancer (CRC). However, CRC screening tests are under-

used, especially among racial/ethnic minority groups, persons without insur-

ance, those with lower educational attainment, and those with lower household

income levels. The Centers for Disease Control and Prevention’s (CDC) Colorectal

Cancer Control Program (CRCCP) has supported state health departments and

tribal organizations in implementing evidence-based interventions to increase

the use of CRC screening tests among their populations. CRCCP program funds

were primarily used to implement evidence-based interventions or strategies

recommended in The Guide to Community Preventive Service (Community

Guide). These strategies included: (1) client reminders, (2) high quality small

media, (3) reduction of structural barriers, (4) provider reminder and recall sys-

tems, and (5) provider assessment and feedback. Joseph et al (2016) report on

two successful evidence-based interventions to address disparities: The Alaska

Native Tribal Health Consortium (ANTHC) and Washington State’s Breast, Cervi-

cal, and Colon Health Program (BCCHP).

ANTHC is a statewide, tribal, nonproit health services organization owned and

managed by Alaska Native populations. To increase CRC screening, ANTHC

facilitated implementation of provider and patient reminders and patient naviga-

tors, who provided one-on-one patient education, small media distribution, and

reduction of structural barriers (e.g., assisting with transportation). After imple-

menting the program, the statewide CRC screening rate increased by eight

percent (from 50.9% in 2009 to 58.4% in 2012). Some regions reported increases

as high as 43% (from 24.4% in 2010 to 67.6% in 2012).

BCCHP has contracts with six regional contractors to administer program ser-

vices across Washington state. BCCHP identiied patient care coordinators in

each clinic who coordinated staff training on CRC screening and integrated client

and provider reminder systems. After implementing the program, the CRC

screening rate increased by 24% (from 24% in 2011 to 48% in 2014) among the

seven participating clinics, with all clinics showing improvements.

Nurse Use

Nurses can be active in establishing evidence-based interventions in the com-

munity to meet a health care need and reduce health disparities. Using multi-

component interventions in a single clinical site or facility can support more

organized screening programs and potentially result in greater increases in

screening rates than relying on a single strategy. The focus on developing proj-

ects to meet needs and improve health care outcomes must be based on the

evidence that shows these partnerships are needed to solve the health care

need and improve health care outcomes.

HISTORY OF EVIDENCE-BASED PRACTICE

During the mid- to late 1970s there was growing consensus

among nursing leaders that scientiic knowledge should be used

as a basis for nursing practice. During that time, the Division

of Nursing in the U.S. Public Health Service began funding

research utilization projects. Research utilization has been de-

ined as “the process of transforming research knowledge into

practice” (Stetler, 2001, p 272) and “the use of research to guide

clinical practice” (Estabrooks et al, 2004, p 293).

Three projects funded by the Division of Nursing received

the most attention and were the most inluential in shaping

nursing’s view of using research to guide practice:

• The Nursing Child Assessment Satellite Training Project

(NCAST) (Barnard and Hoehn, 1978; King et al, 1981)

• The Western Interstate Commission for Higher Education

(WICHE) Regional Program for Nursing Research Develop-

ment (WICHEN) (Krueger, 1977; Krueger et al, 1978; Lindeman

and Krueger, 1977)

• The Conduct and Utilization of Research in Nursing Project

(CURN) (Horsley et al, 1978; Horsley et al, 1983)

Using very different approaches and methods, each project

tested interventions to facilitate research use in practice.

172 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

Although nursing continued to focus on research utilization

projects, medicine also began to call for physicians to increase

their use of scientiic evidence to make clinical decisions. In the

late 1970s, David Sackett, a medical doctor and clinical epidemi-

ologist at McMaster University, published a series of articles in

the Canadian Medical Association Journal describing how to read

research articles in clinical journals. The term critical appraisal

was used to describe the process of evaluating the validity and

applicability of research studies (Guyatt and Rennie, 2002). Later,

Sackett proposed the phrase “bringing critical appraisal to the

bedside” to describe the application of evidence from medical

literature to client care. This concept was used to train resident

physicians at McMaster University and evolved into a “philoso-

phy of medical practice based on knowledge and understanding

of the medical literature supporting each clinical decision”

(Guyatt and Rennie, 2002, p xiv).

With Gordon Guyatt as Residency Director of Internal

Medicine at McMaster, the decision was made to change the

program to focus on “this new brand of medicine” that Guyatt

eventually called evidence-based medicine (Guyatt and Rennie,

2002, p xiv). Guyatt and Rennie described the goal of evidence-

based medicine as being “aware of the evidence on which one’s

practice is based, the soundness of the evidence, and the

strength of inference the evidence permits” (2002, p xiv).

In 1992 the Evidence-Based Medicine Working Group pub-

lished an article in the Journal of the American Medical Asso-

ciation expanding the concept of evidence-based medicine

and calling it a “paradigm shift.” A paradigm shift simply

means a change from old ways of knowing to new ways of

knowing and practicing. Ways of knowing in nursing have

included the following:

• The empirical knowledge, or the science of nursing

• The aesthetic knowledge, or the art of nursing

• Personal knowledge, or interpersonal relationships and caring

• Ethical knowledge, or moral and ethical codes of conduct

usually established by professional organizations (Bradshaw,

2010)

Nursing practice has often focused less on science and more

on the other four ways of knowing described here.

According to the Working Group (Evidence-Based Medi-

cine Working Group, 1992), the old paradigm viewed unsys-

tematic clinical observations as a valid way for “building and

maintaining” knowledge for clinical decision making (p 2421).

In addition, principles of pathophysiology were seen as a “suf-

icient guide for clinical practice” (p 2421). Training, common

sense, and clinical experience were considered suficient for

evaluating clinical data and developing guidelines for clinical

practice. The Working Group cited developments in research

over the past 30 years as providing the foundation for the

paradigm shift and a “new philosophy of medical practice”

(p 2421).

The new paradigm, evidence-based medicine, acknowl-

edges clinical experience as a crucial, but not sufficient, part

of clinical decision making. Systematic and unbiased re-

cording of clinical observations in the form of research will

increase confidence in the knowledge gained from clinical

experience. Principles of pathophysiology are seen as neces-

sary but not sufficient knowledge for making clinical deci-

sions. The Working Group also stressed that physicians

need to be able to critically appraise the research literature

to appropriately apply research findings in practice. Knowl-

edge gained from authoritative figures also was not suffi-

cient for practice in the new paradigm (Evidence-Based

Medicine Working Group, 1992).

In the years since the Working Group began, evidence-based

practice has been proposed as a term that integrates all health

professions. The underlying principle is that high-quality care

is based on evidence rather than on tradition or intuition

(Hoffmann, Bennett, Del Mar, 2013).

The current nursing literature on evidence-based practice is

primarily associated with applications in the acute and primary

care settings, and little is reported about its use in community

settings. However, the basic principles of evidence-based prac-

tice can be applied at the individual level or at the community

level. Although deinitions of EBP vary widely in the literature,

the common thread across disciplines is the application of the

best available evidence to improve practice (Makic et al, 2014;

Leufer and Cleary-Holdforth, 2009).

CHECK YOUR PRACTICE?

As a student at the health department, you have been asked to look for

evidence that would support a community level intervention to improve

outcomes related to diabetes self-management in the population. What

would you do?

TYPES OF EVIDENCE

No matter which deinition is supported, what counts as evi-

dence has been the issue most hotly debated. A hierarchy of

evidence, ranked in order of decreasing importance and use,

has been accepted by many health professionals. The double-

blind, randomized controlled trial (RCT) generally ranks as

the highest level of evidence, followed by:

• Other RCTs

• Nonrandomized clinical trials

• Quasi-experimental studies

• Prospective cohort studies

• Case-control reports

• Qualitative studies

• Expert opinion (Russell-Babin, 2009)

Some nurses would argue that this hierarchy ignores evi-

dence gained from clinical experience. However, the defini-

tion of evidence-based nursing presented earlier indicates

that clinical expertise as evidence, when used with other

types of evidence, is used to make clinical decisions. Also in

the hierarchy of evidence, expert opinion can be gained from

the following:

• Non–research-based published articles

• Professional guidelines

• National guidelines

173CHAPTER 10 Evidence-Based Practice

• Organizational opinions

• Panels of experts

• The nurse’s clinical expertise

Because it is dificult to ind or perform RCTs in the commu-

nity, other types of evidence have been highlighted as the

best evidence in public health literature on which to base

evidence-based public health practice:

• Scientiic literature found in systematic reviews

• Scientiic literature used or quoted in one or more journal

articles

• Public health surveillance data

• Program evaluations

• Qualitative data obtained from community members and

other stakeholders

• Media and marketing data, such as the results of a media

campaign to reduce smoking, word of mouth, and personal

or professional experience (Brownson, Fielding, Maylahn,

2013; Jacobs et al, 2012)

FACTORS LEADING TO CHANGE OR BARRIERS TO EVIDENCE-BASED PRACTICE

EBP represents a cultural change in practice. It provides an envi-

ronment to improve both nursing practice and client outcomes.

Nursing is known for providing care based on the following:

• Environmental and client assessments

• Critical observations

• Development of questions or hypotheses to be explored

• Collection of data from the environment through commu-

nity or organizational assessments

• Client history

• Physical assessment

• Review of past health records

• Analyzing data to develop plans of care for the individual

client, family, group, or community

• Drawing conclusions on which to base care for the purpose

of improving client outcomes (Vanhook, 2009)

However, several factors have been identiied in the literature

that support implementation of EBP or that will need to be

overcome for nursing and other disciplines to successfully im-

plement EBP. These factors include the following:

• Knowledge of research and current evidence

• Ability to interpret the meaning of the evidence

• Individual professional’s characteristics, such as a willing-

ness to change, or personal viewpoints about the quality and

credibility of evidence

• Commitment of the time needed to implement EBP and to

engage in education and directed practice

• The hierarchy of the practice environment and the level of

support of managers and the ability to engage in autono-

mous practice

• The philosophy of the practice environment and the willing-

ness to embrace EBP

• The resources available to engage in EBP, such as amount of

work, proper equipment, computer-based EBP programs,

and information systems

• The practice characteristics, such as leadership and colleague

attitudes

• Links to outside supports, for example, teaching facilities

such as a teaching health department or a university

• Political constraints and the lack of relevant and timely

public health practice research (Brownson, Fielding, Maylahn,

2013; Gerrish, Cooke, 2013; Layde et al, 2012; Lovelace et al,

2015; Rychetnik et al, 2012)

Although a community agency may subscribe to the use of

EBP in theory, actual implementation may be affected by the

realities of the practice setting. Community-focused nursing

agencies may lack the resources needed for its implementation

in the clinical setting, such as time, funding, computer re-

sources, and knowledge. Nurses may be reluctant to accept

indings and feel threatened when long-established practices

are questioned. Cost also can be a barrier if the clinical decision

or change will require more funds than the agency has available.

Compliance can be a barrier if the client will not follow the

recommended intervention. Public health departments are

moving toward EBP and are seeking accreditation through the

national public health accreditation board. The accreditation

process began in 2012.

STEPS IN THE EVIDENCE-BASED PRACTICE PROCESS

EBP is a philosophy of practice that respects client values.

Melnyk and Fineout-Overholt (2015) have described a seven-

step EBP process (Box 10.1). Yes, the irst step is step zero. This

process was initially described as a ive-step process by others

(Craig and Smyth, 2007; Dawes et al, 2004; Dicenso et al, 2005).

The unique features of the model by Melnyk et al is the empha-

sis on the spirit of inquiry and the sharing of the results of the

process.

Step zero involves a curiosity about the interventions that

are being applied. Do they work, or is there a better approach?

In public health nursing, for example, are there better parenting

outcomes if the parents attend classes at the health department?

Evidence-based practice (EBP) is a philosophy of practice that respects client

values. Melnyk et al (2015) have described the following seven-step EBP

process:

0. Cultivating a spirit of inquiry

1. Asking compelling, clinical questions

2. Searching for the best evidence

3. Critically appraising the evidence

4. Integrating the evidence with clinical expertise and client preferences and values

5. Evaluating the outcomes of the practice decisions or changes based on

evidence

6. Disseminating EBP results

BOX 10.1 Seven Steps in the Evidence-Based Practice Process

From Melnyk BM, Fineout-Overholt E: Evidence-based practice in

nursing and healthcare: a guide to best practice, ed 3, Philadelphia,

2015, Wolters Kluwer Health.

174 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

Or are home visits to new mothers and babies more effective for

achieving a healthy baby? Step one requires asking questions in

a “PICOT” format. Although Melnyk et al developed a speciic

process for the PICOT, the process was irst described by Sackett

et al (1996), who discussed the following:

• The need to deine the (P)opulation of interest

• The (I)ntervention or practice strategy in question

• The population or intervention to be used for (C)omparison

• The (O)utcome desired

• The (T)ime frame

Step two involves searching for the best evidence to answer the

question. This step involves searching the literature. In the case

of the earlier example, a literature search would focus on a

search of key terms such as public health nursing, parenting of

new babies, parenting classes, and home visits.

Step three requires a critical appraisal of the evidence found

in step two. To appraise the literature found, Melnyk et al sug-

gest asking three questions about each of the articles found in

the literature search: (1) the validity, (2) the importance, and

(3) whether the results of the article will help you as a nurse

provide quality care for your clients.

Step four is the step in which the evidence found is inte-

grated with clinical expertise and client values. Institutional

standards and practice guidelines, as well as cost of care and

support of the health care environment to implement the ind-

ings, are all factors considered in this step.

Step ive requires an evaluation of the outcomes of practice

decisions and changes that were based on the answers to the

irst four steps. The goal in evaluation is a positive change

in quality of care and health care outcomes. In the example

of group parenting classes versus home visits to new mothers

and babies, current literature suggests improved quality and

health care outcomes with home visits (Doggett, 2013).

Step six is disseminating outcomes of the results to others,

to colleagues, to the employing agency’s administration, to

faculty and other students, and through a poster or podium

presentation of the student nurse organizations or profes-

sional organizations. Professional organizations often sponsor

student presentations for undergraduates and graduate stu-

dents. Sharing of information is most important because it

prevents each individual nurse from trying to ind the best

answer to the same question answered by someone else and

gives us the basis for asking new questions. Sharing makes

practice more eficient and improves quality and health care

outcomes.

In a busy community practice setting, it is often dificult for

nurses to access evidence-based resources. Using evidence-

based clinical practice guidelines is one way for nurses to pro-

vide evidence-based nursing care in an eficient manner. Clini-

cal practice guidelines are usually developed by a group of

experts in the ield who have reviewed the evidence and made

recommendations based on the best available evidence. The

recommendations are usually graded according to the quality

and quantity of the evidence. The Public Health Practice Refer-

ence is an example of practice guidelines developed for use by

population-centered nurses.

APPROACHES TO FINDING EVIDENCE

Returning to the previous example, the clinical question has

been stated, and the population has been deined as new moth-

ers and babies. Two interventions will be compared. The out-

come is stated as healthy babies, and the time frame may be

6 months, 1 year, or another time at which the outcomes of

the interventions will be evaluated.

Four approaches are described that allow the nurse to read

research and nonresearch evidence in a condensed format.

The irst, a systematic review, is “a method of identifying, ap-

praising, and synthesizing research evidence. The aim is to

evaluate and interpret all available research that is relevant to

a particular research question” (Grove, Gray, and Burns, 2015,

p. 513). A systematic review is usually done by more than

one person and describes the methods used to search for the

evidence and evaluate the evidence. Systematic reviews can

be accessed from most databases, such as Medline and the

Cumulative Index to Nursing and Allied Health (CINAHL).

The Cochrane Library is an electronic database that contains

regularly updated evidence-based health care databases main-

tained by the Cochrane Collaboration, a not-for-proit orga-

nization (http://www.cochrane.org). The Cochrane Library is

composed of three main branches: systematic reviews, trials

publishes systematic reviews on a wide variety of topics. Sys-

tematic reviews differ from traditional literature review pub-

lications in that systematic reviews require more rigor and

contain less opinion of the author. Systematic reviews for

public health can be found in the Guide to Community Pre-

ventive Services (2007, 2010), the Cochrane Public Health

Group, the Center for Reviews and Dissemination, and the

Campbell Collaboration (Box 10.2).

The second approach, meta-analysis, is “a speciic method

of statistical synthesis used in some systematic reviews, where

the results from several studies are quantitatively combined and

summarized” (Rychetnik et al, 2003, p 542). A well-designed

systematic review or meta-analysis can provide stronger evi-

dence than a single randomized controlled trial.

The integrative review is a form of a systematic review that

does not have the summary statistics found in the meta-analysis

because of the limitations of the studies that are reviewed (e.g.,

small sample size of the population). A narrative review is a

review done on published papers that support the reviewer’s

particular point of view or opinion and is used to provide a

general discussion of the topic reviewed. This review does not

often include an explicit or systematic review process.

Undergraduate students often perform narrative reviews.

However, it is important to learn the process for systematic re-

views, especially the use of the results of systematic reviews.

Reading systematic reviews that have been completed is helpful

in answering the question related to the EBP process.

What counts as evidence also has been argued in the pub-

lic health literature (Victora and Habicht, 2004). RCTs, which

are the highest level of evidence used to make clinical deci-

sions, are appropriate for evaluating many interventions in

http://www.cochrane.org

175CHAPTER 10 Evidence-Based Practice

Data from Titler MG, Kleiber C, Steelman VJ, et al: The Iowa model of evidence-based practice to promote quality care, Crit Care Nurs Clin North

Am 13:497-509, 2001.

BOX 10.2 Resources for Implementing Evidence-Based Practice

The following resources can assist nurses in developing evidence-based practice

(EBP) in nursing:

1. The Evidence-Based Practice for Public Health Project (http://library.

umassmed.edu/ebpph/) at the University of Massachusetts Medical

School Library has developed a website for EBP in public health. Many

bibliographic databases, such as Medline, do not list all the journals of

interest to public health workers. The project provides access to numerous

databases of interest concerning public health. From the project’s website,

nurses can access free public health online journals and databases.

2. The Agency for Healthcare Quality and Research (AHRQ) (http://www.ahrq.

gov) developed clinical guidelines based on the best available evidence for

several clinical topics, such as pain management. The guidelines are acces-

sible via the agency’s website and serve as a resource to nurses involved in

individual client care.

3. The National Guideline Clearinghouse (http://www.guideline.gov/), an initia-

tive of the AHRQ, is an online resource for evidence-based clinical practice

guidelines. The AHRQ also supports Evidence-Based Practice Centers, which

write evidence reports on various topics.

4. PubMed (http://www.pubmed.gov/) is a bibliographic database developed

and maintained by the National Library of Medicine. Bibliographic informa-

tion from Medline is covered in PubMed and includes references for nurs-

ing, medicine, dentistry, the health care system, and preclinical sciences.

Full texts of referenced articles are often included. Searches can be limited

to type of evidence (e.g., diagnosis, therapy) and systematic reviews.

5. The Cochrane Database of Systematic Reviews (http://www.cochrane.org) is

a collection of more than 1000 systematic reviews of effects in health care

internationally. These reviews are accessible at a cost via the website.

Nurses may also have free access from a medical library.

6. The Evidence-Based Nursing Journal is published quarterly. The purpose of

the journal is to select articles reporting studies and reviews from health-

related literature that warrant immediate attention by nurses attempting to keep

pace with advances in their profession. Using predeined criteria, the best quan-

titative and qualitative original articles are abstracted in a structured format,

commented on by clinical experts, and shared in a timely fashion. The research

questions, methods, results, and evidence-based conclusions are reported. The

website for the journal is http://www.evidencebasednursing.com.

7. The Honor Society of Nursing, Sigma Theta Tau International (http://www.

nursingsociety.org/), sponsors the online peer-reviewed journal Worldviews

on Evidence-Based Nursing, which publishes systematic reviews and re-

search articles on best evidence that supports nursing practice globally. The

journal is available by subscription.

8. The Task Force on Community Preventive Services (http://www.the

communityguide.org) is an independent, nonfederal task force appointed by

the director of the Centers for Disease Control and Prevention (CDC). Informa-

tion about the task force may be found at the website. The task force is

charged with determining the topics to be addressed by the CDC’s Community

Guide and the most appropriate means to assess evidence regarding population-

based interventions. The task force reviews and assesses the quality of

available evidence on the effects of essential community preventive ser-

vices. The multidisciplinary task force determines the scope of the Com-

munity Guide that will be used by health departments and agencies to

determine best practices for preventive health in populations.

medicine but are often inappropriate for evaluating public

health interventions. For example, an RCT can be designed

ethically to test a new medication for diabetes, but not for a

smoking cessation intervention. In a smoking cessation inter-

vention, subjects could not be assigned randomly to smoking or

nonsmoking groups because a smoking cessation intervention

is not appropriate for someone who does not smoke. In this

situation, a case-control study would be most appropriate.

Today there are many community-based clinical trials assist-

ing in inding answers to the questions of which population

level intervention has the best outcomes. (Visit the CDC web-

site to review these trials.)

9. The U.S. Preventive Services Task Force (USPSTF) (http://www.ahrq.gov/

clinic/uspstix.htm) is an independent panel of private-sector experts in

prevention and primary care. The USPSTF conducts rigorous, impartial as-

sessments of the scientiic evidence for the effectiveness of a broad range

of clinical preventive services, including screening, counseling, and preven-

tive medications. Its recommendations are considered the gold standard for

clinical preventive services. The mission of the USPSTF is to evaluate the

beneits of individual services based on age, gender, and risk factors for

disease; make recommendations about which preventive services should

be incorporated routinely into primary medical care and for which popula-

tions; and identify a research agenda for clinical preventive care. Recom-

mendations of the USPSTF are published as the Guide to Clinical Preventive

Services. The guide is available online.

10. The Centers for Disease Control and Prevention (CDC) (http://www.CDC.

gov) publishes guidelines on immunizations and sexually transmitted dis-

eases. Guidelines are developed by experts in the ield appointed by the

U.S. Department of Health and Human Services and the CDC.

11. The Cochrane Public Health Group (PHRG) (http://www.ph.cochrane.org/),

formerly the Cochrane Health Promotion and Public Health Field, aims to

work with contributors to produce and publish Cochrane reviews of the

effects of population-level public health interventions. The PHRG under-

takes systematic reviews of the effects of public health interventions to

improve health and other outcomes at the population level, not those tar-

geted at individuals. Thus it covers interventions seeking to address mac-

roenvironmental and distal social environmental factors that inluence

health. In line with the underlying principles of public health, these reviews

seek to have a signiicant focus on equity and aim to build the evidence to

address the social determinants of health.

12. The Center for Reviews and Dissemination (CRD) (http://www.york.ac.uk/

inst/crd/index.htm) is part of the National Institute for Health Research and

is a department of the University of York. The CRD, which was established

in 1994, is one of the largest groups in the world engaged exclusively

in evidence synthesis in the health ield. The CRD undertakes systematic

reviews evaluating the research evidence on health and public health ques-

tions of national and international importance.

13. The Campbell Collaboration (http://www.campbellcollaboration.org/), named

after Donald Campbell, was founded on the principle that systematic

reviews on the effects of interventions will inform and help improve

policy and services. The collaboration strives to make the best social

science research available and accessible. Campbell reviews provide

high-quality evidence of what works to meet the needs of service providers,

policymakers, educators and their students, professional researchers, and

the general public. Areas of interest include crime, justice, education, and

social welfare.

http://www.ahrq.gov

http://www.guideline.gov/

http://www.pubmed.gov/

http://www.cochrane.org

http://www.evidencebasednursing.com

http://www.nursingsociety.org/

http://www.thecommunityguide.org

http://www.ahrq.gov/clinic/uspstfix.htm

http://www.CDC.gov

http://www.ph.cochrane.org/

http://www.york.ac.uk/inst/crd/index.htm

http://www.campbellcollaboration.org/

176 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

APPROACHES TO EVALUATING EVIDENCE

One approach used in evaluating evidence is grading the strength

of evidence. When evidence is graded, the evidence is assigned a

“grade” based on the number and type of well-designed studies

and the presence of similar indings in all of the studies. Grading

evidence has been debated so strongly that in 2002 the Agency for

Healthcare Research and Quality (AHRQ) commissioned a study

to describe existing systems used to evaluate the usefulness of

studies and strength of evidence. The report reviewed 40 systems

and identiied three domains for evaluating systems for the grad-

ing of evidence quality, quantity, and consistency:

• The quality of a study refers to the extent to which bias is

minimized.

• Quantity refers to the number of studies, the magnitude of

the effect, and the sample size.

• Consistency refers to studies that have similar indings, using

similar and different study designs. (Melnyk and Fineout-

Overholt, 2015)

An example of grading the strength of evidence is the process

the U.S. Preventive Services Task Force used in developing the

Guide to Clinical Preventive Services (2016a).

As indicated, many frameworks exist for evaluating the

strength and usefulness of the evidence found in the literature

and other sources, such as professional standards. A popular

framework was developed by the AHRQ. Fineout-Overholt et al

(2010) have also developed an approach for evaluating evi-

dence. Although these approaches vary in the factors they

evaluate, the best approach to choose is one that evaluates

not only the strength but also the usefulness of the evidence.

Table 10.1 provides an example of an approach for evaluating

evidence.

The strength of the literature is measured by the type of evi-

dence it represents. For example, the RCT is the evidence that

has the greatest strength on which to make a clinical decision. In

contrast, opinion articles, descriptive studies, and professional

reports of expert committees have less strength. The usefulness

of the evidence is measured by whether the evidence is valid,

whether it is important, and whether it can be used to assist in

making practice decisions or changes in the community envi-

ronment and with the population of interest to improve out-

comes (Facchiano, Snyder, 2012). The best RCT conducted in a

hospital setting, using an intervention to prevent falls, may not

be applicable in a community setting. Therefore, although it

may be a strong study with outcomes that improve health, it

may not have the usefulness for applicability in the community

because of the setting in which it was conducted.

HOW TO Develop an Evidence-Based Protocol

Evidence-based protocols are a recognized approach to providing quality client

care. Such protocols enhance the abilities of providers and can reduce health

care errors. The following are steps to developing a protocol:

• Identify the problem.

• Identify stakeholders.

• Form a team of others to help develop the protocol.

• Develop an action plan with project goals and a timeline.

• Review the available evidence.

• Examine current practice and identify gaps as well as best practices.

• Develop the protocol focusing on gaps.

• Initiate the approval process with the setting.

• Evaluate current practices and modify as needed.

• Educate others who will use the protocol.

• Implement the protocol.

• Evaluate protocol for safety, effectiveness, and adherence.

From McEuen JA, Gardner KP, Barnachea DF, et al: An evidence-based

protocol for managing hypoglycemia, Am J Nurs 110:40-45, 2010.

Type/Category

Strength/How

Established

Considerations for the Level

of Scientiic Evidence—Quality

Quantity/Consistency Data Source

Examples

Evidence-based

Peer review via systematic

or narrative review

Based on study design and execution

External validity

Potential side beneits or harms

Costs and cost-effectiveness

Community Guide

Cochrane reviews

Narrative reviews based on published literature

Effective

Peer review Based on study design and execution

External validity

Potential side beneits or harms

Costs and cost-effectiveness

Articles in the scientiic literature

Research-tested intervention programs

Technical reports with peer review

Promising

III

Written program evaluation

without formal peer

review

Summative evidence of effectiveness

Formative evaluation data

Theory-consistent, plausible, potentially high-reach,

low-cost, replicable

State or federal government reports (without

peer review)

Conference presentations

Emerging

Ongoing work, practice-

based summaries, or

evaluation works in

progress

Formative evaluation data

Theory-consistent, plausible, potentially high-

reaching, low-cost, replicable

Face validity

Evaluability assessments

Pilot studies

National Institutes of Health Research Portfolio

Online Reporting Tools (RePORT) database

Projects funded by health foundations

TABLE 10.1 Typology for Classifying Interventions by Level of Scientiic Evidence

From Brownson RC, Fielding JE, Maylahn CM: Evidence-based public health: a fundamental concept for public health practice, Annu Rev Public

Health 30:175-201, 2009.

177CHAPTER 10 Evidence-Based Practice

Shaughnessy et al (1994) proposed criteria for evaluating

the usefulness of evidence, calling the process patient-

oriented evidence that matters (POEM). In general, the reader

should ask the following questions: “What are the results?

(Are they important?) Are the results valid? How can the

results be applied to client care?” (p 489). Application

of POEM can be found at http://www.essentialevidenceplus.

com. Brownson et al (2013) proposed that the following

questions be asked for EBP (plus suggested application

examples):

• What is the size of the public health problem? What is the

need for improved health outcomes for new mothers and

babies in our community?

• Can interventions be found in the literature to address the

problem (e.g., home visits or parenting classes)?

• Is the intervention useful in this community, with this popu-

lation, or with populations at risk (e.g., the low income or

uninsured)?

• Is the intervention the best one or are there other ways to

address the problem considering cost and potential health

outcomes for the population? (Assess cost and health out-

comes of both of the interventions before choosing, includ-

ing the nurses available to make home visits or who have the

skills to teach the parenting class.)

Several variables are considered important in determining

the quality of evidence used to make clinical decisions (Polit

and Beck, 2014):

• Sample selection: Sample selection should be as unbiased as

possible. For example, a sample is randomly selected when

each subject has an equal chance of being selected from the

population of interest. Random selection offers the least bias

of any type of sample selection. Other types of sample selec-

tion, such as convenience sampling, contain researcher or

evaluator bias.

• Randomization: When testing an intervention, randomly

assign participants to either the intervention or control

group. This type of assignment is less biased than if

participants are allowed to choose the group they want

to join.

• Blinding: The researcher or evaluator should not know

which participants are in the experimental (treatment)

group or which are in the control group. The researcher or

evaluator is “blinded” as to who is receiving the treatment

and who is not receiving the treatment.

• Sample size: The sample size should be large enough to

show an effect of the intervention. In general, the larger the

sample size, the better.

• Description of intervention: The intervention should be

described in detail and explicitly enough that another person

could duplicate the study if desired.

• Outcomes: The outcomes should be measured accurately.

• Length of follow-up: Depending on the intervention, the

participants should be followed for a long enough period to

determine whether the intervention continued to work or if

the results were just by chance.

• Attrition: Few subjects should have dropped out of the

study.

• Confounding variables: Variables that could affect the out-

come should be accounted for by either statistical methods

or study measurements.

• Statistical analysis: Statistical analysis should be appropri-

ate to determine the desired outcome.

APPROACHES TO IMPLEMENTING EVIDENCE-BASED PRACTICE

The irst step toward implementing EBP in nursing is recogniz-

ing the current status of one’s own practice and believing that

care based on the best evidence will lead to improved client out-

comes (Melnyk et al, 2015). EBP is a relatively new concept, and

thus, many practicing nurses are not familiar with the applica-

tion of EBP and may lack computer and Internet skills necessary

to implement EBP. Also, implementation will be successful only

when nurses practice in an environment that supports evidence-

based care. Public health nurses consider EBP as a process to

improve practice and outcomes and use the evidence to inlu-

ence policies that will improve the health of communities.

CURRENT PERSPECTIVES

COST VERSUS QUALITY

Much of the pressure to use EBP comes from third-party payers

and is a response to the need to contain costs and reduce legal li-

ability. Nurses must question whether the current agenda to con-

tain health care costs creates pressure to focus on those research

results that favor cost saving at the expense of quality outcomes

for clients. Outcomes include client and community satisfaction

and the safety of care. Costs can be weighed against outcomes

when EBP is used to show the best practices available to reduce

possible harm to clients (Makic et al, 2014; Melnyk et al, 2014).

LEVELS OF PREVENTION

Using Evidence-Based Practice

According to evidence collected and averaged by the Task Force on Community

Preventive Services, the following are interventions supported by the literature

at each level of prevention:

Primary Prevention

Extended and extensive mass media campaigns reduce youth initiation of

tobacco use.

Secondary Prevention

Client reminders and recalls via mail, telephone, e-mail, or a combination

of these strategies are effective in increasing compliance with screening

activities such as those for colorectal and breast cancer.

Tertiary Prevention

Diabetes self-management education in community gathering places improves

glycemic control.

From Task Force on Community Prevention Services: All indings of the

Community Preventive Services Task Force. In: The Community Guide:

The guide to community preventive services, Atlanta, GA, 2016b, Centers

for Disease Control and Prevention. Retrieved July 2016 from http://

www.thecommunityguide.org/about/conclusionreport.html.

http://www.essentialevidenceplus.com

http://www.thecommunityguide.org/about/conclusionreport.html

178 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

INDIVIDUAL DIFFERENCES

EBP cannot be applied as a universal remedy without attention

to client differences. When EBP is applied at the community

level, the best evidence may point to a solution that is not sensi-

tive to cultural issues and distinctions and thus may not be

acceptable to the community. Ethical practice in communities

requires attention to community differences.

APPROPRIATE EVIDENCE-BASED PRACTICE METHODS FOR COMMUNITY-ORIENTED NURSING PRACTICE

Gaining various perspectives in a speciic community is impor-

tant for nurses using EBP. Nursing has a legitimate role to play

in interprofessional community-focused practice and can con-

tribute to its evidence base. Nurses are obliged to ensure that

the evidence applied to practice is acceptable to the community.

Establishing an EBP culture depends on the use of both qualita-

tive and quantitative research approaches or the best evidence

available at the time. For example, a quantitative research study

of a community health center could provide information about

patterns of client use, the cost of various services, and the use of

different health care providers. However, when quantitative re-

search is combined with qualitative research, the nurse can gain

an understanding of why clients use or do not use the services

and can help the health center be both clinically effective and

cost-effective. Evidence from multiple research methods has

the potential to enrich the application of evidence and im-

prove nursing practice (Stevens, 2013). The Quality and Safety

Education for Nurses (QSEN) box gives an example of how to

use evidence for making a change in a community’s health.

The rising cost of health care will demand a more critical

look at beneits and costs of EBP. Finding resources to imple-

ment EBP will continue to be a challenge requiring creative

strategies. An emphasis on quality care, equal distribution of

health care resources, and cost control will continue. Imple-

menting EBP can assist nurses in addressing these issues in the

clinical setting. However, EBP can save money by providing the

best care possible.

As nurses implement EBP in an environment focused on

cost savings, the potential for governments, managed care

organizations, or other health care agencies to endorse reim-

bursement of health care options solely on the basis of

cost, without allowing for individual variation or considering

environmental issues, will continue to be a concern. Nurses

must use caution in adopting EBP in a prescriptive manner in

different community environments. One aspect of the Patient

Protection and Affordable Health Care Act of 2010 (ACA;

PL 111-148) addresses the development of task forces on

preventive services and community preventive services to

develop, update, and disseminate EBP recommendations of

the use of community preventive services. In addition, grant

programs to support EBP delivery in the community are

addressed in the ACA.

Although the Internet is one source of evidence data (see

Box 10.2), there may be a lack of quality indicators to evaluate the

myriad websites claiming to contain evidence-based informa-

tion. It is essential to evaluate the quantity of the information on

the website, whether it comes from a reputable agency or scholar,

Prepared by Gail Armstrong, DNP, ACNS-BC, CNE, Associate Professor, University of Colorado Denver College of Nursing.

FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES

Targeted Competency: Evidence-Based Practice—Integrate best current

evidence with clinical expertise and client and family preferences and

values for delivery of optimal interventions.

Important aspects of EBP include:

• Knowledge: Describe EBP to include the components of research evidence,

clinical expertise, and client and family values.

• Skills: Locate evidence reports related to clinical practice topics and

guidelines.

• Attitudes: Value the need for continuous improvement in clinical practice

based on new knowledge.

Evidence-Based Practice Question:

As a nurse in the community, you are working within a Native American community

that has a high prevalence of diabetes. As you visit with clients in their homes, you

notice that many have a standardized “Diabetes Care” handout they received from

the same primary care clinic. Your clients comment that the nutritional recommen-

dations are unrealistic in the context of their regular diet. You decide to initiate a

focus group with clients who attend the diabetes clinic at the health department to

customize diabetic nutritional guidelines for this community.

1. Go to The National Guideline Clearinghouse website at http://www.guideline.

gov. This website is an initiative of the Agency for Healthcare Research and

Quality and is a reservoir for evidence-based clinical guidelines.

2. On the home page, type “diabetes” in the search box.

3. The second result is: Guideline Synthesis: Nutritional Management of

Diabetes Mellitus.

4. Review the various areas of the guidelines: Medical Nutritional Therapy,

Carbohydrates, Protein, Fiber, Sucralose, Alcohol Consumption, Dietary Fat

and Cholesterol, Micronutrients, Nutritional Interventions for Preventing and

Managing Complications, and Physical Activity and Weight Management.

5. What baseline data might you gather from your focus-group participants to be

best informed in how to tailor the evidence-based recommendations for this

community?

6. What might be effective strategies in writing up the community-speciic

guidelines and distributing them that might enhance their adoption?

Answer:

• Understanding the common elements of this community’s diet is a good place

to start. What carbohydrates, proteins, and sources of sugar, dietary fat, and

cholesterol are commonly consumed?

• How does the common diet compare to the National Clearinghouse Guide-

lines? Are there healthy sources of carbohydrates and healthy fats that are

part of the diet that can be emphasized?

• What are common alcohol consumption patterns in the community? Would

educational efforts regarding the deleterious effects of alcohol on diabetes be

helpful?

• Writing up community-based guidelines with assistance from leaders in the

community would be a helpful strategy. You could include healthy recipes

from community leaders in your guidelines. Your community-based guidelines

might be distributed at a community celebration or gathering by members of

the community who helped develop them.

http://www.guideline.gov

179CHAPTER 10 Evidence-Based Practice

HEALTHY PEOPLE 2020 OBJECTIVES

Healthy People 2020 objectives offer a systematic approach to

health improvement. See the Healthy People 2020 box for the

most recent objectives to improving clients’ understanding

of EBP and how they can contribute to health care decisions.

EXAMPLE OF APPLICATION OF EVIDENCE- BASED PRACTICE TO PUBLIC HEALTH NURSING

This example describes the Intervention Wheel, a population-

based practice model for public health nursing. The model

consists of three levels of practice at the community, sys-

tems, and individual and family levels. It also consists of

17 public health interventions for improving population

health (Minnesota Department of Public Health, 2003).

(See Appendix C.4.) The model was originally developed

using a qualitative grounded theory process but did not in-

clude a systematic review of evidence to support the inter-

ventions or their application to practice. Initially, the model

was developed from an extensive analysis of the actual work

of 200 practicing public health nurses working in a variety

of settings. The 17 interventions grew out of this analysis, as

did the three levels of practice. The authors indicated that

the original intent was to provide a description of the scope

and breadth of public health nursing practice. Because of

the positive response to the Intervention Wheel, the deci-

sion was made to complete a systematic review of the evi-

dence supporting the use of the Intervention Wheel. The

goal was to examine the evidence underlying the interven-

tions and the levels of practice. The systematic review in-

volved answering six questions, a comprehensive search of

the literature, a survey of 51 bachelor of science in nursing

(BSN) programs in five states, and a critique (by five gradu-

ate students) of the 665 pieces of evidence found in the lit-

erature review for rigor (strength and usefulness). After

limiting the final review to 221 sources of evidence, each

source was independently rated by at least two members

of a 42-member panel of practicing public health nurses

and educators. The 42-member panel met to reach consen-

sus on the outcomes of the reviews. The outcomes were

field-tested with 150 practicing nurses, then critiqued by a

national panel of 20 experts. The Intervention Wheel is the

result of this systematic review and critique (Keller et al,

2004). Although this critique may appear overwhelming, the

undergraduate or graduate student may be involved in such

a systematic critique as one of many participants contribut-

ing to the outcome of such a review. Table 10.2 applies some

of the interventions to the core functions of public health.

APPLYING CONTENT TO PRACTICE

This chapter emphasizes that it is important for nurses to acknowledge and

understand evidence-based practice. They can participate by using it or they

can add to the research base for the public’s health through active programs of

research or reviewing the best available evidence by reading published sys-

tematic reviews. Nurses can demonstrate leadership in supporting evidence-

based practice (EBP) by becoming change agents, fostering a cultural change

in the practice environment, and assisting nurses who do not know how to use

EBP to make a difference in practice.

For example, nurses who have recently graduated are knowledgeable about

the use of evidence in practice. The new nurses can assist nurses who have

been out of school for a while to ind sources of evidence on which to base

their practice, such as referring them to the Guide to Community Preventive

Services. Using evidence in practice will demonstrate its value, but implemen-

tation can be dificult because of the sheer volume of evidence and increasing

population needs. Sharing knowledge and engaging in teamwork can help

overcome these barriers.

Nurses have an important role to play in developing and using clinical guide-

lines for community practices. Use of a community development model and

engaging in community partnerships will ensure that the community’s perspec-

tive is included (see Chapter 12).

Nurses active in EBP can devote attention to understanding how best to

incorporate the guidelines into practice, demonstrating practice excellence.

EBP offers the opportunity for shared decision making because it can help

nurses focus their thinking, observe process outcomes, and thus improve care

for clients by communicating with leaders and other nurses what they have

observed. Participation in EBP offers continuing professional growth (Grifin

and Titler, 2015).

Information access is important to ensure clients and communities have the

correct information to make evidence-based health care decisions. The Healthy

People 2020 objectives related to providing resources are as follows:

• HC/HIT-6.3: Increase the proportion of persons who use electronic personal

health management tools.

• HC/HIT-4: Increase the proportion of patients whose doctor recommends

personalized health information resources to help them manage their

health.

• HC/HIT-12: Increase the proportion of crisis and emergency risk messages,

intended to protect the public’s health, that demonstrate the use of best

practices.

• HC/HIT-11: Increase the proportion of meaningful users of health informa-

tion technology.

• HC/HIT-13: Increase the social marketing in health promotion and disease

prevention.

HEALTHY PEOPLE 2020

Jamie Lee is the occupational health nurse at the T-shirt factory in town. Re-

cently the health clinic at the T-shirt factory had budget cuts, resulting in the

reduction of services and personnel. The once full-time clinic is now open only

3 days a week, and Ms. Lee no longer has support staff to help her with her

paperwork responsibilities.

From her interactions with the workers, Ms. Lee has observed several risky

health behaviors (e.g., unhealthy diets, smoking) among them. Although she is

very busy in the clinic, Ms. Lee would like to develop a health promotion program

to address these risky health behaviors, but she is not sure where to start.

CASE STUDY

Developing an Evidence-Based Health Promotion

Program

and whether the source of the website has a inancial interest in

the acceptance of the evidence presented. (Refer to Chapter 11 on

health education, which discusses the Internet as a source of data

and how to evaluate its usefulness and reliability.)

180 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

From U.S. Department of Health and Human Services: Healthy People 2020: roadmap to improving all Americans’ health, Washington, DC, 2010,

U.S. Government Printing Ofice..

Core Functions Related Nursing Interventions

Assessment Diagnose and investigate health problems and hazards in the community

Mobilize community partnerships to identify and solve health problems

Link people to needed health services

Use evidence-based practice for new insights and innovative solutions to health problems

Policy development Inform, educate, and empower communities about health issues

Develop policies and plans using evidence-based practice that supports individual and community health efforts

Assurance Monitor health status to identify community health problems

Enforce laws and regulations that protect health and ensure safety

Ensure the provision of health care that is otherwise unavailable

Ensure a competent public health and personal health care workforce

Use evidence-based practice to evaluate effectiveness, accessibility, and quality of personal and population-based services

TABLE 10.2 Core Public Health Functions and Related Evidence-Based Nursing Interventions

P R A C T I C E A P P L I C A T I O N

A nurse who is the director of a part-time, nurse-managed

clinic is in the process of analyzing how best to expand services

to operate as a full-time clinic in the most cost-effective and

clinically effective manner. The director gathers evidence from

the literature on nurse-managed clinics in other rural settings

to evaluate the cost and clinical effectiveness of various models.

The nurse also considers evidence from the following sources in

the decision-making process: client satisfaction research data,

knowledge of clinic staff, expert opinion of community advi-

sory board members, evidence from community partners, and

data on service needs in the state. Having examined the evi-

dence, the nurse decides that incremental (step-by-step) growth

toward full-time status is warranted. Evidence of needs in the

community and analysis of statistical data indicate that the

addition of services for children is a priority and a pediatric

nurse practitioner is hired as a irst step while planning for full-

time status continues.

Evaluation of the evidence gathered demonstrates which of

the following?

A. Effectiveness of the intervention in communities

B. Application of the data to populations and communities

C. Existence of positive or negative health outcomes

D. Economic consequences of the intervention

E. Barriers to implementation of the interventions in

communities

Explain how this example applies principles of evidence-

based practice.

Answers can be found on the Evolve website.

R E M E M B E R T H I S !

• Evidence-based practice was developed in other countries

before its use in the United States.

• Application of evidence-based practice in relation to clinical

decision making in population-centered nursing concen-

trates on interventions and strategies geared to communities

and populations rather than to individuals.

• The goals, as evidenced through Healthy People 2020, are to

increase the quality and years of healthy life and to eliminate

health disparities in populations (U.S. Department of Health

and Human Services, 2010).

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182

Using Health Education and Groups in the Community

Jeanette Lancaster

11 C H A P T E R

ACTS, 189

affective domain, 184

andragogy, 190

cognitive domain, 184

cohesion, 196

conlict, 199

democratic leadership, 198

education, 184

established groups, 199

evaluation, 194

formal group, 196

group, 195

group culture, 197

group purpose, 196

Health Belief Model (HBM), 193

health literacy, 192

informal group, 196

leadership, 197

learning, 184

long-term evaluation, 195

maintenance functions, 196

maintenance norms, 197

motivational interviewing, 188

National Assessment of Adult Literacy

(NAAL), 192

norms, 197

patriarchal leadership, 198

pedagogy, 190

Precaution Adoption Process Model

(PAPM), 193

process evaluation, 194

psychomotor domain, 184

reality norms, 197

role structures, 197

selected membership group, 199

short-term evaluation, 195

task function, 196

task norm, 197

teach-back, 189

Transtheoretical Model (TTM), 193

K E Y T E R M S

Healthy People 2020 Objectives for Health Education

Education and Learning

The Nature of Learning

The Educational Process

Identify Educational Needs

Establish Educational Goals and Objectives

Select Appropriate Educational Methods

Skills of the Effective Educator

Motivational Interviewing

Developing Effective Health Education Programs

Educational Issues and Barriers to Learning

Population Considerations Based on Age and Cultural

and Ethnic Backgrounds

C H A P T E R O U T L I N E

Educator-Related Barriers

Learner-Related Barriers

Use of Technology in Health Education

Evaluation of the Educational Process

Evaluation of Health and Behavioral Changes

Groups: A Tool in Health Education

Group: Deinitions and Concepts

Choosing Groups for Health Change

Beginning Interactions and Dealing with Conlict

Evaluation of Group Progress

After reading this chapter, the student should be able to:

1. Discuss ways that people learn.

2. Identify the steps and principles that guide health education.

3. Describe the importance of literacy, especially health literacy,

in health promotion and health education.

4. Describe factors that inluence group functioning and how

members of groups learn about health behaviors.

O B J E C T I V E S

5. Describe how nurses can work with groups to promote the

health of individuals and communities.

6. Explain strategies that nurses can use to provide effective

health education.

183CHAPTER 11 Using Health Education and Groups in the Community

One of the best ways to manage health care costs is to help

people stay healthier. Nurses are ideal health care practitioners

to lead in health promotion through health education because

(1) they educate clients across all three levels of prevention:

primary, secondary, and tertiary; and (2) they work with indi-

viduals, families, groups, and communities. The goal is to help

clients attain optimal health, prevent health problems, identify

and treat health problems early, and minimize disability. Educa-

tion allows individuals to make knowledgeable health-related

decisions, assume personal responsibility for their health, and

cope effectively with alterations in their health and lifestyles.

Often the goal in health promotion and health education is

helping clients change their behaviors; a key part of public

health nursing practice is to teach people to promote health,

prevent illness, and manage chronic illness.

This chapter discusses ways to develop individual, group, and

community health promotion programs. Speciic content in the

chapter includes information about how people learn, the se-

quence of actions that a nurse follows when developing an educa-

tional program, using skills, such as motivational interviewing in

health promotion, selected models of health promotion, and the

important topic of literacy, especially health literacy. The role of

groups in health promotion is also presented. Many of the objec-

tives of Healthy People 2020 address the importance of health

promotion, and selected objectives are cited in this chapter.

HEALTHY PEOPLE 2020 OBJECTIVES FOR HEALTH EDUCATION

As mentioned in chapters throughout the text, Healthy People

2020 lists national health needs and outlines goals and objec-

tives designed to improve health. The Healthy People 2020 edu-

cational objectives emphasize the importance of educating

various populations (based on age and ethnicity) about health

promotion activities in the priority areas of unintentional in-

jury, violence, suicide, tobacco use and addiction, alcohol or

other drug use, unintended pregnancy, human immunodei-

ciency virus (HIV) and acquired immunodeiciency syndrome

(AIDS), sexually transmitted diseases (STDs), unhealthy dietary

In designing, implementing, and evaluating health educa-

tion activities, it is important to learn about the primary health

problems in the community, as well as education principles re-

lated to both learning and teaching. The goal of an educational

program is to teach what people think they want to learn and in

ways that facilitate their learning. In public health it is impor-

tant for learners to participate in identifying their learning

needs. Then education programs are designed to meet the health

need or problem in that population. Generally these programs

involve educating individual members of the population about

health promotion, illness prevention, and treatment. For exam-

ple, in a community in which childhood and adolescent asthma

is a problem, a community-based asthma education and train-

ing program can be developed. If childhood obesity is a major

health concern, a program to educate children in their schools

and their parents or caregivers about healthy eating, cooking,

and exercise may be useful.

To develop a community-based educational program for

education about asthma or childhood obesity, the nurse would

need to follow a set of steps. The steps are listed here and dis-

cussed in detail throughout the chapter. Typical steps to follow

in developing a health education program include (1) identify

a population-speciic learning need for the community health

client; (2) select one or more learning theories to use in the

education program; (3) consider which educational principles

are most likely to increase learning and choose those that are

most appropriate and feasible; (4) examine educational issues,

such as population-speciic or cultural concerns, identify bar-

riers to learning, such as limited literacy or limited or lack of

health literacy, and choose the most appropriate teaching and

learning strategies based on the age, gender, cultural back-

ground, education, and learning needs of the learners; (5) de-

sign and implement the educational program using carefully

chosen strategies; (6) evaluate the effects of the educational

program. The steps used in educational programs parallel

those of the nursing process—assessment, planning, imple-

mentation, and evaluation.

Selected examples related to health education are as follows:

• ECBP-2: Increase the proportion of elementary, middle, and senior high

schools that provide comprehensive school health education to prevent

health problems in the following areas: unintentional injury, violence, sui-

cide, tobacco use and addiction, alcohol or other drug use, unintended

pregnancy, HIV/AIDS and sexually transmitted infections (STIs), unhealthy

dietary patterns, and inadequate physical activity.

• ECBP-3: Increase the proportion of college and university students who

receive information from their institution on each of the priority health-risk

behavior areas listed previously.

• ECBP-8: Increase the proportion of worksites that offer a comprehensive

employee health promotion program to their employees.

• ECBP-11: Increase the proportion of local health departments that have

established culturally appropriate and linguistically competent community

health promotion and disease prevention programs.

HEALTHY PEOPLE 2020

Source: Graff M, Scott RA. Justice AE, et al: Genome-wide physical

activity interactions in adiposity-A meta-analysis of 200,452 adults,

PLOS, Genetics on Line, April 27, 2017.

HEALTH EDUCATION AND INFLUENCE OF GENOMICS

As has been discussed in many chapters of this text, there is a correlation

among weight, health, and exercise. It has recently been determined that

even if obesity is in your genes, regular exercise can help keep pounds from

accruing to you. Researchers at the University of North Carolina at Chapel Hill

found that people who carried the FTO gene variant that increases the risk of

obesity could reduce the effects of their DNA by about one third by engaging

in regular exercise. One thing that the study shows is that people do not have

to be victims to their genes. They have choices. With this gene variant, regu-

lar exercise can interrupt to some extent the effects on weight. Overall the

research team found that exercise weakened the gene variant’s effects by

about 30 percent.

patterns, and inadequate physical activity (US Department of

Health and Human Services [USDHHS], 2010).

184 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

domains of learning. Each domain has speciic behavioral compo-

nents that form a hierarchy of steps, or levels. Each level builds on

the previous one. Understanding these three learning domains is

crucial in providing effective health education (Bloom et al, 1956).

First, consider assumptions about how adults learn. Speciically,

adults are motivated to learn when (1) they think they need to know

something, (2) the new information is compatible with their prior

life experiences, (3) they value the person(s) providing the informa-

tion, and (4) they believe they can make any necessary changes that

are implied by the new information (Knowles et al, 2015).

Cognitive Domain The cognitive domain includes memory, recognition, under-

standing, reasoning, application, and problem solving and is di-

vided into a hierarchical classiication of behaviors. Learners

master each level of cognition in order of dificulty and move up

the learning hierarchy (Bloom et al, 1956). Start by assessing the

cognitive abilities of the learners. This is especially important

when learners have a limited level of literacy either of the language

used in the instruction or of the content presented. A later section

will discuss literacy in general and health literacy in particular.

Teaching above or below a person’s level of understanding can

lead to frustration and discouragement. The components of the

cognitive domain are as follows (Bloom et al, 1956):

1. Knowledge: Requires recall of information

2. Comprehension: Combines recall with understanding

3. Application: New information is taken in and used in a dif-

ferent way

4. Analysis: Breaks communication down into parts to under-

stand both the parts and their relationships to one another

5. Synthesis: Builds on the irst four levels by assembling them

into a new whole

6. Evaluation: Learners judge the value of what has been learned

Affective Domain The affective domain includes changes in attitudes and the de-

velopment of values. For affective learning to take place, nurses

consider and attempt to inluence what learners feel, think, and

value. Because the attitudes and values of nurses may differ from

those of their clients, it is important to listen carefully to detect

clues to feelings that learners have that may inluence learning. It

is dificult to change deeply rooted attitudes, beliefs, interests, and

values. To make such changes, people need support and encour-

agement from those around them. Affective learning, like cogni-

tive learning, consists of the following series of steps:

1. Knowledge: Receives the information

2. Comprehension: Responds to the information received

3. Application: Values the information

4. Analysis: Makes sense of the information

5. Synthesis: Organizes the information

6. Evaluation: Adopts behaviors consistent with new values

Psychomotor Domain The psychomotor domain includes the performance of skills

that require some degree of neuromuscular coordination and

emphasizes motor skills (Bloom et al, 1956). Clients are taught

a variety of psychomotor skills, including bathing infants,

changing dressings, giving injections, measuring blood glucose

APPLYING CONTENT TO PRACTICE

Just as objectives in Healthy People 2020 (USDHHS, 2010) recommend that health

education and promotion be used to provide public health care, so do other key

documents, such as the American Nurses Association’s Scope & Standards of

Practice: Public Health Nursing. Standard 5b, labeled Health Education and Health

Promotion, says that the “public health nurse employs multiple strategies to pro-

mote health, prevent disease, and ensure a safe environment for populations”

(American Nurses Association [ANA], 2007, p 23). Similarly, the Core Competences

for Public Health Professionals of the Council on Linkages between Academia and

Public Health Practice (2010) lists six competencies related to communication skills;

ive of them relate directly to this chapter. These competencies, which are dis-

cussed and illustrated throughout the chapter, are as follows:

1. Assesses the health literacy of populations served

2. Communicates in writing and orally, in person, and through electronic

means, with linguistic and cultural proiciency

3. Solicits input from individuals and organizations

4. Uses a variety of approaches to disseminate public health information

5. Applies communication strategies in interactions with individuals and groups

EDUCATION AND LEARNING

Education is an activity designed to help people change their

knowledge, attitudes, and skills about a speciic topic. Knowledge

is the least dificult area to change, followed by attitudes, and then

the most dificult is behavior. Nurses provide people with health

information so they can improve their decision-making abilities

and thereby decide if they will change their behavior. Education

emphasizes the provider of knowledge and skills. In contrast,

learning emphasizes the recipient of knowledge and skills and the

person(s) in whom a change is expected to occur. Remember that

learning involves change, and change is dificult for many people.

People learn in a variety of ways. Many people learn best

through active involvement in their learning, in contrast to learners

who are like sponges and prefer to simply soak up the information

that is presented. Learners accept information based on many fac-

tors, including what they already know, what they believe, the cul-

ture in which they have been raised, their generational experiences

related to learning, and how well they can understand and relate to

the information that they receive. What people hear is iltered

through their past experiences; the social groups to which they

belong; assumptions, values, level of attention, and knowledge; and

the esteem in which they hold the person communicating the

information. Effective health education is a competency that is in-

cluded in many documents that describe the role of public health

professionals, including nurses. The Applying Content to Practice

box illustrates the relationship between health education and se-

lected standards, expectations, and competencies in public health.

A variety of educational principles can be used to guide the

selection of health information for individuals, families, commu-

nities, and populations. Three of the most useful categories of edu-

cational principles are those associated with the nature of learning,

the educational process, and the skills of effective educators.

THE NATURE OF LEARNING

One way to think about the nature of learning is to examine the

cognitive (thinking), affective (feeling), and psychomotor (acting)

185CHAPTER 11 Using Health Education and Groups in the Community

To summarize, when assessing a client’s ability to learn a

skill, be sure to evaluate intellectual, emotional, and physical

ability and then teach at the level of the learner’s ability. Some

clients do not have the intellectual ability to learn the steps that

levels, taking blood pressures, and walking with crutches, as

well as many skills related to health promotion exercises.

When you are teaching a skill, irst show clients how to do

the skill. You can show the client using pictures, a model, or a

device or via a live demonstration, video, CD, or the Internet.

There are many helpful teaching materials available on YouTube.

Next, allow clients to practice, which is a repeat demonstration

or teach-back approach to validate that what was being taught

was learned. Also, if the teaching is being done in a class, par-

ticipants may learn by observing one another master a task.

Psychomotor learning depends on learners meeting the follow-

ing three conditions (Bloom et al, 1956; Dembo, 1994):

• The learner must have the necessary ability, including both cogni-

tive and psychomotor ability. For example, you may ind that a

person with Alzheimer’s disease can follow only one-step instruc-

tions. Thus you need to tailor your education plan to that person.

• The learner must have a sensory image of how to carry out

the skill. For example, when teaching a group of women how

to cook heart-healthy meals, ask the women to describe their

kitchen and how they would actually go about the shopping

and cooking process.

• The learner must have opportunities to practice the new skills.

Provide practice sessions during the program to help the

client adapt the skill to the home or work environment

where the skill will be performed.

THE EDUCATIONAL PROCESS

The educational process builds on an understanding of education,

learning, and how people learn. The ive steps of the educational

process are discussed next.

IDENTIFY EDUCATIONAL NEEDS

To learn about clients’ health education needs, begin by conduct-

ing a systematic and thorough needs assessment. Assessment

steps are listed in Box 11.1. Once needs are identiied, prioritize

them beginning with the most critical educational needs.

Factors that can inluence a person’s learning needs and ability

to learn include the learner’s demographic, physical, geographic,

economic, psychological, social, and spiritual characteristics.

To apply the three learning domains, consider this clinical situation: In the commu-

nity being served, the nurse identiies a large number of women who are newly di-

agnosed as having diabetes. The goals of the nurse would include: (1) learning what

the women know about their health condition; (2) providing basic information about

diabetes and self-care (cognitive domain); and (3) teaching them how to correctly

inject insulin and to determine the amount of insulin each would need at a given

time (psychomotor domain). It is important to demonstrate insulin injection and ask

each woman to do a repeat demonstration to verify that she has the necessary abil-

ity and dexterity to self-inject insulin. During the teaching session, the nurse learns

that the women have a limited understanding of the possible long-term complica-

tions of diabetes. Teaching at this level will include the affective domain in that the

women may be denying the seriousness of their illness. They may think that a dis-

ease that causes limited pain and discomfort in its early stages cannot lead to many

complications if not properly managed. In this case the nurse would be guided by six

principles of effective education. First, the nurse would convey the information

clearly, using words that the women understand. A place for the teaching would be

chosen that is private and comfortable, and the nurse would organize her teaching

approach to it the needs of the learner. In diabetes education, it is important not only

to give information but to demonstrate and then ask the learners to practice in the

class what they are learning. Evaluation of the effectiveness of the session(s) can be

accomplished by asking the learners what they have learned and by watching and

listening to them as they discuss and practice their new learning.

Application to other clinical examples: How would you apply the three domains

of learning to developing an educational session for a group of women who have

young children in the home and need to be better informed about safety practices

in terms of water, stoves, poisons, medicines, tools, and so forth?

CASE STUDY

Teaching About Diabetes

FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES

Targeted Competency: Client-Centered Care—Key aspects of client-

centered care include the following:

• Knowledge: Integrate understanding of multiple dimensions of client-

centered care: information, communication, and education.

• Skills: Communicate client values, preferences, and expressed needs to

other members of the health care team.

• Attitudes: Respect and encourage individual expression of client values,

preferences, and expressed needs.

Client-centered care question:

Providing health information in a way that is not understandable or useful to

the recipient is a poor form of client-centered communication. If you were

teaching a group of four women about wound care after surgery, what steps

would you take to ensure that the message the women received was the

message that you intended to send?

Answer: Generally you would begin by providing the needed information by

describing each step; you might include an easy-to-understand handout in the

language the four women understand, or you might give them a CD to take home

that has the information on it. Next, you would demonstrate how to clean the

wound. Then you would ask each woman to repeat the cleaning process that you

just demonstrated. Finally, you would ask each woman if she has the facilities

and supplies to clean the wound at home; then you would ask each woman if she

had any questions or concerns that you might answer. What else would you do?

BOX 11.1 Steps of a Needs Assessment

1. Identify what the client wants to know. (Consider Healthy People 2020

educational objectives.)

2. Collect data systematically to obtain information about learning needs,

readiness to learn, and barriers to learning.

3. Analyze assessment data that have been collected and identify cognitive,

affective, and psychomotor learning needs.

4. Think about what will increase the client’s ability and motivation to learn.

5. Assist the client to prioritize learning needs.

Data from Cronenwett L, Sherwood G, Barnsteiner J, et al: Quality

and safety education for nurses, Nurs Outlook 55:122-131 2007.

make up a complex procedure. Others may have cultural beliefs

that conlict with healthy behaviors. Another person may be

tremulous and have poor eyesight, making him incapable of

learning insulin self-injection.

186 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

Also consider the learner’s knowledge, skills, and motivation to

learn, as well as resources available to support and possibly pre-

vent learning. Resources include printed, audio or visual materi-

als, equipment, agencies, and other individuals. Barriers for the

presenter include lack of time, skill, conidence, money, space,

energy, and organizational support.

ESTABLISH EDUCATIONAL GOALS AND OBJECTIVES

After you identify the learner’s needs, develop the goals and objec-

tives for the educational program. Goals are broad, long-term ex-

pected outcomes, such as, “Each child in the third-grade class will

participate in 30 minutes of daily physical exercise, 4 days per week

for 2 months.” Program goals should deal directly with the clients’

overall learning needs. The learning need of the third graders is to

know the importance of exercise and itness to their health.

Objectives are speciic, short-term criteria that are met as steps

toward achieving the long-term goal, such as, “Within 2 weeks,

each child will be able to demonstrate at least two exercises they

have learned.” Objectives are written statements of an intended

outcome or expected change in behavior and should deine the

minimum degree of knowledge or ability needed by a client. Ob-

jectives must be stated clearly and deined in measurable terms,

and they typically imply an action (Knowles et al, 2015).

SELECT APPROPRIATE EDUCATIONAL METHODS

Choose educational methods that will facilitate the eficient

and successful accomplishment of program goals and objec-

tives. The methods also should be appropriately matched to

the strengths and needs of both the client and the presenter.

Choose the simplest, clearest, and most succinct manner of

presentation and avoid complex program designs. Try to vary

the methods to hold the attention of the learners and to meet

the needs of different learners. Some people learn best by

being actively involved in the program (Fig. 11.1), such as by

brainstorming, role playing, simulation, games, group partici-

pation, demonstrations, and ield trips. Others learn by a

more solitary approach, such as watching a video, listening to

a guest speaker, case studies, reading printed materials, or re-

lecting on how they might apply the content to their health

situation.

Educators also need to be able to deliver presentations,

lead group discussions, organize role-plays, provide feedback

to learners, share case studies, use media and materials, and,

where indicated, administer examinations. Consider the con-

tent to include, how to organize and sequence the informa-

tion, what your rate of delivery will be, whether you need

to include repetition, how much practice time should be

included, how you will evaluate the effectiveness of the

teaching, and ways that you can provide reinforcement and

rewards (Box 11.2).

When choosing educational methods, consider age, gen-

der, culture, developmental disabilities or special learning

needs, educational level, knowledge of the subject, and size of

the group. For example, clients with a visual impairment

need more verbal description than those with no sight im-

pairment. Persons who have hearing impairments or lan-

guage limitations need more visual material and speakers or

translators who can use sign language or speak their native

language. Also, when the learners have limitations in atten-

tion and concentration, educators can use creative methods

and tools to keep them focused. For example, you might in-

clude frequent breaks; provide simple surroundings with few

or no distractions; use small-group interactions to keep

learners involved and interested; and use hands-on equip-

ment, such as mannequins, models, interactive games, and

other materials and devices the learner can physically

manipulate. Involve the learner appropriately, actively, and

creatively in learning. Interactive educational programs often

are more effective than noninteractive ones. Interactive strate-

gies include discussion, small group work, games, and role-

playing, whereas noninteractive strategies are lectures, videos,

or demonstrations. Box 11.3 details descriptions of learning

formats.

The goal of nurses who use Healthy People 2020 as a guide in

educating clients is to foster healthy communities, mainly

through primary and secondary prevention.

BOX 11.2 How to Effectively Teach Clients

Use the TEACH mnemonic:

Tune in. Listen before you start teaching. The client’s needs should direct the

content.

Edit information. Teach necessary information irst. Be speciic.

Act on each teaching moment. Teach whenever possible. Develop a good

relationship.

Clarify often. Make sure your assumptions are correct. Seek feedback.

Honor the client as a partner. Build on the client’s experience. Share responsi-

bility with the client.

Modiied from Hansen M, Fisher J: Patient-centered teaching from

theory to practice, Am J Nurs 98:56-60, 1998.

FIG. 11.1 The instructional methods need to meet the learn-

187CHAPTER 11 Using Health Education and Groups in the Community

The Centers for Disease Control and Prevention (CDC) of-

fers excellent tips for planning health events. For example,

these include (1) how to plan a health fair, (2) how to plan a

health seminar, (3) how to plan a town hall meeting on a health

issue, (4) how to plan a wellness walk, and (5) how to plan a

health fair site (CDC, 2013). Health fairs are a popular way to

provide primary and secondary health education. The objec-

tives of holding health fairs are to increase awareness by pro-

viding health screenings, activities, information and educa-

tional materials, and demonstrations. A health fair can target a

speciic population or focus on a speciic health issue, as well

as target a range of groups and cover a variety of health educa-

tion and health promotion topics. The fair can be held in many

BOX 11.3 Examples of Learning Formats

Presentation: This method can be used when the group is large and you want

to be consistent in the message that is delivered to all participants. Remem-

ber, people tend to have a short attention span. So what can you do to keep

them engaged? You might ask them to spend some time talking with one

another in small groups and then have the group respond to questions or

ask attendees to write answers to questions and invite several to share

their answers. The presentation can take many forms, ranging from a health

seminar to a town hall meeting.

Demonstration: This technique is often used to show attendees how to per-

form a task. For example, insulin injection demonstration, heart-healthy

food preparation, and breastfeeding may be demonstrated.

Small informal group: Because learners often learn as much from one an-

other as from the instructor, small groups can be valuable. This is especially

true when the content lends itself to members sharing their own experi-

ences. For example, in working with women in a shelter for abused women,

participants may be able to share with one another actions they took to

remove themselves safely from the violent environment. They might also be

able to jointly plan how each might move to the stage of independent living

outside the shelter.

Health fair: See the How To box on ways to plan, implement, and evaluate a

health fair. For example, you might offer a health fair in a senior center and

have displays, such as posters; videos; live demonstrations; handouts on

such topics as reducing fat in selected recipes (including samples) and age-

appropriate exercises for lexibility; as well as screenings for elevated blood

pressure, glucose, or cholesterol or for osteoporosis and vision.

Nonnative language sessions: You could adapt the health fair approach for

a Hispanic group by holding the session in Spanish and providing all of the

materials in Spanish. Then ask Spanish-speaking nurses to staff each of the

stations for health learning.

Primary Prevention

Education at health fairs regarding immunizations for children, older adults,

and people with chronic illnesses.

Secondary Prevention

Education at health fairs regarding early diagnosis and treatment of diabetes

and hypercholesterolemia, along with providing health screenings, with the

goal of shortening disease duration and severity.

Tertiary Prevention

Education in rehabilitation centers or adult daycare centers to help individuals

who have had a stroke maximize their functioning.

LEVELS OF PREVENTION

HOW TO Plan, Implement, and Evaluate a Health Fair

1. Form a planning committee with 2–12 people who represent the groups

who will be part of the health fair (i.e., health professionals, representa-

tives from health agencies, schools, churches, employers, the media, and

the target audience).

2. Identify the target group. Develop a theme.

3. Establish goals, expected outcomes, and screening activities consistent

with the needs and wishes of the target group. Your primary goal might be

to improve the health of a speciic population, such as workers at one

plant or children in one school. You might have secondary goals, such as

for the workers to reduce health care costs and for the children to reduce

absenteeism.

4. Develop a timeline and schedule.

5. Choose a site and consider the site logistics. Do this about 1 year ahead.

Think about the size of the site you will need and the trafic low from one

booth or demonstration to another, whether parking is available and free or

low cost, and whether there are toilets and places to get food and drinks. If

the site is inside, consider adequate exits; the possible risks to children, the

elderly, or handicapped people; and other safety and security issues. You may

need to create a map both for how to get to the fair and another one to help

attendees get from one table, exhibit, or screening station to another. Be sure

to include on the map the location of amenities like toilets and food vendors.

6. Plan for the needed supplies, such as tables, chairs, electronic equipment,

and accessories such as extension cords, ofice supplies, sign-in sheets

(and what information should be included), release forms for screenings,

name tags, bags for attendees to gather the educational information,

and evaluation forms. Set your budget. Obtain supplies in advance.

7. Recruit and manage exhibitors. Do this about 4 months ahead. Develop

a list of possible exhibitors and sponsors and contact them via letter, fax,

e-mail, telephone, or in person. Follow up with a conirmation letter (or

fax) that outlines the details of the health fair.

8. Publicize the health fair. The planning committee will have many good ideas

about how to publicize in the speciic community. Examples might be liers,

posters, memos, brochures, e-mail blasts, local print, radio, or television.

9. On the day of the fair, greet attendees.

10. Evaluate the health fair by having exhibitors, participants, and volunteers

ill out a form. You will need a speciic form for each of these groups.

11. Stay after the event concludes to thank the committee and volunteers.

12. After the event, analyze the evaluations and develop a list of lessons

learned. Include any recommendations for the next health fair. Pay bills.

Send thank-you notes to the committee, volunteers, sponsors, and others

who made the health fair a success.

locations and can be either inside or outside (Fig. 11.2). The

How To box lists guidelines to assist nurses who chair, co-chair,

or serve on a planning committee for a health fair.

Data from Rice CS, Pollard JM: Health fair planning guide, AgriLIFE

EXTENSION, ed 2, College Station, Tex, 2011, Texas A&M System.

Retrieved February 2016 from http://fcs.tamu.edu/health/hfpg/Health-

Fair-Planning-Guide-with-Appendix.pdf. And Centers for Disease

Control and Prevention, How to Plan a Health Fair, 2013. Retrieved

February 2016 from www.cdc.gov/women/events/fair/index.htm.

SKILLS OF THE EFFECTIVE EDUCATOR

The educator needs to understand the basic sequence of

instruction. The following steps are useful in planning an

educational program. Begin by (1) gaining the attention of

the learners and helping them understand that the informa-

tion being presented is important and beneicial to them; then

http://fcs.tamu.edu/health/hfpg/Health-Fair-Planning-Guide-with-Appendix.pdf

http://www.cdc.gov/women/events/fair/index.htm

188 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

(2) tell the learners the objectives of the instruction; (3) ask

learners to recall previous knowledge related to the topic of

interest so they link new knowledge with previous knowledge;

(4) present the essential material in a clear, organized, and

simple manner and in a way consistent with the learners’

strengths, needs, and limitations; (5) help learners apply the

information to their lives and situations; (6) encourage learn-

ers to demonstrate what they have learned, which will help you

correct any errors and improve skills; and (7) provide feedback

to help learners improve their knowledge and skills. By using

these steps, nurses may help clients maximize learning experi-

ences. If steps of this process are omitted, supericial and

fragmented learning may occur.

MOTIVATIONAL INTERVIEWING

Before developing a health education program or plan, do a

careful assessment of the speciic need. The health education

goal is to engage the clients in wanting to learn ways in which

they can change their behavior. Pay attention to the words you

use, avoid medical jargon, and use simple language. Motiva-

tional interviewing (MI) is an evidence-based intervention

used in clinical areas in which the goal is change in client be-

havior (Clancy and Taylor, 2016). It is a collaborative partner-

ship between the teacher and the learner designed to help

people make their own choices. This tool is useful in health

education. MI can help clients resolve their ambivalence about

change and uses the techniques of elaboration, afirmation,

relection, and summary to engage people in talking about

change (Miller and Rose, 2009). MI combines warmth, respect,

and empathy with a technique of focused listening to persuade

the client to want to change. MI is generally used in conjunc-

tion with other communication techniques. MI has four es-

sential steps: engaging, which includes person-centered,

empathic listening; guiding, which includes a particular identi-

ied target for change; evoking of the client’s own motivations

for change; and planning. Using open-ended questions, relec-

tions, and an understanding of the client’s values, the clinician

can form a partnership with the client. The nurse facilitates

rather than dictates in order to help the client state ideas and

plans (Minkin et al, 2014; Treasure, 2004).

MI was initially designed to treat problem drinkers and is

often used with individuals rather than groups. However, the

principles can be applied to health education. For example,

if a public health nurse determines that she has four women

in a community group she leads who are overweight, eat

high-calorie foods, and indicate they don’t exercise, how

could the nurse use MI? First, the nurse needs to form a

partnership with each of the women, in which she and the

clients can communicate easily and in which each woman

trusts the nurse. The nurse draws each woman out and

learns what, if anything, each wishes to change. The nurse

also learns about each one’s motivation to change and ability

to do so.

CHECK YOUR PRACTICE?

Consider the client, Anna, and examine her motivation to change her eating

and activity patterns. Anna says that her family will only eat fried foods, so to

get her husband and children to eat a meal, she fries their meats and vegeta-

bles. The family does eat fresh fruit and drink milk. Anna says that she gets

exercise by walking to the bus stop en route to work and cleaning her home.

She has not considered other forms of regular exercise. If you want to use MI

with Anna and incorporate these principles, how would you design your nurs-

ing plan? The principles are as follows:

1. Expressing empathy by trying to see the world through Anna’s eyes

2. Building on Anna’s strengths and helping her believe that she has the ability

to make a change (self-eficacy)

3. Rolling with resistance when Anna is ambivalent about her ability to change

4. Developing discrepancy by helping Anna recognize that her current actions

conlict with her expressed goals of eating healthy foods and exercising

regularly

Do you agree that you could incorporate into your strategy

the counseling skills that are part of MI—open-ended questions,

afirmations, relections, and summaries (OARS)? These commu-

nication skills are useful in any nurse–client interaction. Open-

ended questions refer to those that are not easily answered with

yes or no or a short answer. These questions invite elaboration and

more thinking about what is being asked. In helping Anna prepare

healthier meals, ask her to describe the dinner she cooked the

previous night. Afirmations are designed to recognize client

strengths; they must be genuine and correct. Once Anna begins to

explore the idea of preparing more nutritious food, you would

afirm her progress and encourage her to continue working to-

ward that goal. Relections or relective listening is possibly the

most critical skill in that it conveys empathy because you are lis-

tening carefully. You can then guide Anna toward dealing with her

ambivalence about change by examining the positive and negative

aspects of the present situation. Using relective listening, if Anna

expresses concern or dificulty in her goal of preparing different

meals, you can focus on her concern and possible ambivalence

about sticking to the plan for change. What are other strategies

you could use?

MI uses the term change talk to refer to statements by cli-

ents that they are motivated and willing to make a change. An

FIG. 11.2 A nurse conducts a health fair. (From Harkreader H, Hogan

MA, Thobaben M: Fundamentals of nursing, ed 3, Philadelphia, 2007,

Saunders.)

189CHAPTER 11 Using Health Education and Groups in the Community

HOW TO Use Plain Language in Health Education

1. Organize the audience.

• Know your audience and purpose before you begin.

• Put the most important message irst.

• Present other information in order of importance to the audience.

• Break text into logical chunks, and use headings.

2. Choose words carefully.

• Write in the active voice.

• Choose words and numbers the audience knows; do not use jargon or

technical or slang words.

• Keep words, sentences, and paragraphs short.

• Include “you” and other pronouns.

• Use upper- and lowercase words.

• Use examples.

3. Make information easy to ind.

• Use headings and text boxes.

• Delete unnecessary words sentences and paragraphs.

• Create lists and tables. (CDC, n.d.)

Apply the DARN-CAT to the goal you and Anna have for her to

learn ways to prepare more nutritious meals. Although MI is a set of

skills that requires training to use completely, nurses can incorporate

some of the MI techniques into their communication with clients.

DEVELOPING EFFECTIVE HEALTH EDUCATION PROGRAMS

All programs, including sessions that use the skills of MI, should in-

clude a clear message conveyed in a format appropriate to the learners

and in an environment that is free from distractions and consistent

with the message. Remember that emotions, such as anxiety, stress,

anger, or fear, can interfere with the listener actually hearing the mes-

sage being sent. Also, provide information that is understandable to

the listener. Use plain language and avoid jargon and complex medi-

cal terms. Use words the listener will know and recognize. For exam-

ple, some people are more familiar with terms such as high blood

pressure and high blood sugar levels than hypertension and increased

glucose levels. On the other hand, be careful not to oversimplify your

terms if your audience is knowledgeable about health care. You want

to avoid “talking down” or “over the head” of your listeners.

Using plain language is more than a good idea. On October 3,

2010, President Obama signed the Plain Writing Act of 2010.

Although this law requires that federal agencies use “clear govern-

ment communication that the public can understand and use,”

this law can be transferred to health education programs. See

Plain Language.gov. The CDC has developed guidelines for “plain

language” communication your audience understands the irst

time. See the How To box on plain language in health education.

easy-to-use mnemonic is “DARN-CAT,” which refers to the

following:

The Quad Council Practice Competences for Public Health

Nursing in Domain 3 list competences related to communi-

cation skills. They begin with assessing the health literacy

of the individuals, families, groups, and communities being

served. They emphasize the importance of effective written,

oral, and electronic communication, as well as communication

delivered in a culturally responsive and relevant fashion (Swider

et al, 2013).

The type of learning format you select will depend on the

learners. If they are young, you will want an interactive format,

and many of your options will include the use of technology.

You could use a game, such as developing a bingo game with

food groups to teach about healthy eating. The old adage “A

picture is worth a thousand words” still holds true. People tend

to remember what they see or hear; a lively format rather than

a passive one encourages learning. Most people have a short

attention span, so you need to make your point quickly and

directly. It may help to provide take-home written materials or

a CD for further reminders and follow-up of what is taught.

People often learn better when they are actively engaged in the

learning; thus small-group discussion, role-playing, use of a

computer-based program, and question-and-answer sessions

may reinforce learning.

A patient education tool that is being increasingly used

and has been briely mentioned in the chapter is “teach-

back.” Teach-back is a health literacy tool that allows nurses

to immediately assess what the individual, family, or group

has learned by having the person or group immediately say or

demonstrate what they learned during the session. It is con-

sidered to be a “show me” approach whereby the nurse can

clarify immediately any misunderstandings (Caplin and

Saunders, 2015). Nurses can also use ACTS (assess, collabo-

rate, train, and survey) with clients and client groups. Assess

the client’s main concern (can be a person, family or com-

munity group); then assess learning needs and baseline level

of knowledge, how they prefer to learn, their core values, and

potential inluential language, cultural, social or physical in-

luences. Next compare the assessed needs with the resources

available. The next step is to use Teach 3 or teach-back strate-

gies. Teach 3 means that you teach the audience three or

fewer key actions, pieces of information, or skills. Attendees

then restate or demonstrate what was taught. Just as with teach-

back, any misunderstandings can be immediately corrected.

The key point in the two teaching strategies is to teach a

small amount at any one time, and then immediately have

the attendees provide feedback on what they heard or saw

(French, 2015).

Fig. 11.3 shows a community group being educated, and

Box 11.4 lists ways to design clear educational programs.

EDUCATIONAL ISSUES AND BARRIERS TO LEARNING

There are three important educational issues to consider when

you are planning educational programs. First, different popula-

tions of learners require different teaching strategies. Second, be

prepared to overcome barriers to learning. And third, consider

the appropriateness of using technology in the programs.

Preparatory Change Talk

Implementing Change Talk

Desire (I want to change)

Ability (I can change)

Reason (It’s important to

change)

Need (I should change)

Commitment (I will make changes)

Activation (I am ready,

prepared, willing to change)

Taking steps (I am taking

actions to change)

190 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

Nurses have held the number one position every year except

one since they were added to the list in 1999. In 2001 ireight-

ers were ranked number one (Saad, 2015). The increase in

populations of varying cultural and ethnic backgrounds and

the aging of Baby Boomers require that community health

education cross age and cultural boundaries. In terms of age,

children, adults, and older adults have different learning needs

and respond to different educational strategies. In each age

group, learners also vary in their cognitive ability, personality,

and prior knowledge. Some people learn better with more di-

rect instruction, supervision, and encouragement than do

other people. As discussed in Chapter 5 culture can be “deined

by group membership, such as racial, ethnic, linguistic or geo-

graphical groups, or as a collection of beliefs, values, customs,

ways of thinking, communicating, and behaving” (CDC, 2015).

Nurses need to tailor their education to the cultural group(s)

they are teaching. The Quad Council Practice Competences for

Public Health Nursing in Domain 4 discuss Cultural Compe-

tency Skills. They say that the public health nurse uses the so-

cial and ecological determinants of health to work effectively

with diverse individuals, families, and groups and to develop

culturally responsive interventions with communities and

populations (Swider et al, 2013, p 530).

Learning strategies for children and individuals with little

knowledge about a health-related topic are characterized as

pedagogy. In the pedagogical model of learning, the teacher

makes decisions about what will be learned and how and when

it will be learned. This form of learning is teacher directed.

Learning strategies for adults, older adults, and individuals with

some health-related knowledge about a topic are called andra-

gogy. In the andragogical model, learners inluence what they

need and want to learn. Andragogy is a more transactional way

of learning than the pedagogical model. Each model has useful

elements (Knowles et al, 2005). For example, when learners are

dependent and entering a totally new content area, they may

require more pedagogical experiences. Consider both the age of

the learner population and their learning needs as you choose

the pedagogical or andragogical principles for the program. In

educational programs for children, provide information that

matches the developmental abilities of the group. Nurses can

use the following age-speciic strategies to tailor educational

programs for children.

• With younger children, use more concrete examples and

word choices. You might tell 3-year-olds to brush their teeth

two times per day; for 10-year-olds, you can explain to them

the beneits of brushing their teeth and the risks in not

brushing and talk about issues such as the care of the teeth

with braces.

• Using objects or devices, as opposed to discussion of ideas,

will increase attention. When teaching a group of children

with asthma how to use inhalers, hand out inhalers to each

one so he or she can practice proper technique with the in-

halers rather than just giving them a handout with instruc-

tions or demonstrating how to use an inhaler while they

watch you.

• Incorporating repetitive health behaviors into games will

help children retain knowledge and acquire skills. Learning

1. Develop the content for your message.

2. Identify the most appropriate format and location for your program, taking

into account your budget, location, and other available resources and

constraints. See Box 11.3 for examples of formats.

3. Organize the learning experience to suit the audience; consider how to

engage the learners in the process.

4. Plan how you will deliver the material using the following points:

• Limit the number of points you wish to cover to the most important ones.

• Begin with a strong opening and close with a strong ending; people re-

member most what is said irst and last.

• Fit your use of language to the learners; use an active voice and empha-

size the positive. For example, “Many people are able to lose weight by

reducing their intake by 500 calories a day and exercising 45 minutes at

least four times a week.”

• Use examples, stories, and other vivid messages. Limit statistics and

complex terminology.

• Refer to trustworthy sources. In general, government, educational, or

professional association sources are peer reviewed by professionals

and are dependable. The Centers for Disease Control and Prevention,

National Cancer Institute, American Association of Public Health, and

the American Academy of Pediatrics are four examples of organizations

whose sites offer useful information.

• Use aids to highlight your message. For example, you might have posters,

handouts, or CDs to give to attendees. You might also incorporate a clip from

a website, such as http://www.YouTube.com, to emphasize your point.

5. Do not forget to plan the evaluation when you are initially planning the

program.

BOX 11.4 Designing Clear Educational Programs

FIG. 11.3 A nurse educates a community group about envi-

ronmental health issues and gathers their concerns. (From

Centers for Disease Control and Prevention, 2009, courtesy

Dawn Arlotta.)

POPULATION CONSIDERATIONS BASED ON AGE AND CULTURAL AND ETHNIC BACKGROUNDS

Nurses are a trusted source of health education in the com-

munity; nurses continue to be rated via the Gallup Poll as the

highest professional group in terms of honesty and ethics.

http://www.YouTube.com

191CHAPTER 11 Using Health Education and Groups in the Community

to cook healthier food is often more effectively learned if

the teacher demonstrates the new way of cooking, allows

the participants to taste the food, discusses what changes

would need to be made to prepare healthier food, and then

has the participants each prepare one dish in the demonstra-

tion menu.

The average person, both adults and children, washes his or

her hands too hastily to remove germs. The actual physical

activity of washing hands is more beneicial in germ control

than the soap used.

Check your practice: Assume that you are trying to teach a

group of 5-year-olds how to effectively wash their hands before

meals. You know that an activity often helps young children

learn. So you:

• Ask each child to wash his or her hands while completely

singing a favorite song.

• The song “Twinkle, Twinkle Little Star” takes about the ex-

act amount of time to sing as is recommended for effective

hand washing.

• Other songs can be used when they are appropriate to the

season, such as “Jingle Bells.”

• By singing a song as a group or one child at a time, learn-

ing the appropriate length to wash hands can be fun and

easy to accomplish.

Children especially are able to learn health promotion behav-

iors when learning is fun and is appropriate to what they know

and can actually do.

It is also important to consider characteristics of learners

that depend on the generation to which they belong. People

born after 1980 are considered the net generation because they

have always had digital media and access to the Internet, use

mobile devices to access and process information, and are

“always on and connected to their devices.” They typically

prefer to work in groups or teams, are active learners who seek

innovation, want an immediate response to their questions,

and are able to multitask. These learners prefer “augmented

reality,” such as simulations and virtual reality, and they want

to construct information on their own, which is consistent

with their desire for independence. They do enjoy being men-

tored by older generations. Generation X members were born

between 1960 and 1980, and they tend to be self-directed, like

to work in teams, and may need to develop skills because they

are not as likely to be as tech savvy as the net generation.

Members of this group can tolerate delayed gratiication, they

want clear information with practical value, and they are able

to have fun and engage in games and activities when appro-

priate. The Boomers, who were born between 1940 and 1960,

are accustomed to being dependent on the teacher, want to be

in charge of their own learning, respond positively to feed-

back, and want to do a good job. They prefer a caring environ-

ment and want to connect learning to the mission of the

agency. They also want to be connected with other people.

Clearly, these three generations have different characteristics,

and the teacher is often a member of a generation different

from that of the learner(s).

In thinking about culture, it is important to know that by

2050 approximately 50% of the US population will consist of

ethnic minorities, such as Asians, African Americans, Hispanic

Americans, Native Americans, and Paciic Islanders. Culture

inluences family structure and interactions, as well as views

about health and illness. These demographic changes present

new challenges to nurse educators. Nurses need to understand

the health belief systems of the ethnic populations being served

and be familiar with populations who are prone to develop

certain health problems. When presenting seminars or provid-

ing written, audio, or visual information, make sure that the

information is provided in a culturally competent manner.

For example, in a rural farming area, there might be a large

population of Mexican migrant crop workers. Knowing that

this Spanish-speaking group is more likely to have tuberculosis

than other segments of the community, nurses may visit the

migrant worker camp to present information on tuberculosis,

such as prevention, symptom identiication, early diagnosis,

and treatment. An interpreter may accompany the nurses and

provide oral content in Spanish. Written handouts can be in

Spanish and designed to be read and understood on the level

at which the group comprehends.

Barriers to learning fall into two broad categories: one con-

cerning the educator and the other concerning the learner.

EDUCATOR-RELATED BARRIERS

Some common educator-related barriers to learning, together

with strategies to minimize them, are as follows (Knowles et al,

2005):

• Fear of public speaking. Be well prepared, use icebreakers,

recognize and acknowledge the fear, and practice in front of

a mirror or video camera or with a friend.

• Lack of credibility with respect to a certain topic. In-

crease your conidence by carefully preparing for the talk

so that you think you have included useful information

and you understand the information. Avoid apologizing

for lack of expertise and instead convey the attitude of an

expert by briely sharing your personal and professional

background.

• Limited professional experiences related to a health topic.

You may want to describe personal experiences (brief ones),

share experiences of others, or use analogies, illustrations, or

examples from movies, current news, or famous people. Be

certain the examples it the audience.

• Inability to deal with dificult people who need to learn

health-related information. One strategy that may help

with handling dificult learners is to confront the problem

learner directly. Other strategies include using humor, using

small groups to foster the participation of timid people, and

asking disruptive people to give others a chance to speak, or,

if this does not work, asking them to leave.

• Lack of knowledge about how to gain participation. You

can foster participation by asking open-ended questions,

inviting participation, and planning small-group activities

in which a person responds based on the group rather than

presenting individual information.

• Lack of experience in timing a presentation so that it is

neither too long nor too short. Strategies to help determine

192 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

whether the length of the presentation is appropriate include

planning well, practicing the presentation, and trying to

speak during the practice at the same pace that you will

speak to the group.

• Uncertainty about how to adjust instruction. You can more

easily adjust instruction when you know the participants’

needs, request feedback, and redesign the presentation

during breaks based on what you have learned about the

participants.

• Discomfort when learners ask questions. Try to anticipate

questions, concisely paraphrase questions to be sure that you

correctly understood the question, and recognize that it is

appropriate to admit that you do not know the answer to a

question.

• Desire to obtain feedback from learners. Solicit informal

feedback during the program and at the end with program

evaluation.

• Concern about whether media, materials, and facilities

will function properly. Test the equipment before the pro-

gram to make sure it runs and also that you know how to

use it. Have back-up plans for how to get help if you have a

problem.

• Dificulty with openings and closings. Strategies to foster

successful openings and closings include developing several

examples of openings and closings, memorizing the opening

and closing, concisely summarizing information, and thank-

ing participants for attending.

• Overdependence on notes. You may wish to use note cards

or visual aids as prompts, and practicing in advance is a

proved way to increase skill at presenting.

LEARNER-RELATED BARRIERS

Two of the most important learner-related barriers are low lit-

eracy and lack of motivation to learn information and make

needed behavioral changes. Nurses often deal with individuals

and populations who are illiterate or who have low literacy

levels. These individuals may be embarrassed to admit this

deicit to health care providers and educators and may try to

appear to understand when they really do not. Speciically, they

may not ask questions to clarify information even when they do

not understand it. As society becomes more multicultural, the

problem of low literacy can increase because of limited use of

the primary language and limited education. It is essential to

assess the literacy, especially health literacy of the learners. The

next paragraphs discuss the signiicance of this problem and the

need for nurses to address health literacy.

The National Assessment of Adult Literacy (NAAL) is the

largest literacy assessment study done in the United States. This

assessment was irst conducted in 1992. At that time, of the ive

levels in the assessment, 50% of American adults were in the top

two levels and 50% were in the bottom three levels of literacy.

The minimal standard needed to function in the workplace is

level 3 proiciency. In 2003 the tool measured literacy in four

levels: below basic, basic, intermediate, and proicient. The liter-

acy scales used in 2003 were prose literacy, document literacy,

and quantitative literacy. Prose examples include searching,

comprehending, and using information from editorials, news

stories, brochures, and instructional materials. Document lit-

eracy refers to searching, comprehending, and using informa-

tion from documents such as job applications, payroll forms,

transportation schedules, maps, tables, and drug and food

labels. Quantitative literacy is the ability to identify and per-

form computations such as balancing a checkbook, completing

an order form, or determining the interest on a loan from an

advertisement. The 2003 test is more than just a survey and

actually asks the test takers to perform tasks to demonstrate

their literacy level (Kutner et al, 2006). The 2003 NAAL in-

cluded information about health literacy, which is an important

topic for nurses. The 2003 NAAL used the Institute of Medi-

cine’s deinition of health literacy: “The degree to which indi-

viduals have the capacity to obtain, process, and understand

basic health information and services needed to make appro-

priate health decisions” (Ratzan and Parker, 2000). Kutner et al

(2006) found that the majority of participants had an interme-

diate (53%) literacy level, 12% were proicient, 22% were basic,

and 14% had below basic levels of literacy. The assessment was

given to over 19,000 adults in households or prisons. Interest-

ingly, women had a higher literacy level than men; white and

Asian/Paciic Islander adults had higher scores than African

American, Hispanic, American Indian/Alaska Native, and mul-

tiracial adults; and adults 65 years of age or older and persons

living below the poverty line had a lower average literacy level

than others surveyed. The Health Resources and Services Ad-

ministration (HRSA) added medically underserved people to

the list of individuals who were more likely to have low health

literacy (HRSA, n.d.). In addition, the National Action Plan to

Improve Health Literacy (USDHHS, Ofice of Disease Preven-

tion and Health Promotion, 2010) adds recent refugees and

immigrants to the list of people who may have low health

literacy including nonnative English speakers.

Of every five Americans, one reads below the fifth-grade

level, and one of every three lacks the literacy ability needed

to understand health care providers (Roberts, 2004). Typi-

cally, individuals read three to five grade levels below the last

year of school completed. It has been found that most health

instructions continue to be written at the 10th-grade reading

level, which is too difficult for almost half of the adult read-

ers in the United States (Health Literacy Innovations, 2010).

Several tests are used to evaluate literacy levels, including the

Fry-Based Electronic Readability Formula, Flesch Reading

Ease Score, Precise SMOG, and Gunning-Fog (Health Liter-

acy Innovations, 2010). Examine one of them and apply it to

a paper you have written to learn at what level you typically

write.

Individuals with limited literacy may be unable to under-

stand instructions on prescription bottles, seek preventive

care, understand the relationship between risky behavior and

health, manage chronic health conditions, interpret health ap-

pointment cards, ill out health insurance forms, and read and

understand self-care or hospital discharge instructions. Also,

individuals may have weak literacy and numeracy skills in

193CHAPTER 11 Using Health Education and Groups in the Community

their native language, and even translated materials may be

dificult for them to understand because not all languages

have words that directly translate into English (CDC, 2015).

The following may happen when someone has health illiteracy.

The person may:

• Have limited vocabulary and general knowledge and not ask

for clariication

• Focus on details and deal in literal or concrete concepts

versus abstract concepts

• Select responses on a survey or questionnaire without neces-

sarily understanding them

• Be unable to understand math (which is important in calcu-

lating medications)

Health illiteracy is expensive when people cannot understand

their health care treatment or follow directions correctly. This

inability can lead to increased numbers of emergency room vis-

its, hospitalizations and health care complications resulting

from those hospitalizations, poorer health care outcomes, and

decreased life expectancy (Kleinbeck, 2005).

Some people are not motivated to learn. Although adults

respond to some external motivators, the most powerful moti-

vators are internal. People are motivated to learn if they value

and feel they will beneit from the outcome of the learning,

if they think they can follow through on what is being taught,

and if it will improve their situation in life or increase their

self-esteem (Ota et al, 2006).

A variety of health promotion models can be used to struc-

ture health education and health promotion plans. One model,

the Health Belief Model (HBM) is an individual-level model

that can be used to plan programs if you think the motivation

of learners might be a concern. Speciically, the HBM was one

of the irst theories of health behavior. It began in an interest-

ing way that is still applicable to the behavior of people today.

In the 1950s the US Public Health Service sent mobile radiog-

raphy units to communities to provide free chest radiographs

as a way to screen for tuberculosis. The radiography examina-

tions were free, convenient, and painless, yet people did not

take advantage of the service. A group of social psychologists

were asked to try to explain the failure to use this screening—

speciically, to determine what would motivate people to seek

health care.

The HBM includes six components that attempt to answer

the question of what motivates an individual to do something.

These components are (1) perceived susceptibility (“Will some-

thing happen to me?”), (2) perceived severity (“If something

does happen to me, will it be a big problem?”), (3) perceived

beneits (“If I do what is suggested, will it really help me?”),

(4) perceived barriers (“Assuming I do what is suggested, will

there be barriers that will be unpleasant, costly, and so forth?”),

(5) cues to action (“What might motivate me to actually do

something?”), and (6) self-eficacy (“Can I really do this?”).

This model has been applauded and criticized. It does offer

guidance in planning health education programs in that it re-

minds nurses to think carefully about what motivates people

to change. To understand motivation, it is important to learn:

(1) how people involved feel about the health problem, (2) whether

they think the problem is serious, (3) whether they think that ac-

tion on their part will make a difference, and (4) whether they

think they can both manage the barriers and actually perform the

action (Edberg, 2015)

Consider the following example of how the HBM might be

applied to a person in the community who has recently been

diagnosed with diabetes. The person, June, is 25 years old and

was diagnosed 2 months ago with diabetes mellitus. She has

found it hard to follow the recommendations of the public

health nurse she saw in the community clinic. When the nurse

asked June what seemed to be getting in her way of complying,

June said that she wondered what might happen to her if she

did not follow the advice the nurse had given her about diet,

exercise, and taking her insulin. June questioned whether some-

thing would really happen to her and, if that was the case,

would it really be a problem? Her ambivalence about making

this change led her to wonder: If she took her medication, ate a

diabetic diet, exercised, and took her insulin correctly, would it

really reduce the seriousness of her disease? She also questioned

whether she could afford the food and insulin and had the time

to cook appropriately and exercise regularly. June was afraid

that insulin self-injection might be painful. If the nurse used

motivational interviewing to help June develop and commit to

a health change plan, what steps would the nurse take? June said

that when she saw her friend Sue, who is also a diabetic patient,

she noticed that Sue was careful about what she ate, talked

about her regular exercise program, and looked better than she

had in the past. How would the nurse use the information that

June reported about her friend Sue?

A second set of models is presented. The selection of these

three models—the HBM, the Transtheoretical Model (TTM),

and Precaution Adoption Process Model (PAPM)—does not

imply that they are the best or only models. They are, however,

useful models in health promotion. The TTM and the PAPM

are discussed together because they both deal with change that

occurs in stages and over time. The TTM has the following six

stages:

1. Precontemplation, in which the person does not plan to

change; this may be because the person does not know

there is a problem or does not want to do anything about it

(Edberg, 2015). For example, the person may not know that

it is not good to cook food in lard.

2. Contemplation, in which the person begins thinking about

making a change in the future and examines the pros and

cons of doing so. The person might have gone to a class in

which he learned that it is better to cook food in canola oil

rather than in lard and is beginning to wonder if his food

would taste as good if he made that change.

3. Preparation, in which the person intends to do something.

In the cooking example, the person might put canola oil on

the shopping list.

4. Action, by which the person actually buys the canola oil and

cooks a chicken with it instead of the lard.

5. Maintenance, when the person decides that he can get used

to eating chicken cooked in oil and begins preparing his food

in that way on a regular basis.

194 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

EVALUATION OF THE EDUCATIONAL PROCESS

Evaluation is important in both the educational process and the

nursing process. Evaluation is a systematic and logical way to

make decisions to improve the educational program. You will

need to evaluate the educator, the process, and the product.

Feedback to the educator provides the educator an opportunity

to modify the teaching process and better meet the learner’s

needs. The educator may receive written feedback from learn-

ers, such as with an evaluation sheet. The educator also may ask

for verbal feedback, as well as get nonverbal feedback by using

return demonstrations to see what learners have mastered and

by observing facial expressions when feedback is being given

(Bastable, 2008). Process evaluation examines the dynamic

6. The person terminates the change process because he is

able to continue the new, more health-conscious way of

cooking.

Although the terms used are slightly different, the intent

of the PAPM is much like that of the TTM. The stages are

(1) unaware of the issue, (2) unengaged by the issue, (3) decid-

ing about acting, (4) deciding not to act, (5) deciding to act,

(6) acting, and (7) maintenance. You can apply the earlier cook-

ing example to these stages, as well.

USE OF TECHNOLOGY IN HEALTH EDUCATION

Many kinds of technologies, such as computer games and pro-

grams, videos, CDs, and Internet resources, can increase learn-

ing. These technologies may enable the learner to control the

pace of instruction, offer lexibility in the time and location of

learning, present an appealing form of education, and provide

immediate feedback. You may want to use a variety of techno-

logical applications in your teaching. It is also important to be

aware that people increasingly are using the Internet as a

source of health information. The Pew Research Center’s unit

studying society and Internet usage has since 2000 conducted

97 national studies. Highlights from 15 years of study found

the following:

• Age: For young adults, especially those with higher levels of

education and those in more afluent households, Internet

use is at full saturation levels. Although older adults have

lagged behind young people, about 85% of senior citizens

use the Internet.

• Class differences: People with college educations are more

likely to use the Internet than those without a high school

diploma. The usage gap among different classes has shrunk

over the past 15 years.

• Racial and ethnic differences: At present, 78% of blacks, 81%

of Hispanics, 85% of whites, and 97% of English-speaking

Asian Americans are Internet users.

• Community differences: Although people who live in rural

areas are less likely to be online, at present, 78% of rural

residents are Internet users (Perrin and Duggan, 2015).

Why do people use the Internet? A major beneit is its conve-

nience: It is available 24 hours per day, 7 days per week, and

there is no need to drive there, take public transportation, or

ind a parking place. Is the Internet a good source of health in-

formation? The answer depends on the site you use to ind your

information.

Educating people through the Internet has been shown to be

more effective in fostering treatment adherence than in-person

counseling, telephone counseling, or self-directed learning (Dauz

et al, 2004). Clients may ask nurses to provide them with infor-

mation about ways to evaluate the quality and reliability of this

information. The following list provides some criteria for assess-

ing the quality of Internet health information (VanBiervliet and

Edwards-Schafer, 2004):

• Authorship: Are the credentials and afiliations of authors

and contributors listed?

• Caveats: Does the site clarify whether its function is to

provide information or to market products?

• Content: Is the information accurate and complete, and is

an appropriate disclaimer provided?

• Credibility: Does the site include the source, currency, rele-

vance, and editorial review process for the information?

• Currency: Are dates listed for when the content was posted

and updated?

• Design: Is the site accessible, capable of internal searches,

easy to navigate, and logically organized?

• Disclosure: Is the user informed about the purpose of the

site and about any proiling or collection of information

associated with using the site?

• Interactivity: Does the site include feedback mechanisms

and opportunities for users to exchange information?

• Links: Have the links been evaluated according to back-

linkages, content, and selection?

The Evidence-Based Practice Box describes mHealth technol-

ogy for use in a free clinic.

EVIDENCE-BASED PRACTICE

The use of technology as a way to provide health education and intervene in

the progress of a chronic illness, hypertension, was presented in a case

study. The authors used TXT2DASH, which is an mHealth program designed

to improve self-management and increase nutritional self-eficacy in pa-

tients who sought care at free health care clinics and who had hypertension.

In this program the patients were sent weekly educational text messages

on the Dietary Approaches to Stop Hypertension (DASH) diet. This diet has

been shown to reduce and control blood pressure. Messages were sent

3 days a week for 4 weeks; each week a different food category was dis-

cussed. Three health care clinics providing free care participated in the

project, and 13 patients completed the inal data collection and demon-

strated dietary behavior improvements, especially in the areas of drinking

soda and using fats and oils.

Nurse Use

It is important in any health education program to consider the readability and

user-friendliness of the program. The cost of the program to the participants or

to the clinic must be considered. If a text messaging program is used, it is

important to determine whether there is any support to the patients to enable

them to have cellular devices.

Welsh, P: Strategies in development of an mHealth technology for

low socioeconomic groups in free healthcare clinics, CIN: Computers,

Informatics, Nursing, 34(1): 3-5, January 2016.

195CHAPTER 11 Using Health Education and Groups in the Community

components of the educational program. It follows and assesses

the movements and management of information transfer and

attempts to make sure that the objectives are being met. Process

evaluation is necessary throughout the educational program to

determine whether goals and objectives are being met and the

time required for their accomplishment. Ongoing evaluation

also allows the teacher to correct misinformation, misinterpre-

tation, or confusion and to periodically reconsider the goals

and objectives of the program.

The educational product, an outcome of the educational pro-

cess, is measured both qualitatively and quantitatively (Bastable,

2008). For example, a qualitative assessment should answer the

question, “How well does the learner appear to understand the

content?” A quantitative assessment should answer the ques-

tion, “How much of the content does the learner retain?” Thus

the quality of the product is measured by improvement and

increase, or the lack thereof, in the learner’s knowledge, skills,

and abilities related to the content of the educational program.

Selected outcomes for the population of interest need to be

identiied when the educational program is designed so you can

measure the program’s effectiveness.

EVALUATION OF HEALTH AND BEHAVIORAL CHANGES

Various approaches, methods, and tools can be used to evaluate

health and behavioral changes. These include questionnaires,

rating scales, surveys, checklists, skills demonstrations, testing,

subjective client feedback, and direct observation of improve-

ments in client mastery of materials (Bastable, 2008). Qualita-

tive or quantitative strategies may be used to measure changes

in knowledge, skills, abilities, attitudes, behavior, health status,

and quality of life. Choose the method of evaluation based on

the situation. For example, when evaluating a person’s ability to

perform a psychomotor skill such as changing a dressing, it is

best to watch the person perform the skill.

Also evaluate both short-term and long-term effects of the

health teaching. A short-term evaluation of whether a client

can perform a return demonstration of breast self-examination

requires minimal energy, expense, or time and shows skill mas-

tery within a matter of minutes. If the short-term objective

is not met, the nurse determines why and identiies possible

solutions so that successful learning can occur. If the short-

term objective is met, the nurse then focuses on long-term

evaluation designed to assess the lasting effects of the education

program.

Long-term follow-up with clients is challenging, and it

focuses on following and assessing the status of an individual,

family, community, or population over time to determine

whether speciic goals and objectives were met. Often, for

nurse educators, the goal of long-term evaluation is to ana-

lyze the effectiveness of the education program for the entire

community, not the health status of a speciic client. Nurses

track the achievement of community objectives over time

but not that of the individual community members. Thus

in a changing population, long-term evaluation of the results

of an education program is still possible. The percentage of

objectives and goals met by sampling the target population

gives valid statistics for program assessment, even though the

population of individuals may have experienced a complete

turnover.

For example, a nurse notes that according to annual health

department data, 60% of the pregnant women in the nurse’s

catchment area received some prenatal care. Wanting to in-

crease this percentage to 100%, the nurse tries an educational

intervention in which radio and television stations make public

service announcements about the importance and availability

of prenatal services.

After 1 year, the nurse discovers that 80% of all pregnant

women now receive prenatal care. The nurse continues to use

public service announcements the following year because good

results are evident. However, the long-term goal of the educa-

tion program to inluence the behavior of 100% of the pregnant

women in the community has not yet been met. Therefore the

nurse enlists volunteers to put informational posters in shop-

ping malls, grocery stores, public transportation stops, laun-

dries, and public transportation vehicles. In the second year

after implementing the revised educational program, again us-

ing the statistics from the health department, the nurse inds

that 95% of all pregnant women in the target area now receive

prenatal care. The nurse can thus evaluate and modify a com-

munity educational program over time to increase the rate,

range, and consistency of progress made toward meeting the

long-term goals of the project.

It may be hard to keep track of the clients to complete the

evaluation; some will move, and others will lose interest and

fail to keep appointments or return calls, text messages, or

e-mails.

A considerable amount of health education is carried out in

the community in groups rather than provided to one person at

a time. For this reason, the following section discusses how

groups can be used as a tool for health education and the pro-

motion of health.

GROUPS: A TOOL IN HEALTH EDUCATION

Nurses often provide health education to groups. Members of

the group may support either beneicial or poor health prac-

tices. For example, a young person may be part of a group that

abuses substances. Another youth might be part of a group

that runs marathons. The health-oriented goals of each of

these two groups are different. A group is an effective and pow-

erful medium to initiate and implement changes for individu-

als, families, organizations, and the community. Groups form

for various reasons. They may form for a clearly stated purpose

or goal, or they may form naturally as shared values, interests,

activities, or personal characteristics attract individuals to

each other.

Community groups represent the collective interests, needs,

and values of individuals; they provide a link between the

individual and the larger social system. Throughout life, group

membership inluences thoughts, choices, behaviors, and values

as people socialize and interact. Through groups, people may

express personal views and relate them to the views of others.

196 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

Groups serve as communication networks and can help orga-

nize various aspects of communities.

Community groups may be informal or formal. Formal

groups have a deined membership and a speciic purpose.

They may or may not have an oficial place in the community’s

organization. In informal groups, the ties among members are

multiple, and the purposes are unwritten yet understood by

members. These groups often form spontaneously when par-

ticipants have a common interest or need. You can ind out

about what formal and informal groups exist in a community

by reading the local newspaper or local Internet sites, listening

to public service information on the radio or television, and

asking residents about the groups to which they belong. Nurses

can help form new groups or create linkages among existing

groups.

Group support often helps people make needed changes

for health that they are unable to accomplish on their own

or with the help of just one individual. For example, groups

may support physical activity and itness, sound nutrition,

conquering smoking or drug abuse, getting out of abusive

relationships, and safe sexual practices. One of the core

competencies for public health professionals is to “use group

processes to advance community involvement” (Council on

Linkages, 2010, p 10).

GROUP: DEFINITIONS AND CONCEPTS

A group is a collection of interacting individuals who have

common purposes. To some extent, each member inluences

and is in turn inluenced by every other member. Groups

form for a variety of reasons. Families, an example of a com-

munity group, share kinship bonds, living space, and eco-

nomic resources. There are many group purposes, such as

teaching the members and providing psychological support

and socialization.

Groups also form in response to community needs, prob-

lems, or opportunities. For example, community residents may

form a neighborhood association to protect their health and

welfare. Community groups occur spontaneously because of

mutual attraction between individuals and to meet personal

needs such as those for socialization and recreation. Health-

promoting groups may form when people meet in community

and health care settings and discover common challenges to

their physical and emotional well-being.

Groups need to identify a clear purpose so they can establish

criteria for member selection and determine an action plan. A

clear statement of purpose proved valuable in forming a new

group in one city’s housing development. The local department

of social services had received numerous reports of child abuse

and neglect. Routine home visits for well-child care docu-

mented high stress between parents and their offspring, and

some parents asked the nurse to teach them about child disci-

pline. The nurse proposed that a parent group address this

community need, and she chose this purpose for the group:

dealing with kids for child and parent satisfaction. The purpose

indicated both the process (to help parents deal with children)

and the desired outcome (satisfaction for parents and children).

Having a group purpose stated enabled parents to decide if they

wanted to join.

Cohesion is the attraction among individual members and

between each member and the group. Individuals in a highly

cohesive group identify themselves as a unit, work toward

common goals, endure frustration for the sake of the group,

and defend the group against outside criticism. Attraction

increases when members feel accepted and liked by others, see

similar qualities in one another, share similar attitudes and

values, and work together to meet group goals. The following

member traits can increase group cohesion and productivity:

(1) attraction to a set of compatible personal and group

goals, (2) attraction to members of the group, and (3) a good

mix among members of problem-solving, leading, and follow-

ing skills.

Groups have both task and maintenance functions. A task

function is anything a member does that deliberately con-

tributes to the group’s purpose. Members with task-directed

abilities become more attractive to the group. These traits

include strong problem-solving skills, access to material re-

sources, and skills in directing. Maintenance functions help

members afirm, accept, and support one another, resolve

conlicts, and create social and environmental comfort.

Groups need members with both task and maintenance func-

tions. In contrast, some member traits can decrease cohesion

and productivity, such as (1) conlicts between personal and

group goals, aversion to some members of the group, and not

understanding the behaviors and attributes of one another;

(2) lack of interest in group goals and activities; (3) poor

problem-solving and communication abilities; and (4) lack

of both leadership and supporter skills and disagreement

about types of leadership. Usually, the more alike group

members are, the stronger is a group’s attraction. Differences

tend to decrease attractiveness and may lead to competition

and jealousy among members. At the same time, personal

differences can increase group cohesion if they support

complementary functioning or provide contrasting view-

points necessary for decision-making. Cohesive factors are

complex, and many factors inluence member attraction to

each other and to the group’s goal. High group cohesion

positively affects productivity and member satisfaction. The

following example illustrates factors that inluence group

cohesion.

A nurse initiated a group for clients who had been treated

for burns. Ten residents from the same town had been dis-

charged after a month in the local burn unit. The stated pur-

pose of the group was to teach coping skills to assist members

in the transition from hospital to home. Each person had been

treated for extensive burns in an intensive care treatment cen-

ter; each had relied heavily on health care workers for physical,

social, and emotional rehabilitation; and each had faced the

challenge of resuming work and family roles. Individuals shared

some similar experiences and hopes for the future but varied in

the amount of trauma and stress experienced. They also dif-

fered widely in psychological readiness for return to ordinary

197CHAPTER 11 Using Health Education and Groups in the Community

daily routines. One woman in the group was able to return

quickly to her job as a cashier in a large supermarket. The

strength of her determination to overcome public reaction to

her scars, coupled with an ability to “use the right words” and

an empathy for others, distinguished her from others in the

group. These differences proved attractive to other members,

inspiring them to work toward a return to their own roles in

life. These members saw her differences as attainable.

This group’s cohesion was provided by the members’ attrac-

tion to the common purpose of returning to successful life pat-

terns and managing relationships with others. Members also

thought that interaction with others with similar burn experi-

ences could help them reach that goal. This example shows that

certain member experiences, such as crises or traumas, may

help individuals identify with each other and increase member

attraction.

Being different from the general population and similar to

the other group members is, for some, a compelling force for

membership in the group. Other members may be repelled by

the group because they do not want to be identiied by an aver-

sive characteristic such as disigurement. Empathy for another’s

pain, learned only through mutual experience, may provide

each individual with a required perspective for problem solving

or afirming another’s view. This nurse helped members use

common experiences and learn from their differences. The

group was effective.

Member attraction to the group also depends on the nature

of the group. Factors include the group programs, size, type of

organization, and position in the community. Attraction to the

group is increased when individuals understand the goals and

see group activities as effective. Cohesive groups tend to be

more productive and able to accomplish their goals; cohesion

can be increased as members better understand the experi-

ences of others and identify common ideas and reactions to

various issues. Nurses facilitate this process by pointing out

similarities, contrasting supportive differences, or helping

members redeine differences in ways that make those dissimi-

larities compatible.

Norms are standards that guide, control, and regulate indi-

viduals and communities. Group norms set the standards for

group members’ behaviors, attitudes, and perceptions. Group

norms suggest what a group believes is important, what it

inds acceptable or objectionable, or what it perceives as of no

consequence. The task norm is the commitment to return to

the central goals of the group. The strength of the task norm

determines the group’s ability to adhere to its work.

Maintenance norms create group pressures to afirm mem-

bers and maintain their comfort. Maintenance behaviors include

identifying the social and psychological tensions of members and

taking steps to support those members at high-stress times. For

example, maintenance norms often refer to things such as sched-

uling meetings at convenient times and in an accessible and

comfortable space with parking as well as seating, refreshments,

and toilets.

Groups also have reality norms, whereby members rein-

force or challenge and correct their ideas of what is real.

Groups can examine the life situations facing members and

help make sense of them. As individuals gather information,

attempt to understand that information, make decisions, and

consider the facts and their implications, they can take respon-

sible action, not only in relation to themselves and their group

but also for the community. Group (task, maintenance, and

reality) norms combine to form a group culture. Reality

norms inluence each member to see relevant situations in the

same way the other members see them. For example, suppose

a group of individuals with diabetes deines an uncontrolled

diet as harmful; members may try to inluence one another to

maintain diet control. The nurse can provide accurate infor-

mation about diet and the disease process while continually

conveying an assurance that health through diet control is

attainable and desirable.

Group members with similar backgrounds may have a lim-

ited scope of knowledge. For example, women members of a

spouse abuse group may think that men are exploitative and

harmful based on their childhood and marriage experiences.

Such a stereotypical view of men could be reinforced by similar

perceptions in other members; this might lead to continuing

anger, fear of interactions with men, and a hostile or helpless

approach to family affairs. Nurses or group members who have

known men in loving, helpful, and collaborative ways can de-

scribe these perceptions of men and offer positive examples.

Nurses bring an important perspective to groups in which

similar backgrounds limit the understanding and interpreta-

tion of personal concerns.

Groups have role structures that deine the expected ways

in which members behave toward one another. The role that

each person assumes serves a purpose in the group. Roles

might be as leader, follower, task specialist, maintenance spe-

cialist, evaluator, peacemaker, and gatekeeper. Box 11.5 in-

cludes descriptions of each of these group roles. Because

leadership is an especially complex role, it will be discussed in

greater detail.

Leadership is a complex concept. It consists of behaviors

that guide or direct members and determine and inluence

group action. Positive leadership deines or negotiates the

There are many examples; this is a representative list of the types of roles

members may use.

Follower: Seeks and accepts the authority or direction of others

Gatekeeper: Controls outsiders’ access to the group

Leader: Guides and directs group activity

Maintenance specialist: Provides physical and psychological support for

group members, thereby holding the group together

Peacemaker: Attempts to reconcile conlict between members or takes

action in response to inluences that disrupt the group process and

threaten its existence

Task specialist: Focuses or directs movement toward the main work of the

group

BOX 11.5 Examples of Group Role Behavior

198 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

group’s purpose, selects and helps implement tasks that accom-

plish the purpose, maintains an environment that afirms and

supports members, and balances efforts between task and

maintenance. An effective leader pays attention to communi-

cations and interactions among the members, including spo-

ken words and body language. This information provides

continuous feedback about the members and the group pro-

cess. By paying close attention to communications and inter-

actions, members detect changing group needs and can take

responsibility and pride in their own involvement. One or

more members may lead the group, or leadership may be

shared by one or more members. Generally, shared leadership

increases productivity, cohesion, and satisfying interactions

among members.

After initiating or establishing a group, nurses may facilitate

leadership within and among members, frequently relinquish-

ing central control and encouraging members to determine the

ultimate leadership pattern for their group. In some settings

and circumstances, a single authority is necessary (e.g., when

members have limited skills or time or are uncomfortable with

shared responsibility for leading). A leadership style that shares

leading functions with other group members is effective when

there are many alternatives and when issues of values and

ethics are involved in the group’s action. Leadership can be

described as patriarchal, paternal, or democratic. Each of these

styles has a particular effect on members’ interaction, satisfac-

tion, and productivity. Groups may relect one or a combina-

tion of styles.

A patriarchal or paternal style is seen when one person has

the inal authority for group direction and movement. A per-

son using patriarchal leadership may control members

through rewards and threats, often keeping them in the dark

about the goals and rationale behind prescribed actions. Pa-

triarchal and paternal styles of leadership are authoritarian;

they can be used in a disaster team, in which immediate task

accomplishment is the goal. Group morale and cohesiveness

are typically low under sustained authoritarian styles of lead-

ership, and members may not learn how to function indepen-

dently. Also, issues of authority and control may disrupt

productivity if the group members challenge the power of the

leader. Democratic leadership is cooperative and promotes

and supports member involvement in all aspects of decision

making and planning. Members inluence each other as they

explore goals, plan steps toward the goals, implement those

steps, and evaluate progress.

CHOOSING GROUPS FOR HEALTH CHANGE

Nurses choose the type of group to use after considering the

overall needs of the community and its people, including client

contacts, expressed concerns of community spokespersons,

health statistics for the area, available health resources, and the

community’s general well-being. These data point to the com-

munity’s strengths and critical needs.

The nurse can identify goals for the community and for

various groups through media reports and from community

informants and colleagues. Community members should be

involved in setting the goals and in planning the interventions.

Alliances or coalitions unite diverse interest groups who share a

common interest in perceived threats to community health to

both analyze the community and develop the plan for change.

Nurses and other professionals are active in groups formed to

address community issues.

Nurses may work with existing groups or form new groups.

Deciding whether to work in established groups or to begin

new ones is based on client needs, the purpose of existing

groups, and the membership ties in existing groups. The

advantages to using established groups for individual health

change are that membership ties already exist, the existing

structure can be used, and it is not necessary to ind new

members because compatible individuals already form a

working group. Established groups usually have operating

methods that have proved successful; an approach for a

new goal is built on this history. Members are aware of each

other’s strengths, limitations, and preferred styles of interac-

tion and may be comfortable working together, and they

may be able to inluence one another. If you choose to work

with an established group, be sure to determine whether

the new focus is compatible with the existing group pur-

poses. Fig. 11.4 shows a breakout session during a commu-

nity forum.

Nurses can use existing community groups as a source

of information to conduct a community assessment. Many

community groups, such as health-planning groups, better

business clubs, women’s action groups, school boards, and

neighborhood councils, are excellent resources for informa-

tion because part of their purpose is to determine and re-

spond to community needs. In addition, they are already

established as part of the community structure. When a

group representing one community sector is selected for

community health intervention, the total community struc-

ture is studied. Groups relect existing community values,

strengths, and norms.

FIG. 11.4 Breakout session in a community forum on envi-

ronmental health concerns. (From Centers for Disease Control

and Prevention, 2009, courtesy Dawn Arlotta.)

199CHAPTER 11 Using Health Education and Groups in the Community

CASE EXAMPLE Nurse working with an established group to intervene in a

community problem: A nurse was asked to meet with a

neighborhood council to help them study and “do something

about” the number of homeless living on the streets. Resi-

dents knew the nurse from a local clinic and from his consult-

ing work at a shelter for the homeless in an adjacent com-

munity. When the council invited him, they stated that “our

intent is to be part of the solution rather than part of the

problem.” The nurse agreed to meet, and he learned that the

neighborhood council had addressed concerns of the neigh-

borhood for 20 years—protecting zoning guidelines, setting

up a recreational program for teens, organizing an after-

school program for latchkey children, and generally repre-

senting the homeowners of the area. The neighborhood was

composed of low-income families who took great pride in

their homes. After meeting with the council and listening to

their description of the situation, the nurse agreed to help,

and he joined the council.

As the irst step in addressing the problem, the council

conducted a comprehensive problem analysis on the home-

less situation. All known causes and outcomes of homeless

persons on the street were identiied, and the relationships

between each factor and the problem were documented

from literature and from the local history. The nurse brought

expertise in health planning and knowledge of the homeless

and their health risks. He suggested negotiation between

the council and the local coalition for the homeless, recogniz-

ing that planning would be most relevant if homeless indi-

viduals participated. The council was cohesive and commit-

ted to the purpose, had developed working operations, and

did not need help with group process. They made adjust-

ments in their usual group operation to use the knowledge

and health-planning skills of the nurse. Interventions for the

homeless included establishing temporary shelters at homes

on a rotating basis, providing daily meals through the city

council or churches, and joining the area coalition for the

homeless.

How might nurses help established groups work toward

community goals? The same interventions recommended for

groups formed for individual health change can be used for

groups focused on community health. Such interventions in-

clude the following:

• Building cohesion through clarifying goals and individual

attraction to groups

• Building member commitment and participation

• Keeping the group focused on the goal

• Maintaining members through recognition and encouragement

• Maintaining member self-esteem during conlict and con-

frontation

• Analyzing forces affecting movement toward the goal

• Evaluating progress

When nurses enter established groups, they need to assess

the leadership, communications, and normative structures.

This facilitates group planning, problem solving, intervention,

and evaluation. The steps for community health changes paral-

lel those of decision making and problem solving in other

methodologies.

This example shows how an established, competent group

addressed a new goal successfully by building on existing

strengths in partnership with the nurse. Community groups,

because of their interactive roles, are logical and natural vehi-

cles for people who work together for community health

change. As the decision-making and problem-solving capabili-

ties of community groups are strengthened, the groups become

more able representatives for the whole community. Nurses

improve the community’s health by working with groups to-

ward that goal.

When it is neither desirable nor possible to use existing

groups, the nurse can initiate a selected membership group.

Choose members who have common health needs or concerns.

For instance, individuals with diabetes can meet to discuss diet

management and physical care and to share problem-solving

remedies; community residents can meet for social support and

rehabilitation after treatment for mental illness; or isolated

older adults can meet to socialize, eat nutritious meals, and ex-

ercise. Consider members’ attributes when composing a new

group. Members are attracted to others from similar back-

grounds, with similar experiences, and with common interests

and abilities.

The size of the group inluences effectiveness; generally, 8 to

12 is a good number for group work focused on individual

health changes. Groups of up to 25 members may be effective

when their focus is on community needs. Large groups often

divide and assign tasks to the smaller subgroups, with the

original large groups meeting less frequently for reporting

and evaluation. Setting member criteria can facilitate recruit-

ment and selection of the most appropriate members for any

group. The criteria usually suggest a mixture of member traits,

allowing for balance for the processes of decision making and

growth.

BEGINNING INTERACTIONS AND DEALING WITH CONFLICT

Work on the stated purpose begins as soon as the group

forms. It is important to help members interact with a degree

of satisfaction. This requires close attention to maintenance

tasks of attending, eliciting information, clarifying, and rec-

ognizing contributions of members. Begin by talking about

what brought each member to the group. Encourage each

person to participate; recognize and support them as they

take on leadership functions. The new group begins to take

shape in the early sessions as members try out familiar roles

and test their individual abilities. The core competency skills

for communication recommended by the Public Health

Foundation (Council on Linkages, 2010) are useful to nurses

who work with groups in the community. Box 11.6 lists these

competencies. Subsequent steps are then planned not only

according to the nurse’s skill and preference but also accord-

ing to the group composition and the skills brought by

members

Conlict normally occurs in all human relations. However,

people generally see conlict as the opposite of harmony and

try to guard against it. This is an unfortunate view because the

200 PART 3 Conceptual Frameworks Applied to Nursing Practice in the Community

tensions of difference and potential conlict actually help

groups work toward their purposes. It is important to under-

stand common causes of conlict and conlict management

and resolution approaches. Conlict signals that antagonistic

points of view must be considered and that one must reexam-

ine beliefs and assumptions underlying relationships. Some

people are concerned about security, control of self and others,

respect between parties, and access to limited resources. In

groups, members may express frustrations about trust, close-

ness and separation, and dependence and independence. These

themes of interpersonal conlict operate to some extent in all

interactions and are not unique to groups. Conlict can be

overwhelming, especially when members think that expressing

controversy is unacceptable or unremitting or when it is sup-

pressed over time and builds up to an explosive stage. A group

that repeatedly avoids expressing conlict becomes fragile, un-

able to adapt, and helpless to face challenges. Conlict may be

destructive if contentious parties fail to respect the rights and

beliefs of others.

Approaches for conlict-acknowledging and problem solv-

ing that respect others and represent self-concerns are irst

learned in families and other small groups. These lessons teach

people that conlict is natural and can support growth and

change. Other people learn to avoid conlict or disregard others

in the promotion of self. Teams that embrace a united desire

for harmony and avoid conlict may hinder collaboration and

personal growth (Gerow, 2001).

EVALUATION OF GROUP PROGRESS

It is important to evaluate individual and group progress to-

ward meeting health goals. Early in the planning, specify the

action steps that should be taken to meet the goals. These small

steps may be responses to learning objectives (listed as action

steps designed to support facilitative forces and deal with resis-

tive forces), or they may relect the group’s problem-solving

plan. The action steps and the indicators of achievement are

discussed and written in a group record. Build recognition of

accomplishments into the evaluation system. Recognition may

include concrete rewards, such as special foods and drinks,

or it may be the personal expression of joy and member-

to-member approval. Celebration of group accomplishments

marks progress, rewards members, and motivates each person

to continue.

P R A C T I C E A P P L I C A T I O N

R E M E M B E R T H I S !

Kristi, a bachelor of science in nursing student, is having her

community health practicum at a local health department. The

health department has gotten many calls from people wanting

information about the H3N2 virus. For Kristi’s community

health intervention project, she decides to do a community

educative piece on this topic.

What is her best course of action?

A. Develop a poster presentation to have on display at the

health department.

• Health education is essential in nursing because the promo-

tion, maintenance, and restoration of health rely on clients’

understanding of health care topics.

• Nurse educators identify learning needs, consider how peo-

ple learn, examine educational issues, design and implement

educational programs, and evaluate the effects of the educa-

tional program on learning and behavior.

• Nurses often use the Healthy People 2020 educational objectives

as a guide to identifying community-based learning needs.

• Education and learning are different. Education is the estab-

lishment and arrangement of events to facilitate learning.

B. Assemble an educative pamphlet to mail to anyone calling

with questions.

C. Work with the health department staff to develop a commu-

nity forum–style presentation and information brochures on

this virus.

D. Develop an in-service program for health department staff

on the potential spread of the virus and ways to prevent its

spread.

Answers can be found on the Evolve website.

Learning is the process of gaining knowledge and expertise

and results in behavioral changes.

• Three domains of learning are cognitive, affective, and

psychomotor. Depending on the needs of the learner,

one or more of these domains may be important for

the nurse educator to consider as learning programs are

developed.

• Nine principles associated with community health educa-

tion are gaining attention, informing the learner of the ob-

jectives of instruction, stimulating recall of prior learning,

presenting the stimulus, providing learning guidance, eliciting

Communication Skills

• Communicates effectively both in writing and orally, including via e-mail.

• Solicits input from individuals and organizations.

• Advocates for public health programs and resources.

• Leads and participates in groups to address speciic issues.

• Uses the media, various technologies, and community networks to convey

information.

• Effectively presents accurate demographic, statistical, programmatic, and

scientiic information for professional and lay audiences.

Attitudes

• Listens to others in an unbiased manner.

• Respects points of view of others.

• Promotes the expression of diverse opinions and perspectives.

BOX 11.6 Core Competencies for Communication Skills of Educators

201CHAPTER 11 Using Health Education and Groups in the Community

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February 2016.

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Core competencies for public health professionals, Washington, DC,

2010, Public Health Foundation. Retrieved February 2016 from

http://www.phf.org.

Cronenwett L, Sherwood G, Barnsteiner J, et al: Quality and safety

education for nurses, Nurs Outlook 55:122–131, 2007.

Dauz E, Moore J, Smith CE, et al: Installing computers in older adults’

homes and teaching them to access a patient education web site: a

systematic approach, Comput Inform Nurs 22:266–272, 2004.

Dembo MH: Applying educational psychology, ed 5, White Plains, NY,

1994, Longman.

Edberg M: Essentials of health behavior: Social and behavioral theory

in public health, ed 2, Burlington, MA, 2015, Jones and Bartlett.

French KS: Transforming nursing care though health literacy ACTS,

Nurs Clin N Am 50:87–98 2015.

Gerow SJ: Teachers in school-based teams: contesting isolation in

schools. In Sockett HT, DeMulder EK, DePage PC, et al, editors:

Transforming teacher education: lessons in professional development,

Westport, Conn, 2001, Bergin & Garvey.

Hansen M, Fisher J: Patient-centered teaching from theory to practice,

Am J Nurs 98:56–60. 1998.

Health Literacy Innovations: Focus on readability and readability

indices, Health Literacy Innovations Newslett 1:1–9, 2010.

Health Resources and Services Administration: Health literacy, n.d.

Retrieved February 2016 from http://www.hrsa.gov/publichealth/

healthliteracy/.

Kleinbeck C: Reaching positive diabetes outcomes for patients with

low literacy, Home Healthcare Nurse 23:16–22, 2005.

performance, providing feedback, assessing performance,

and enhancing retention and transfer of knowledge.

• Often, theory can guide the development of health educa-

tion programs. Two useful ones are the Health Belief Model

and the Transtheoretical Model, which are discussed in con-

nection with the Precaution Adoption Process Model.

• Principles that guide the effective educator include message,

format, environment, experience, participation, and evaluation.

• Educational issues include population considerations, barri-

ers to learning, and technological issues.

• Two important learner-related barriers are low literacy level,

especially health literacy, and lack of motivation to learn

information and make the needed changes.

• The ive phases of the educational process are identifying

educational needs, establishing educational goals and objec-

tives, selecting appropriate educational methods, implement-

ing the educational plan, and evaluating the educational

process and product.

• Evaluation of the product includes the measurement of

short-term and long-term goals and objectives related to

improving health and promoting behavioral changes.

• Working with groups is an important skill for nurses. Groups

are an effective and powerful vehicle for initiating and im-

plementing healthful changes.

• A group is a collection of interacting individuals with a com-

mon purpose. Each member inluences and is inluenced by

other group members to varying degrees.

• Group cohesion is enhanced by commonly shared character-

istics among members and diminished by differences among

members.

• Cohesion is the measure of attraction between members and

the group. Cohesion or the lack of it affects the group’s function.

• Norms are standards that guide and regulate individuals and

communities. These norms are unwritten and often unspo-

ken and serve to ensure group movement to a goal, to main-

tain the group, and to inluence group members’ perceptions

and interpretations of reality.

• Some diversity of member backgrounds is usually a positive

inluence on a group.

• Leadership is an important and complex group concept. Lead-

ership is described as patriarchal, paternal, or democratic.

• Group structure emerges from various member inluences,

including members’ understanding and support of the group

purpose.

• Conlicts in groups may develop from competition for

roles or member disagreement about the roles ascribed

to them.

• Health behavior is greatly inluenced by the groups to which

people belong and for which they value membership.

• An understanding of group concepts provides a basis for

identifying community groups and their goals, characteris-

tics, and norms. Nurses use their understanding of group

principles to work with community groups toward needed

health changes.

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203

PART 4 Issues and Approaches in Health Care Populations

After reading this chapter, the student should be able to:

1. Decide whether nursing practice is community

oriented.

2. Understand selected concepts basic to community-oriented

nursing practice: community, community client, community

health, and partnership for health.

O B J E C T I V E S

3. Compare the nursing process to community-oriented nursing

practice.

4. Decide which methods of assessment, intervention, and

evaluation are most appropriate in selected situations.

5. Develop a community-oriented nursing care plan.

Community Assessment and Evaluation

Mary Gibson, Esther Thatcher, George F. Shuster

C H A P T E R

What Is a Community?

Community as Client

The Community as Client and Partner in Nursing

Practice

Goals and Means of Community-Oriented Practice

Community Health

Healthy People 2020

Community Partnerships

Strategies to Improve Community Health

C H A P T E R O U T L I N E Community-Focused Nursing Process: An Overview

of the Process from Assessment to Evaluation

Assessing Community Health

Assessment Issues

Identifying Community Problems

Planning for Community Health

Implementation in the Community

Evaluating the Intervention for Community Health

Personal Safety in Community Practice

aggregate, 205

change agent, 216

change partner, 216

community, 205

community assessment, 204

community competence, 208

community health, 208

community health problems, 212

community health strengths, 212

community-oriented practice, 207

community partnership, 209

conidentiality, 214

database, 214

data collection, 211

data gathering, 212

data generation, 212

evaluation, 217

goals, 215

implementation, 216

informant interviews, 212

interdependent, 205

intervention activities, 216

objectives, 215

participant observation, 212

partnership, 209

population-centered practice,

206

problem analysis, 215

problem prioritizing, 215

secondary analysis, 213

setting for practice, 205

surveys, 213

target of practice, 205

windshield survey, 211

K E Y T E R M S

In the past, nurses have viewed the community as a client and as

a partner in improving the health status of its citizens. Since the

days of Florence Nightingale and Lillian Wald, nurses have

looked at what is going on in the communities and environ-

ments in which they found their clients. Florence Nightingale

deined her community as war-torn Crimea and discovered that

the lack of fresh air, sanitation, and hygiene was contributing to

the illnesses of the soldiers. Lillian Wald found that the neigh-

borhoods around the Henry Street Settlement were impover-

ished, with poor housing conditions and sanitation, improper

204 PART 4 Issues and Approaches in Health Care Populations

nutrition, and crowding contributing to the problems of

new mothers and children. Both women became political ac-

tivists, worked with the leaders in their communities, and

even solicited help from their respective governments to help

change the conditions for the individuals and families in their

communities.

Although in the past nurses have sometimes viewed the

community as a client, many community-oriented nurses have

come to consider the community their most important client

and, more recently, their partner (Anderson and McFarlane,

2015; Caldwell et al, 2015). This chapter clarifies community

concepts and provides a guideline for nursing practice with

the community client. The core functions of public health

nursing (PHN) include assessment, policy development, and

assurance. A public and private group partnership, the

Council on Linkages between Academia and Public Health

Practice (2014), defined competencies for the core functions

of public health practice (see Chapter 1 for more details). In

the area of assessment, 11 competencies for the nurse and

other health providers working in the community are listed

(Box 12.1).

The nursing process from assessment through evaluation

is used to promote community health. This process begins

with community assessment, one of the core functions,

which involves getting to know the community. It is a logical,

systematic approach to identifying community needs, clarifying

problems, and identifying community strengths and resources.

This chapter provides the nurse with the knowledge necessary

to develop the community assessment core competencies.

Nurses in community health are interested in these concepts

because they want to know how the community’s health affects

their individual, family, and group clients.

WHAT IS A COMMUNITY?

The concept of community varies widely. The World Health

Organization (WHO) includes this deinition:

A group of people, often living in a deined geographical

area, who may share a common culture, values and norms,

and are arranged in a social structure according to relation-

ships 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 modiied in the future.

This deinition is similar to the one used by the Public

Health Accreditation Board (2013, p. 8)

“Community is a group of people who have common char-

acteristics; communities can be deined by location, race,

ethnicity, age, occupation, interest in particular problems or

outcomes, or other similar common bonds. Ideally, there

would be available assets and resources, as well as collective

discussion, decision-making, and action.

(WHO, 2004, p 16)

The most frequently used single deinition of community is

“community of place” or geographic boundaries. With agency

interactions (e.g., among schools, social services, and govern-

mental agencies) extending the ability to solve problems, nurses

working in communities quickly learn that society consists of

many different kinds of communities. Neighborhood and face-

to-face communities are two examples. Some other types of

communities are listed in Box 12.2.

Other communities, such as communities of special interest

or resource communities, are spread out across widely scattered

geographic areas. They are brought together by long-term or

short-term common concerns and interests. An example of an-

other type of community is a community of problem ecology,

which is created when environmental problems affect a wide-

spread area. For instance, a problem such as water pollution can

bring people together from areas that would not normally share

a common interest. Nurses also may work in partnership with

Public health professionals should be able to do the following:

• Deine a problem.

• Determine appropriate uses and limitations of both quantitative and

qualitative data.

• Select and deine variables relevant to the deined public health problems.

• Identify relevant and appropriate data and information sources.

• Evaluate the integrity and comparability of data, and identify gaps in data

sources.

• Apply ethical principles to the collection, maintenance, use, and dissemi-

nation of data and information.

• Partner with communities to attach meaning to collected quantitative and

qualitative data.

• Make relevant inferences from quantitative and qualitative data.

• Obtain and interpret information regarding risks and beneits to the community.

• Apply data collection processes, information technology applications, and

computer systems storage and retrieval strategies.

• Recognize how the data illuminate ethical, political, scientiic, economic,

and overall public health issues

BOX 12.1 Core Competencies for Public Health Professionals

From Council on Linkages between Academia and Public Health Practice:

Core competencies for public health professionals, Washington, DC,

2014, The Council. Retrieved July 2016 from phf.org/corecompetencies.

BOX 12.2 Types of Communities

• Face-to-face community

• Neighborhood community

• Community of identiiable need

• Community of problem ecology

• Community of concern

• Community of special interest

• Community of viability

• Community of action capability

• Community of political jurisdiction

• Resource community

• Community of solution

From Blum HL: Planning for health, New York, 1974, Human Sciences

Press.

http://www.phf.org/corecompetencies

205CHAPTER 12 Community Assessment and Evaluation

political communities, such as school districts, townships, or

counties. Because the nature of each type of community varies,

nurses planning interventions with communities must take into

account the characteristics of that speciic community. Each

community is unique, and its deining characteristics will affect

the nature of the partnership.

In most deinitions, the concept of community includes three

dimensions—people, place, and function—as follows:

1. The people are the community residents.

2. Place refers both to geographic and time dimensions.

3. Function refers to the aims and activities of the community.

Nurses in community health practice regularly need to examine

how the personal, geographic, and functional dimensions of com-

munity shape their nursing practice with individuals, families, and

groups. They can use both a conceptual deinition and a set of

indicators for the concept of community in their practice.

In this chapter, the following conceptual deinition is used:

community is a locality-based entity composed of systems of

formal organizations relecting society’s institutions, informal

groups, and aggregates. As deined in Chapter 1, an aggregate

is a collection of individuals who have in common one or more

personal or environmental characteristics. The components of

community are interdependent, and their function is to meet a

wide variety of collective needs. This deinition of community

includes personal, geographic, and functional dimensions and

recognizes interaction among the systems within a community.

Indicators of the dimensions of this deinition are listed in

Table 12.1.

The next section describes the community as client and

partner of the nurse. The community is irst the setting

for practice for the nurse practicing health promotion and dis-

ease prevention interventions with individuals, families, and

groups. Second, the community is the target of practice for the

public health nurse whose practice is focused on the broader

community rather than on individuals.

Dimensions Measures Examples of Data Sources

Place Geopolitical boundaries

Local or folk name for area

Size in square miles, acres, blocks, or census tracts

Transportation avenues, such as rivers, highways, railroads, and sidewalks

History

Physical environment, such as land use patterns and condition of housing

Maps

Local newspaper

Census data

Chamber of commerce, city, county, or township government

Library archives and local histories

Local housing ofice

People or person Population: number and density

Demographic structure of population, such as age, sex, socioeconomic

factors, and racial distributions; rural and urban character, and depen-

dency ratio

Informal groups, such as block clubs, service clubs, and friendship

networks

Formal groups such as schools, churches, businesses, industries,

governmental bodies, unions, and health and welfare agencies

Linking structures (intercommunity and intracommunity contacts among

organizations)

Census data

Churches, senior centers

Civic groups

Local newspaper

Telephone directory

United Way

Social service agencies

Chamber of commerce

Local or state oficials

Tourist bureau

Chamber of commerce

Function Production, distribution, and consumption of goods and services

Socialization of new members

Maintenance of social control

Adaptation to ongoing and expected change

Provision of mutual aid

State departments

Business and labor

Local library

Social and local research reports

Police station

Social and local research reports

United Way

Welfare agencies

Churches and religious organizations

TABLE 12.1 Concepts of Community Speciied

HOW TO Identify Community Systems

The following is a list of system categories found within a community:

1. Politics and government

2. Safety and transportation

3. Education

4. Physical environment

5. Recreation

6. Economics

7. Communication

8. Health and social services

9. Religion and beliefs

206 PART 4 Issues and Approaches in Health Care Populations

COMMUNITY AS CLIENT

Nurses who have a community orientation are often considered

unique because of their target of practice. The idea of health-

related care being provided within the community is not new.

At the turn of the century, most persons stayed at home during

illnesses. As a result, the practice environment for nurses was

the home rather than the hospital.

As the range of community nursing services expanded, many

different kinds of agencies were started and their services often

overlapped. For instance, both privately established voluntary

agencies and oficial local health agencies worked to control

tuberculosis. The nurses employed by these agencies were called

community health nurses, public health nurses, or visiting nurses.

Nurses practiced in clients’ homes, not in the hospital.

Early PHN textbooks in the 1940s included lengthy descrip-

tions of the home environment and tools for assessing the ex-

tent to which that environment promoted the health of family

members. Health education about the domestic environment

was often a major part of home nursing care.

By the 1950s, schools, prisons, industries, and neighborhood

health centers, as well as homes, had all become areas of practice

for nurses in the community. Many of the new nurses in the com-

munity did not consider the environments in which they prac-

ticed. Although their practices took place within the community,

they focused on the individual client or family seeking care. The

care provided was not population centered; rather, it was oriented

toward the individual or family who lived in the community, and

this is now called community-based nursing practice. This com-

mitment to direct, hands-on, clinical nursing care delivered to

individuals or families in community settings remains a more

popular approach to nursing practice than recognizing the whole

community as the target of nursing practice. This remains true

today. However, the American Public Health Association: Public

Health Nursing Section (APHA: PHN, 2013) statement indicates

that “Public health nursing activities comprise the domains de-

picted by the Public Health Intervention Wheel (see Appendix C.4)

and the 10 Essential Public Health Services (see Chapter 1). These

activities include community collaboration, health teaching, and

policy development, in response to priorities derived from ongo-

ing, comprehensive population-focused assessment. Public health

nurses are members and leaders of interprofessional teams in di-

verse settings and in many different types of agencies and organi-

zations, including all levels of government, community-based and

other nongovernmental service organizations, foundations, policy

think tanks, academic institutions, and other research settings.

Increasing numbers of public health nurses work in global health

in an effort to promote global responsibility and connectivity.

Public health nurses that work with individuals and families do so

within the context of a population focus—applying a systems

perspective to factors that impact health.” When the location of

practice is the community and the focus of practice is the individual

or family, the client remains the individual or family, and the

nurse is practicing in the community as the setting; this is an

example of community-based nursing practice.

The community is the client only when the nursing focus is on

the collective or common good of the population instead of on

individual health. Population-centered practice seeks healthful

change for the whole community’s beneit (Nash et al, 2016).

Although the nurse may work with individuals, families or

other interacting groups, aggregates, institutions, communities, or

within a population, the resulting changes are intended to affect

the whole community. For example, an occupational health

nurse’s target might be preventing illness and injury for the indi-

vidual worker. This would result in maintaining or promoting the

health of an entire company workforce. Because of this focus, the

nurse would help an individual disabled worker become indepen-

dent in activities of daily living. The nurse would also become

involved with promoting vocational rehabilitation services in

the community and seek reasonable employment policies for all

disabled workers through the community government.

THE COMMUNITY AS CLIENT AND PARTNER IN NURSING PRACTICE

Population-focused health care is experiencing a rebirth, and the

community as client is important to nursing practice for several

reasons. When focusing on the community as client, direct

clinical care can be a part of population-focused community

health practice (Sidorov and Romney, 2016). For example,

sometimes direct nursing care is provided to individuals and

family members because their health needs are common

community-related problems. Changes in their health will affect

the health of their communities (Lathrop and Hodnicki, 2014).

In such cases, decisions are made at the individual level because

the individual’s health is related to the health of the population as

a whole and because the individual has an effect on the commu-

nity’s health. Improved health of the community remains the

overall goal of nursing intervention. Interventions to stop spouse

abuse and elder abuse are two examples of nursing interventions

done primarily because of the effects of abuse on society and

therefore on the population as a whole. Also, the treatment of a

client for tuberculosis reduces the risk to other community mem-

bers. This care reduces the risk for an epidemic in the community.

The community client also highlights the complexity of the

change process. Change for the beneit of the community client

often must occur at several levels, ranging from the individual

to society as a whole. For example, health problems caused by

lifestyle, such as smoking, overeating, and speeding, cannot be

solved simply by asking individuals to choose health-promoting

habits. Society must also provide healthy choices. Most indi-

viduals cannot change their habits alone; they require the

support of family members, friends, community health care

systems, and relevant social policies. Individuals who have life-

style health problems are often blamed for their illness because

of their choices (e.g., to smoke). In his classic work, Ryan (1976)

points out that the “victim” cannot always be blamed and ex-

pected to correct the problem without changes also being made

at the same time in the helping professions and in public policy.

Some communities have no-smoking areas in restaurants to

prevent secondhand smoke from harming others. This is an

example of a community-level policy to change behavior.

Commitment to the health of the community client re-

quires a process of change at each of these levels. One nursing

role emphasizes individual and direct personal care skills,

another nursing role focuses on the family as the unit of

207CHAPTER 12 Community Assessment and Evaluation

service, and a third focuses on the community as a unit of ser-

vice. Collaborative practice models involving the community

and nurses in joint decision making and speciic nursing roles

are required (Green, 2015; Pilon et al, 2015). Korazim-Kőrösy

et al (2014) note that nurses must remember that collaboration

means shared roles and a cooperative effort in which partici-

pants want to work together. These participants must see them-

selves as part of a group effort and share in the process, begin-

ning with planning and including decision making. This means

sharing not only the power but also the responsibility for the

outcomes of the intervention.

Viewing the community as client and thus as the target of

service means embracing two key concepts: (1) community

health and (2) partnership for community health. These two

concepts form not only the goal (community health) but also

the means of population-centered practice (partnership).

GOALS AND MEANS OF COMMUNITY-ORIENTED PRACTICE

In community-oriented practice, the nurse and community

seek healthful change together (Mpofu, 2015). Their common

goal of community health involves an ongoing series of health-

promoting changes rather than a ixed state. The most effective

means of completing healthy changes in the community is

through this same partnership.

COMMUNITY HEALTH

Like the concept of community, community health has three

common characteristics or dimensions: status, structure, and

process. Each dimension relects a unique aspect of community

health (Cottrell, 1976).

Status Community health in terms of status or outcome is the most well-

known and accepted approach; it involves biological, emotional,

and social parts. The biological (or physical) part of community

health is often measured by traditional morbidity and mortality

rates, life expectancy indices, and risk factor proiles. Morbidity

and Mortality Weekly Report (Consensus set of health status indi-

cators, 1991) published the work of a consensus committee

involving representatives from a number of community health-

related organizations. This committee identiied by consensus

18 community health status indicators, presented in Box 12.3.

More recently, the Centers for Disease Control and Prevention

(CDC), in partnership with some public health organizations,

has relaunched the Community Health Status Indicators (CHSI)

project to provide an overview of key health indicators for local

communities, such as those identiied by the Morbidity and

Mortality Weekly Report (Consensus set of health status indicators,

1991). Health status indicator data on thousands of communities

can be found at http://wwwn.cdc.gov/CommunityHealth/.

The emotional component of health status can be measured

by consumer satisfaction and mental health indexes. Crime

rates and functional levels relect the social part of community

health. Other status measures, such as worker absenteeism and

infant mortality rates, relect the effects of all three parts.

Structure Community health, when viewed from the structure of the com-

munity, is usually deined in terms of services and resources. Mea-

sures of community health services and resources include service

use patterns, treatment data from various health agencies, and

provider-to-client ratios. These data provide information, such as

the number of available hospital beds or the number of emergency

room visits to a particular hospital. The problems that can be found

when structure measures are used are serious. For example, prob-

lems related to access to care and quality of care are well known

through stories reported in local newspapers. Less well known,

but of equal concern, is the false thought that simply providing

health care improves health. Such problems require cautious use of

health services and resources as measures of community health.

A structural viewpoint also deines the characteristics of the

community structure itself. Characteristics of the community

structure are commonly identiied as social measures, or cor-

relates, of health. Measures of community structure include

demographics, such as socioeconomic and racial distributions,

age, and educational level. Their relationships to health status

have been thoroughly documented. For example, studies have

Indicators of Health Status Outcome

1. Race-speciic and ethnicity-speciic infant mortality, as measured by the

rate (per 1000 live births) of deaths among infants less than 1 year of age

Death Rates (per 100,000 Population)† for:

2. Motor vehicle crashes

3. Work-related injury

4. Suicide

5. Lung cancer

6. Breast cancer

7. Cardiovascular disease

8. Homicide

9. All causes

Reported Incidence (per 100,000 Population) of:

10. Acquired immunodeiciency syndrome (AIDS)

11. Measles

12. Tuberculosis

13. Primary and secondary syphilis

Indicators of Risk Factors

14. Incidence of low birth weight, as measured by percentage of total

number of live-born infants weighing less than 2500 g at birth

15. Births to adolescents (females 10–17 years of age) as a percentage of

total live births

16. Prenatal care, as measured by percentage of mothers delivering live

infants who did not receive prenatal care during the irst trimester

17. Childhood poverty, as measured by the proportion of children younger

than 15 years of age living in families at or below the poverty level

18. Proportion of persons living in counties exceeding US Environmental

Protection Agency standards for air quality during the previous year

BOX 12.3 Consensus Set of Indicators* for Assessing Community Health Status

From Consensus set of health status indicators for the general

assessment of community health status: United States, MMWR

Morb Mortal Wkly Rep 40:449-451, 1991 (updated August 2001). *Position or number of the indicator does not imply priority. †Age adjusted to the 1940 standard population.

http://wwwn.cdc.gov/CommunityHealth/

208 PART 4 Issues and Approaches in Health Care Populations

repeatedly shown that health status decreases with age and

improves with higher socioeconomic levels (Agency for Health-

care Research and Quality, 2015).

Process The view of community health as the process of effective com-

munity functioning or problem solving is well established.

However, it is especially appropriate to nursing because it di-

rects the study of community health to promote effective com-

munity action for health promotion.

Community competence, deined originally in a classic work by

Cottrell (1976), provides a basic understanding of the process

dimension of community health. Community competence is a

process whereby the parts of a community—organizations, groups,

and aggregates—“are able to collaborate effectively in identifying

the problems and needs of the community; can achieve a working

consensus on goals and priorities; can agree on ways and means to

implement the agreed-on goals; and can collaborate effectively in

the required actions” (Cottrell, 1976, p 197).

Ruderman (2000) further expanded on Cottrell’s deinition

by indicating that community competence indicates the

capacity of a community to implement change by assessing

the need or the demand for change. Once change is indicated,

then the community must deine and make available the

resources for the change to occur.

The term community health, as used in this chapter, is the

meeting of collective needs by identifying problems and manag-

ing interactions within the community itself and between the

community and the larger society. This deinition emphasizes

the process dimension but also includes the dimensions of status

and structure. Measures for all three dimensions are listed in

Table 12.2.

The use of status, structure, and process dimensions to deine

community health, as shown in Table 12.2, is an effort to develop

a broad deinition of community health, involving indicators that

often are not included when discussions focus only on individual

and family risk factors as the basis for community health.

Consideration of health risks guides us to think upstream—to

identify risks that could be prevented to make and keep people

healthy. Most community-oriented and population-oriented

approaches to health are grounded in the notion that the earlier in

the causal process (or the more upstream) interventions occur,

the greater the likelihood of improved health. Frequently, preven-

tion or upstream action requires community-wide intervention

Dimensions Measures Examples of Data Sources

Status Vital statistics (live births, neonatal deaths, infant deaths, maternal

deaths)

Incidence and prevalence of leading causes of mortality and morbidity

Health risk proiles of selected aggregates

Functional ability levels

Census data

State health department annual vital statistics

Census data

State health department

Local health department

Support groups

Local nonproit organizations

Census data

US Department of Labor

Structure Health facilities such as hospitals, nursing homes, industrial and school

health services, health departments, voluntary health associations,

categorical grant programs, and prepaid health plans

Local chamber of commerce

United Way

Health-related planning groups Local newspapers

Local magazines

Local government

Health manpower, such as physicians, dentists, nurses, environmental

sanitarians, social workers

Telephone directory

State and local labor statistics

Professional licensing boards

Health resource use patterns, such as bed occupancy days and client

and provider visits

Medicare and Medicaid databases (federal and state government)

Annual reports from hospitals, health maintenance organizations

(HMOs), nonproit agencies

Process Commitment to community health Local government

Real estate agencies (e.g., turnover and vacancy rates)

Awareness of self and others and clarity of situational deinitions Local history

Neighborhood help organizations

Effective communication Local/neighborhood newspapers and radio programs

Local government

Conlict containment and accommodation Social services department

Participation Existence of and participation in local organizations

Management of relationships with society Windshield survey—observation of interactions

Machinery for facilitating participant interaction and decision making Notices for community organizations and meetings in public

places (e.g., supermarkets, newspapers, radio)

TABLE 12.2 Concept of Community Health Speciied

209CHAPTER 12 Community Assessment and Evaluation

directed toward social, economic, and environmental conditions

that correlate with low health status (Braveman and Gottlieb, 2014).

HEALTHY PEOPLE 2020

One important guideline available for nurses working to im-

prove the health of the community is Healthy People 2020,

a 2010 publication from the US Department of Health and

Human Services (USDHHS). It offers a vision of the future for

public health and speciic objectives to help attain that vision.

The Healthy People 2020 vision recognizes the need to work col-

lectively, in community partnerships, to bring about the changes

that will be necessary to fulill this vision. Healthy People 2020

provides the foundation for a national health promotion and

disease prevention strategy built on four goals:

1. Attain high-quality, longer lives free of preventable disease,

disability, injury, and premature death.

2. Achieve health equity, eliminate disparities, and improve the

health of all groups.

3. Create social and physical environments that promote good

health for all.

4. Promote quality of life, healthy development, and healthy

behaviors across all life stages.

In Section IV of the Advisory Committee Findings and Rec-

ommendations for the Role and Function of Healthy People

2020, there is a direct discussion about the relationship between

individuals and their communities. It states,

The Advisory Committee believes Healthy People 2020 can

best be described as a national health agenda that commu-

nicates a vision and a strategy for the nation. Healthy Peo-

ple 2020 should provide overarching, national-level goals.

On a practical level, it is a road map showing where we

want to go as a nation and how we are going to get there.

COMMUNITY PARTNERSHIPS

The executive summary written by the advisory committee for

Healthy People 2020 identiies a model for action that will require

community partnership as key to meeting program goals. Com-

munity partnership is necessary because when there is commu-

nity partnership, lay community members have a vested interest

in the success of efforts to improve the health of their community.

Lay community members who are recognized as community

leaders also possess credibility and skills that health professionals

often lack. Therefore successful strategies for improving the com-

munity’s health must include community partnership as the basic

means, or key, for improvement (Adams and Canclini, 2008).

Community partnership is a basic focus of such population-

centered approaches as Mobilizing for Action through Planning

and Partnerships (MAPP) (National Association of Community

and City Health Oficials [NACCHO], 2016).

Most changes must aim at improving community health

through active partnerships between community residents and

health workers from a variety of disciplines. Unfortunately,

community residents are often viewed only as sources of

information and receivers of interventions. This form of part-

nership is called passive participation. Passive participation is

the opposite of the partnership approach in which all are in-

volved in assessing, planning, and implementing needed com-

munity changes (Korazim-Kőrösy et al, 2014).

The community member–professional partnership approach

speciically emphasizes active participation. Power is shared

among lay and professional persons throughout the assessment,

planning, implementation, and evaluation processes. Partner-

ship means the active participation and involvement of the com-

munity or its representatives in bringing about healthful change

(O’Donnell, 2009). For example, breast cancer is an issue for ru-

ral Native American women, and an active community partner-

ship involving the Native American women helped develop and

ensure an effective, ongoing program (Espey et al, 2014).

Partnership, as deined here, is a concept that is as essential for

nurses to know and use as are the concepts of community, com-

munity as client, and community health. Experienced nurses

know that partnership is important because health is not a static

reality. Rather, it is continuously generated through new and in-

creasingly effective means of community member–professional

collaboration. However, such changes also require other active

professional service providers, such as school teachers, public

safety oficers, and agricultural extension agents. Partnership in

identifying problems and setting goals is especially important

because it brings commitment from all persons involved, which is

essential to successful change (Archer, Cary, and Malone, 2014).

A growing body of literature supports the signiicance and

effectiveness of partnership in improving community health. Stud-

ies document the use of partnership models for a wide range of

outcomes such as improving access to quality, low-cost snacks in

after-school programs, reducing vehicle idling near public schools,

improving breast and cervical cancer screening, and increasing lu

vaccination rates of homeless populations (Beets et al, 2014;

Eghbalnia et al, 2013; Espey et al, 2014; Metcalfe and Sexton,

2014). The roles of these partners in health have included listening

sympathetically, offering advice, making referrals, and starting

programs among a wide range of communities. These include

working with vulnerable populations, such as American Indian

and Alaska Native women, Hispanic/Latino men who have sex

with men (MSM), and rural Hispanic migrant farm workers

(Espey et al, 2014; Rhodes et al, 2015; Sánchez et al, 2012). They

include partnerships with older adults in retirement communities,

as well as smaller, more rural communities (Pinto, Waldemore, and

Rosen, 2015; Perry et al, 2015). There are also examples of com-

munity partnerships for at-risk students at the grade school or

middle school level, for building community capacity for advocat-

ing for policy change, and for disaster planning (Cheezum et al,

2013; Duff and Poole, 2016; Santibañez et al, 2015). Upvall and

Leffers (2014) advocate using partnership models in global health

nursing, provided certain ethical challenges and issues are addressed

such as power imbalances between those receiving assistance and

those providing it. In international health, partnership models gen-

erally are viewed as empowering people, through their lay leaders,

to control their own health destinies and lives. In the United States,

partnership models have often involved informal community

leaders, organizations such as churches, and communities.

Partnerships involving nurses working with community orga-

nizations offer one of the most effective means for interventions

210 PART 4 Issues and Approaches in Health Care Populations

because they actively involve the community and build on exist-

ing community strengths. Nurses working with community

groups and organizations fulill many different roles. These roles

include media advocacy, political action, “grass roots health com-

munication and social marketing,” and outreach facilitation to

get more community members involved, for example, in a school

health fair. Regardless of what roles nurses fulill as their contri-

bution to the partnership, they must remember to “start where

the people are” (Minkler, 2012).

STRATEGIES TO IMPROVE COMMUNITY HEALTH

Healthy People 2020 has stimulated joint efforts to develop

strategies for achieving its goals. These efforts have involved

such organizations as the CDC, the American Public Health

Association (APHA), the Association of State and Territorial

Health Oficials (ASTHO), and the NACCHO. The results

of these efforts are publications and guidelines that provide

detailed strategies for achieving the objectives in the Assess-

ment Protocol for Excellence in Public Health (APEXPH),

the Planned Approach to Community Health (PATCH), and,

more recently, MAPP. Each of these approaches offers step-

by-step guidelines for community planning and interventions

(see Chapter 16). Most recently, the CDC’s Healthy Commu-

nities Program has developed the Community Health As-

sessment and Group Evaluation (CHANGE) Tool, which is

designed to help assess for community change and establish-

ing community priorities. It is available for free at http://www.

c d c . g o v / n c c d p h p / d c h / p r o g r a m s / h e a l t hy c o m m u n i t i e s

program/tools/change.htm.

In addition to these approaches, there have been efforts to

apply the evidence-based practice approach to community-

level interventions. The Community Guide provides recom-

mendations for population-based interventions to promote

health and to prevent disease, injury, disability, and prema-

ture death, and it is appropriate for use by communities and

health care systems. The initial Community Guide was a result

of the work of the Task Force on Community Preventive

Services (2016a), which has been updated and continues to

systematically review published scientiic studies, weigh the

evidence, and determine the effectiveness of interventions in

a particular area. For instance, in regard to physical activity

promotion, the Task Force recommends community-wide

campaigns, individually adapted health behavior change pro-

grams, school-based physical education, social support inter-

ventions in community contexts, and creating or improving

access to places for physical activity combined with informa-

tional outreach (Task Force on Community Prevention Ser-

vices, 2016b). The work of this Task Force is ongoing, and

updates as well as publications on a wide range of public

health areas can be found at http://www.thecommunityguide.

org/index.html.

The National Center for Chronic Disease Prevention and Health

Promotion website (2017) includes links to CDC-supported public

health programs that have been found to be effective. Links to

guides and kits for the programs also can be found. Examples in-

clude the following:

• Well-Integrated Screening and Evaluation for Women Across

the Nation—WISEWOMAN (lifestyle intervention programs

addressing cardiovascular and other chronic disease risk

factors)

• Kids in Parks (activity)

• Trailnets Healthy, Active, and Vibrant communities

(activity)

• Eat Well Play Hard in child care settings (healthy eating and

activity)

Healthy People provides science-based, 10-year national objectives for improving

the health of all Americans. For three decades, Healthy People has established

benchmarks and monitored progress over time in order to do the following:

Encourage collaborations across sectors.

Guide individuals toward making informed health decisions.

Measure the impact of prevention activities.

For the implementation of Healthy People 2020, the development of a con-

sortium is occurring. The consortium is a diverse, motivated group of agencies

and organizations committed to achieving Healthy People 2020 goals and ob-

jectives. Any agency or organization that supports Healthy People 2020 is a

welcome partner. Examples of partners include the following:

Health care providers

State and local public health professionals

Educators

Community members

Businesses

Environmental health professionals

Housing professionals

From USDHHS: Healthy People 2020: a roadmap for health, Washington,

DC, 2010, US Government Printing Ofice.

HEALTHY PEOPLE 2020

Community Consortium and Partners

EVIDENCE-BASED PRACTICE

The landmark Institute of Medicine 1988 report, The Future of Public Health,

recommended all public health agencies to regularly and systematically collect

and analyze information on the health of the community. Theoretically, such

data would provide a logical order for public health practice decision-making

and actions; however, implementation barriers, such as low capacity, lack of

funds and infrastructure, and constrained resources, are well documented.

Researchers Rabarison, Timsina, and Mays (2015) conducted a study investigat-

ing the connection between assessment and planning and its impact on deci-

sion making related to program activities. Rabarison et al (2015) analyzed the

likelihood of chronic disease prevention activities delivery if the local health

agencies (LHAs) implemented a community health assessment and improve-

ment plan in their communities. The researchers linked data from the 2010

National Association of County and City Health Oficials proile of LHAs and the

2010 County Health Rankings to create a statistically matched sample of imple-

mentation LHAs (those with a community health assessment and improvement

plan) and comparison LHAs (those without an assessment and plan). Results

indicated that implementation LHAs were twice as likely to deliver population-

based chronic disease prevention programs than the comparison LHAs.

Nurse Use

Routine implementation of a community health assessment and improvement

plan leads to improved public health decision-making and actions. The nurse may

be involved in all steps of the assessment, from data collection to data analysis

to planning and implementing interventions to strengthen the community.

http://www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/tools/change.htm

http://www.thecommunityguide.org/index.html

211CHAPTER 12 Community Assessment and Evaluation

Several different population-centered health promotion

approaches have been noted here. Regardless of what ap-

proach is taken, specific strategies to improve community

health often depend on whether the status, structure, or

process dimension of community health is being empha-

sized. If the emphasis is on the status dimension, the best

strategy is usually at the level of primary or secondary pre-

vention because the objective is either to prevent a disease or

to treat it in its early stages. Immunization programs are an

example of a nursing intervention at the primary prevention

level.

Nursing intervention strategies focused on the structural

dimension are directed to either health services or demographic

characteristics. Interventions aimed at altering health services

might include program planning. Interventions aimed at affect-

ing demographic characteristics might include community

development.

When the emphasis is on the process dimension, the best

strategy is usually health promotion, which is also a primary

prevention strategy. For example, if family-life education

is lacking in a community because of ineffective communi-

cation among families, children, school board members,

religious leaders, and health professionals, the most effec-

tive strategy may be to open discussion among these

groups and help community members develop education

programs.

COMMUNITY-FOCUSED NURSING PROCESS: AN OVERVIEW OF THE PROCESS FROM ASSESSMENT TO EVALUATION

Most nurses are familiar with the nursing process as it applies

to individually focused nursing care. Using it to promote com-

munity health makes this same nursing process community

focused (Anderson and McFarlane, 2011). The phases of the

nursing process that directly involve the community client as

partner begin at the start of the contract or partnership and

include assessment, diagnosis, planning, implementation, and

evaluation.

ASSESSING COMMUNITY HEALTH

Community assessment is one of three core functions of PHN

and is the process of critically thinking about the community.

This involves getting to know and understand the community

as client. Nurses start an assessment by clearly deining their

client in terms of the three dimensions of place, people, and

function presented in Table 12.1. Before data are collected in the

assessment phase, the nurse must be able to answer questions

such as the following:

• What are the geographic boundaries of this community?

• Which people are members of this community?

• What characteristics do they have in common?

For example, homebound older adults in a particular city are

a community of special interest individuals with shared needs,

who are deined by their age and homebound status. Once the

nurse is clear about the boundaries of the community as client,

FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES

Targeted Competency: Client-centered Care—Recognizes the client or

designee as the source of control and as a full partner in providing compas-

sionate and coordinated care that is based on the preferences, values, and

needs of the client

• Knowledge: understanding of multiple dimensions of client-centered care

• Skill: for individual, family, aggregate, or community elicits values, prefer-

ences, and expressed needs as part of clinical interview

• Attitude: support care for each client level whose values differ from

one’s own

Question

The Quad Council core competency of analytic and assessment skills indicates

the beginning PHN should collect data, both quantitative and qualitative, to be

used in community assessment. The PHN then assesses data collected as part

of the community assessment process to make inferences about clients (values,

culture, preferences for health care).

In order to develop, revise, or even improve community health care delivery,

how would the PHN use the outcomes of the community assessment? What

steps would the nurse take to make change based on client choice?

The assessment helps the nurse in community health to un-

derstand individual, family, and group problems and to know

what community strengths and resources are available to help

the nurse solve the client’s problems. The community assess-

ment phase involves a logical, systematic approach to the initial

phase of the nursing process. Community assessment helps in

the following ways:

• To identify community needs

• To clarify problems

• To identify strengths and resources

There are different types of community assessment. Com-

munity assessments can be short and simple or long and com-

plex. One example of a short and simple community assessment

is the windshield survey, which is discussed on page 213.

Comprehensive community assessment is the necessary initial

phase of the nursing process in community health with the

community client as partner.

Assessing community health requires the following three steps:

1. Gathering relevant existing data and generating missing

data

2. Developing a composite database

3. Interpreting the composite database to identify community

problems and strengths

Data Collection and Interpretation The primary goal of data collection is to get usable information

about the community and its health. The systematic collection

of data about community health requires the following:

• Gathering or compiling existing data

• Generating missing data

• Interpreting data

• Identifying community health problems and community

abilities

the community assessment phase can be continued. (See QSEN

box below).

212 PART 4 Issues and Approaches in Health Care Populations

Data Gathering. Data gathering is the process of obtaining existing, readily available data. The following data usually de-

scribe the demography of a community:

• Age of the residents

• Gender distribution of the residents

• Socioeconomic characteristics

• Racial distributions

• Vital statistics, including selected mortality and morbidity data

• Community institutions, including health care organiza-

tions and the services they provide

• Health personnel characteristics

Often these data have been collected by others via structured

interviews, questionnaires, or surveys and are available in pub-

lished reports at the library or local public health department.

These data give the nurse a snapshot of how the clients receiv-

ing services it into the community.

Data Generation. Data generation is the process of developing data that do not already exist, through interaction with com-

munity members, individuals, families, or groups. This type of

information is more dificult to obtain and is generally not sta-

tistical. Data that often must be generated include the following:

• Information about a community’s knowledge and beliefs

• Values and sentiments

• Goals and perceived needs

• Norms

• Problem-solving processes

• Power

• Leadership

• Inluence structures

These data are more likely to be collected by interviews and

observation.

Composite Database Analysis. Combining the gathered and generated data creates a composite database. Data analysis seeks

to make sense of the data, as follows:

1. First, data are analyzed and synthesized, and themes are noted.

2. Community health problems, or needs for action, and

community health strengths, or abilities, are determined.

3. The resources available to meet the needs are identiied.

4. Problems are indicated by differences between the nurse’s

and community’s goals for community health.

5. Strengths, on the other hand, are suggested by similarities

between the nurse’s and community’s concepts of commu-

nity health and available data.

6. Finally, the resources available to meet the needs are identiied.

Data-Collection Methods Several methods to collect data are needed. Methods that encour-

age the nurse to consider the community’s perception of its health

problems and abilities are as important as methods structured to

identify knowledge that the nurse considers essential.

Five useful methods of collecting data are as follows:

1. Informant interviews

2. Participant observation

3. Windshield surveys

4. Secondary analysis of existing data

5. Surveys

These methods can be grouped into the following two dis-

tinct but complementary categories:

1. Methods that rely on what is directly observed by the data

collector

2. Methods that rely on what is reported to the data collector

Collection of Direct Data. Informant interviews, participant observation, and windshield surveys are three methods of directly

collecting data. All three methods require the following:

• Sensitivity

• Openness

• Curiosity

• The ability to listen, taste, touch, and smell

• The ability to see life as it is lived in a community

Informant interviews, which consist of directed talks with

selected members of a community about community members

or groups and events, are basic to effective data collection. Talk-

ing to key informants is a critical part of the community assess-

ment. Key informants are not always people who have a formal

title or position; they often have an informal role within the

community. Examples of informal key informants are a mem-

ber of a minority group who is listened to by other members

of the group, a church deacon, and a parent who is active and

vocal about the school health curriculum.

Also basic is participant observation, the deliberate sharing,

if conditions permit, in the life of a community. For example, if

the nurse lives in the community, activities such as participating

in clinical organizations and church life and reading the newspa-

per give the nurse “observations” of the community’s life. Infor-

mant interviews and participant observation are good ways to

generate information about community beliefs, norms, values,

power and inluence structures, and problem-solving processes.

Such data can seldom be reported in numbers, so they are not

often collected. Even worse, conclusions that are based on intu-

ition and are unchecked are sometimes used to replace this type

of data. Conclusions from direct data collection methods should

be conirmed by those people providing the information.

Alan Thompson is a nurse in community health and a member of a committee

assigned to assess the health care needs of the aging “Baby Boomers” in

Duxbury County. Mr. Thompson and his committee are aware that as the Baby

Boomer population ages, health care professionals need to prepare for a rapid

increase in the number of people older than 65 years. The committee’s purpose

is to make suggestions to the health department and county oficials about

how to prepare for the inlux in health services that will be needed for these

older adults.

Currently, 25% of the population in Duxbury County is older than 65 years.

However, in 25 years this percentage is expected to increase to more than

50%. Currently, ive primary care providers are in the county, with service wait-

ing lists ranging from 1 to 3 weeks; only one of these providers specializes in

geriatric care. One 54-bed long-term nursing care facility is located in the

northern region of the large county. Because of rural roads, there is no public

transit system. However, residents may call a hospital shuttle program if they

need transportation to a physician’s appointment.

CASE STUDY

Community-Based Health Service Needs

of an Aging Population

213CHAPTER 12 Community Assessment and Evaluation

Informant interviews with social workers and religious lead-

ers can provide data that describe a community that has

well-deined clusters of persons with similar problems, such

as persons of low income, persons with concerns about adoles-

cent pregnancy, and persons with worries about the health of

babies. These data could be dificult to acquire without personal

interviews.

Windshield surveys are the motorized equivalent of simple

observation. They involve the collection of data that will help

deine the community, the trends, stability, and changes that

will affect the health of the community (The University of

Kansas, 2016).

While driving a car or riding public transportation, the

nurse can observe many dimensions of a community’s life and

environment through the windshield, such as the following:

• Common characteristics of people on the street

• Neighborhood gathering places

• The rhythm of community life

• Housing quality

• Geographic boundaries

Windshield surveys can be used by themselves for short and

simple assessments. An example of a windshield survey is found

in Table 12.3.

Collection of Reported Data. Secondary analysis and surveys are two methods of collecting reported data. In secondary analy-

sis, the nurse uses previously gathered data, such as minutes

from community meetings. This type of analysis is extremely

valuable because it saves time and effort. Many sources of data

are readily available and useful for secondary analysis, including

the following:

• Public documents

• Health surveys

• Minutes from meetings

• Statistical data

• Health records

Each community has its own characteristics. These characteristics, along with demographic data, provide valuable information in understanding the population

that lives within the community and the health status, strengths and limitations, risks, and vulnerabilities unique to the “population of interest.” Once you have

deined a “community of interest” to assess, a windshield survey is the equivalent of a community head-to-toe assessment. The best way to conduct a wind-

shield survey is to have a designated driver and at least one other passenger to scan the outline and take notes. Having one pair of eyes on the road, you can

beneit from having several other individuals noticing the unique characteristics of the community and a shared experience provides additional insight. As you

analyze your indings, it may be necessary to make a second tour to ill in any blanks. Many of us take these characteristics for granted, but they provide a rich

context for understanding communities and populations and have signiicant impact on the health status of the community in general. You will report your ind-

ings in practicum conference and use relevant indings in your Community Problem Analysis paper, so collect your indings and analysis in a useful format.

Elements Description

Boundaries What deines the boundary? Roads, water, railroads? Does the area have a name? A nickname?

Housing and zoning What is the age of the houses? What kind of materials in the construction? Describe the housing, including space between houses,

general appearance and condition, and presence of central heating, air conditioning, and modern plumbing.

Open space Describe the amount, condition, use of open space. Is the space used? Safe? Attractive?

Commons Where do people in the neighborhood congregate? Who congregates there and at what hours during the day?

Transportation How do people get from one place to another? Is public transportation available? If so, what kind and how effective? How timely?

Personal autos? Bikes, etc.?

Social service centers Do you see evidence of recreation centers, parks, social services, ofices of doctors and dentists, pharmacies?

Stores Where do residents shop? How do they get to the shops? Do they have groceries or sources of fresh produce? Is this a “food

desert”?

Street people and

animals

Who do you see on the streets during the day? Besides the people, do you see animals? Are they loose or contained?

Condition of the area Is the area well kept or is there evidence of trash or abandoned cars or houses? What kind of information is provided on the signs in

the area?

Race and ethnicity What is the race of the people you see? What do you see about indices of ethnicity? Places of worship, food stores, restaurants? Are

signs in English or other languages? (If the latter, which ones?)

Religion What indications do you see about the types of religion residents practice?

Health indicators Do you see evidence of clinics, hospitals, mental illness, substance abuse?

Politics What indicators do you see about politics? Posters, headquarters?

Media Do you see indicators of what people read? If they watch television? Listen to the radio?

Business and industry What type of business climate exists? Manufacturers? Light or heavy industry? Large employers? Small business owners? Retail?

Hospitality industry? Military installation? Do people have to seek employment elsewhere?

TABLE 12.3 Windshield Survey Guidelines

Adapted from Mizrahi TM: School of Social Work, Virginia Commonwealth University, Richmond, VA, September 1992; Stanhope MS, Knollmueller

RN: Public and community health nurse’s consultant: a health promotion guide, St. Louis, 1997, Mosby.

HOW TO Identify a Key Informant for Interviews

The following individuals may be key informants:

• County health department nurses or church leaders

• Many community members whom nurses know and who can identify other

key informants

• President of the parent–teacher organization

• Mayor or other local politicians

• The mother who organized the local chapter of Mothers Against Drunk

Driving (informal leader)

214 PART 4 Issues and Approaches in Health Care Populations

Surveys report data from a sample of persons. They are

equally useful, but they take more time and effort than observa-

tional methods and secondary analyses because they require

time-consuming and costly data collection (see discussion of

how to identify a key informant for interviews). Thus the nurse

does not often use the survey method. However, surveys are

necessary for identifying certain community problems. For ex-

ample, a lack of accessible personal health services cannot be

documented readily and accurately in any other way.

Community Reconnaissance Community reconnaissance, that is, suring the Web, requires a

computer and access to the Web instead of the automobile

commonly used in windshield surveys noted in the previous

section. However, both windshield surveys and community re-

connaissance require superb detective skills.

What can you learn about a community by suring the Web?

Many counties and municipalities have their own websites. Many

are represented in statewide and national databases. You can often

ind the address of a website (URL) for a community by using the

county format noted in the Bernalillo County, New Mexico, ex-

ample (http://bernalillo.nmgenweb.us/) and substituting the name

of the county and state in which a particular community is located,

or by browsing several websites identiied by a search engine.

Local and state sites are, for example, very revealing of commu-

nity economics and civic engagement. These sites typically adver-

tise their communities to potential residents and businesses. They

seldom disclose data about community issues, however, although

they may include links to community newspapers and radio and

television stations that will report issues. Small communities, how-

ever, may lack resources to develop their own websites.

An assessment guide is a useful tool for a community recon-

naissance (see the assessment checklist on page 218 as an example).

A guide structures Web browsing and allows the community asses-

sor (you!) to recognize the strengths and limitations of Web data.

Demographic data and vital statistics about the populations living

in the community and data about the eight community systems

delineated by Anderson and McFarlane (2010) are one possible

guide, although many students have found it helpful to add a ninth

system to their assessment guide, called Religion and Faith.

HOW TO Obtain a Quick Assessment of a Community

• One way to obtain a quick, initial sense of the community is to do a wind-

shield assessment using a format like the one provided as an example in

Table 12.3.

• Nurses interested in doing a windshield assessment need to take public

transportation, have someone else drive while they take notes, or plan to

frequently stop and write down what they see.

• The windshield survey example is organized into 15 elements with speciic

questions to answer that are related to each element.

• Some of the questions will need to be answered by visiting the library to

get secondary data.

• Nurses who use this approach will have an initial descriptive assessment

of the community when they are inished.

• Interventions are planned, based on the survey.

HOW TO Determine the Usefulness of Websites

Questions to ask about websites before using the data:

1. How current is the reported information?

2. When was the site last updated?

3. How credible is the data source?

4. Is an author identiied?

5. Are demographic data reported about the people?

6. Are data reported about different community systems?

7. Is there any obvious bias in the reporting of data?

8. Is the community voice (or voices) represented?

ASSESSMENT ISSUES

Gaining entry or acceptance into the community is perhaps

the biggest challenge in assessment. The nurse is usually an

outsider and often represents an established health care system

that is neither known nor trusted by community members

who may therefore react with indifference or even active hos-

tility to the nurse. In addition, nurses may feel insecure about

their skills as a community worker and the community may

refuse to acknowledge its need for those skills. Because the

nurse’s success depends largely on the way he or she is viewed,

entry into the community is critical. Often the nurse can gain

entry by:

• Taking part in community events

• Looking and listening with interest

• Visiting people in formal leadership positions

• Employing an assessment guide

• Using a peer group for support

• Keeping appointments

• Clarifying community members’ perceptions of health needs

• Respecting an individual’s right to choose whether he or she

will work with the nurse

Maintaining conidentiality is important. Nurses must be

very careful to protect the identity of community members who

provide sensitive or controversial data. In some cases the nurse

may consider withholding data; in other situations the nurse

may be legally required to disclose data. For example, nurses are

required by law to report child abuse.

IDENTIFYING COMMUNITY PROBLEMS

The windshield assessment activities and the creation of a

composite database, will result in a list of community

strengths and health problems. Each problem needs to be

identiied and stated clearly. The health risk to the commu-

nity is stated, the person(s) affected is named, and the

CHECK YOUR PRACTICE?

You are a new nurse in the community and you have been asked to implement

a community needs assessment. One of the greatest obstacles is acceptance

of you by the community. What would you do to work on gaining acceptance

as a new nurse?

http://bernalillo.nmgenweb.us/

215CHAPTER 12 Community Assessment and Evaluation

community factors that led to the problem are deined. This

process is an important first step to planning. In the plan-

ning phase, priorities are established, and interventions are

identified.

Each community has its own unique characteristics. Some of

these characteristics are strengths on which the nurse can build,

but others contribute to the problem identiied.

Frequently, multiple community health problems will be

identiied during the assessment phase. When multiple prob-

lems exist, priorities for resolving the problems must be set

based on the following (McKenzie and Pinger, 2014):

• Which problems are important to the community?

• Which segments of the population are most affected?

• What are the beneits to the community?

• What happens to the community or the population if the

problem is or is not resolved?

• How much does it cost to implement solutions, in terms of

money and resources, to improve the problem and to save

lives?

• How do politics, community values, and community priori-

ties affect efforts to solve the problem?

• What does the community expect to happen?

PLANNING FOR COMMUNITY HEALTH

The planning phase includes the following:

• Analyzing the community health problems identiied in the

community nursing diagnoses

• Establishing priorities among them

• Establishing goals and objectives

• Identifying intervention activities that will accomplish the

objectives

Problem Analysis During analysis, the nurse seeks to clarify the nature of the

problems. The nurse identiies the following:

• The origins and effects of the problem

• The points at which intervention might be undertaken

• The parties who have an interest in the problem and its solution

Analysis often requires identifying the following:

• The direct and indirect factors that contribute to the problem

• The outcomes of the problem

• Relationships among the problems (i.e., whether one prob-

lem causes or is affected by other problems)

• Factors that contribute to the problem

This is important because the nurse can anticipate that

several of the same factors that contribute to a problem and

affect the outcomes of a problem also cause many other

problems.

Problem analysis should be undertaken for each identiied

problem. It often requires organizing a special group composed

of the nurse and the following:

• Persons whose areas of expertise relate to the problem

• Individuals whose organizations are capable of intervening

• Representatives of the community experiencing the problem—

the client

Together they can identify the factors contributing to the

problem and explain the relationships between each factor and

the problem.

Problem Priorities Infant malnutrition represents only one of several community

health problems identiied by the community assessment. In

reality, several community health problems may be identiied.

They may include lack of clinics, poor housing conditions, a

mortality rate from cardiovascular disease that is higher than

the national norm, and—as expressed by many residents—a

desire to quit smoking.

Each problem identiied as part of the assessment process

must be put through a ranking process to determine its impor-

tance. This is known as problem prioritizing.

Problem Priority Criteria. Answers to the following questions have been helpful in ranking identiied problems:

• How aware is the community of the problem?

• Is the community motivated to resolve or better manage the

problem?

• Is the nurse able to inluence problem resolution?

• Are there available experts to solve the problem?

• How severe are the outcomes if the problem is unresolved?

• How quickly can the problem be solved?

The members of the partnership answer questions related

to their ability to inluence or change the situation, and the

nurse and the community agree on the ability to resolve the

problem. One example of the difference between the percep-

tions of the nurse and community members is smoking in

public buildings; the community nurse might identify smok-

ing as a public health problem, but community members

might view smoking as an issue of individual choice and per-

sonal freedom. For example, recently a midsize community,

through the local government and the health department,

passed a regulation to forbid smoking in all public places, in-

cluding restaurants and bars. The outcry from the community

residents has been loud. Residents believe their individual

rights and freedoms have been taken away by government

regulations. It does not matter to the residents that lung cancer

rates are high.

This process is repeated separately for each identiied

problem, and all of the problems are compared. Priorities

among the identiied problems are established.

Establishing Goals and Objectives Once high-priority problems are identiied, relevant goals and

objectives are developed. Goals are generally broad statements

of desired outcomes. Objectives are the precise statements in-

dicating the means of achieving desired outcomes.

The objectives must be precise, behaviorally stated, and mea-

surable and can be solved in a series of steps implemented over

time rather than all at once.

As noted, establishing these goals and objectives involves

collaboration between the nurse and representatives of the

community groups affected by both the problem and the

216 PART 4 Issues and Approaches in Health Care Populations

proposed intervention. This often requires a great deal of

negotiation among everyone taking part in the planning

process. One important advantage offered by the continuous

active involvement of people affected by the outcomes is

that they have a vested interest in those outcomes and there-

fore are supportive of and committed to the success of

the intervention. Once goals and objectives are chosen, in-

tervention activities to accomplish the objectives can be

identified.

Identifying Intervention Activities Intervention activities, the means by which objectives are met,

are as follows:

• The strategies used to meet the objectives

• The ways change will be effected

• The ways the problem cycle will be broken

Because alternative intervention activities do exist, they

must be identiied and evaluated. Clearly it is more valuable

in the long term to educate others in how to assess the

community problems and interventions to solve them. It is

also necessary to analyze the change process necessary to

complete the objectives.

IMPLEMENTATION IN THE COMMUNITY

Implementation, the fourth phase of the nursing process,

involves the work and activities aimed at achieving the

goals and objectives. Implementation efforts 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.

Factors Inluencing Implementation Implementation is shaped by the following:

• The nurse’s chosen roles

• The type of health problem selected as the focus for inter-

vention

• The community’s readiness to take part in problem solving

• Characteristics of the social change process

The nurse taking part in community-oriented intervention

has knowledge and skills that the other interveners do not have;

the question is how the nurse uses the position, knowledge, and

skills.

Nurse’s Role. Nurses can act as content experts, helping com- munities select and attain task-related goals. In the example of

infant malnutrition, the nurse can use epidemiological skills to

determine the incidence and prevalence of malnutrition. The

nurse can serve as a process expert by increasing the commu-

nity’s ability to document the problem rather than by providing

help only as an expert in the area.

Content-focused roles often are considered change agent

roles, whereas process roles are called change partner roles.

Change agent roles stress gathering and analyzing facts and

implementing programs, whereas change partner roles include

those of enabler-catalyst, teacher of problem-solving skills, and

activist advocate.

The Problem and the Nurse’s Role. The role the nurse chooses depends on the following:

• The nature of the health problem

• The community’s decision-making ability

• Professional and personal choices

• Some health problems clearly require certain intervention

roles, as follows:

• If a community lacks democratic problem-solving abili-

ties, the nurse may select teacher, facilitator, and advocate

roles. Problem-solving skills must be explained, and the

nurse becomes a role model.

• A problem with determining the health status of the com-

munity, on the other hand, usually requires fact-gatherer

and analyst roles.

• Some problems require multiple roles. Managing conlict

among the involved health care providers, a common

problem, demands process skills.

• Collecting and interpreting the data necessary to docu-

ment a problem require both interpersonal and analytical

skills.

• The community’s history of taking part in decision mak-

ing is a critical factor. In a community skilled in identify-

ing and successfully managing its problems, the nurse

may best serve as technical expert or advisor.

Different roles may be required if the community lacks

problem-solving skills or has a history of unsuccessful

change efforts. The nurse may have to focus on developing

problem-solving capabilities or on making one successful

change so that the community becomes empowered to take

on the job of promoting change on its own behalf.

Social Change Process and the Nurse’s Role. The nurse’s role also depends on the social change process. Not all commu-

nities are open to change. The ability to change is often related

to the extent to which a community focuses on traditional

norms. The more traditional the community, the less likely it is

to change. The ability to change is often directly related to the

following (Rogers, 2003):

• High socioeconomic status

• A perceived need for change

• The presence of liberal, scientiic, and democratic values

• A high level of social participation by community residents

For example, people living in a community might go to an

immunization clinic rather than to a private physician if the

clinic is nearby and less expensive and if the physician is not

always available when needed.

Changes also are easier to accept in the following situations

(Rogers, 2003):

• The change is shared in ways that it in with the communi-

ty’s norms, values, and customs.

• Information is spread by the best communication mode

(e.g., mass media for early adopters [people open to change]

and face to face for late adopters [people who have more dif-

iculty with change]).

• Other communities support the change efforts.

• Opinion leaders are identiied and used.

• Communication about the change is clear and straightforward.

217CHAPTER 12 Community Assessment and Evaluation

EVALUATING THE INTERVENTION FOR COMMUNITY HEALTH

Simply deined, evaluation is the appraisal of the effects of

some organized activity or program. An example of evaluation

is provided in the Evidence-Based Practice box on page 210.

Evaluation may involve the design and conduct of evaluation

research, or it may involve the more elementary process of as-

sessing progress by contrasting the objectives and the results

(Fink, 2013). This section deals with the basic approach of con-

trasting objectives and results.

Evaluation begins in the planning phase, when goals and

measurable objectives are established and goal-attaining ac-

tivities are identiied. After implementing the intervention,

only the accomplishment of objectives and the effects of inter-

vention activities have to be assessed. Nursing progress notes

direct the nurse to perform such appraisals concurrently with

implementation. In assessing the data recorded there, the nurse

is requested to evaluate whether the objectives were met and

whether the intervention activities used were effective. Such an

evaluation process is oriented to community health because

the intervention goals and objectives come from the nurse’s

and the community’s ideas about health.

Fig. 12.1 presents a summary of the complete nursing pro-

cess with a community client.

Role of Outcomes in the Evaluation Phase The measurement of outcomes is a particularly important part

of the evaluation process. This is one reason for placing empha-

sis on measurable objectives. Cashman et al (2008) emphasize

outcomes questions about appropriate and effective interven-

tions, such as the following:

• Was the appropriate intervention done ineffectively or

effectively?

• Were the objectives sensitive enough to measure change?

• Was an inappropriate intervention used?

• Has the health problem been resolved or the risk reduced?

Emphasizing epidemiology and the correct use of rates

and numbers are means of evaluating intervention outcomes

among deined communities. Often data collected over time

also can provide important outcomes information about

health trends within the community. As indicated, epidemio-

logical data and trends do not provide the only measure of

success, but they do provide important information about the

intervention. Nurses need to consider the collection of this

type of outcomes data for use as part of the evaluation phase.

Outcomes can be measured by looking at changes from before

and after the intervention to solve the problems. Changes in

the following can be used to see the outcomes of the interven-

tions (Fink, 2013):

• Demographics

• Socioeconomic factors

• Environmental factors

• Individual and community health status

• Use of health services

PERSONAL SAFETY IN COMMUNITY PRACTICE

Effective nursing practice starts with personal safety, and this

remains important throughout the process. An awareness of

the community and common sense are the two best guidelines

for judgment. For example, common sense suggests not leav-

ing anything valuable on a car seat or leaving the car unlocked.

Similar guidelines apply to the use of public transportation.

Calling ahead to schedule meetings will help prevent delays or

confusion, and it gives the nurse an opportunity to lay the

groundwork for the meeting. If there is no telephone or access

Establishment of partnership

Assessment phase

Nursing diagnosis

Planning phase

Implementation phase

Evaluation phase

Renegotiate as needed

FIG. 12.1 Flowchart illustrating the nursing process with the community as client.

218 PART 4 Issues and Approaches in Health Care Populations

to a neighbor’s telephone, plan to establish a time for

any future meetings during the initial visit. Regardless of

whether there has been telephone contact, there are rare

situations when a meeting is postponed because the nurse

arrives at a location where people are unexpectedly loitering

by the entrance and the nurse has concerns about personal

safety.

For nurses who are either just beginning their careers in

community health or who are just starting a new position, the

following three clear sources of information will help answer

any questions about personal safety:

1. Other nurses, social workers, or health care providers who

are familiar with the dynamics of a given community. They

can provide valuable insights into when to visit, how to get

there, and what to expect because they function in the com-

munity themselves.

2. Community members. The best sources of information

about the community are the community members them-

selves, and one beneit of developing an active partnership

with community members is their willingness to share their

insight about day-to-day community life.

3. The nurse’s own observations. Knowledge gained during

the data collection phase of the process should provide a

solid basis for an awareness of day-to-day community

activity. Nurses with experience practicing in the com-

munity generally agree that if they feel uncomfortable

in a situation, they should trust their feelings and

leave.

CHECKLIST FOR A COMMUNITY ASSESSMENT

Asset Development

 Land

 Libraries

 Parks

 Police stations

 Fire stations

Community Organizations

 Crime Watch

 Neighborhood Watch

 Women’s clubs

 Optimist

 Kiwanis

 Lions

 Businesses

 Schools

 Colleges

Government Assistance

 Number of families receiving Aid to Families with Dependent Children

 Number of persons receiving public assistance

 Number of persons receiving Medicaid

 Number of persons receiving food stamps

Health Risk Variables

Population Variables

 Population

 Total population density

 Population age groups (0–4 yr, 5–17 yr, 18–64 yr, 65 yr)

Ethnicity

 Percentage White

 Percentage African American

 Percentage Hispanic

Socioeconomic Data

 Percentage of persons below the federal poverty guideline

 Total number of households

 Estimated per capita income

 Estimated average household income

 Percentage of households with incomes less than $15,000

 Unemployment rate

 Occupational status

 Value of housing

 Educational level

Birth and Birth-Related Information

 Fertility rate

 Percentage of teen births

 Percentage of low birth weight

 Percentage of infant mortality

Age-Adjusted Death Rates

 Accident

 Cancer

 Cirrhosis

 Diabetes

 Heart disease

 Human immunodeiciency virus

 Homicide

 Pneumonia and lu

 Respiratory

 Stroke

 Suicides

Access to Primary Care

 Primary care physicians per population (family practice, general practice,

pediatrics, internal medicine, and obstetrics and gynecology)

 Primary care providers per population (nurse-midwives, nurse practitioners,

and physician assistants)

Inpatient Discharges per 1000 Population

 Discharges per 1000 population for each service area or the county as a

whole excluding newborns

 Discharges per 1000 population for each service area or the county as a

whole for the top ive discharges

Survey Data

 Top ive health concerns

 Insurance status

 Access to care

From Pickens S, Boumbulian P, Tietz M: Community assessment: strengths, assets & management, Inside Prevent Care 1(6), 1995.

219CHAPTER 12 Community Assessment and Evaluation

American Public Health Association: Public Health Nursing Section:

Public Health Nursing Section, Washington, DC, 2009, APHA.

Anderson ET, McFarlane J: Community as partner: theory and practice

in nursing, ed 7, Philadelphia, 2015, Wolters Kluwer.

Archer R, Cary AH, Malone B: The academic health department: the

case for building partnerships to enhance the health of the public,

Public Health Nurs 31:193–195, 2014.

Beets MW, Tilley F, Turner-McGrievy G, et al: Community partner-

ship to address snack quality and cost in after-school programs,

J Sch Health 84:543–548, 2014.

Blum HL: Planning for health, New York, 1974, Human Sciences Press.

Braveman P, Gottlieb L: The social determinants of health: it’s time to

consider the causes of the causes, Public Health Rep 129:19–31, 2014.

REFERENCES

Agency for Healthcare Research and Quality: 2014 National Health-

care Quality and Disparities Report, Rockville, Md, 2015. AHRQ.

Retrieved August 2016 from http://www.ahrq.gov/sites/default/

iles/wysiwyg/research/indings/nhqrdr/nhqdr14/2014nhqdr.pdf.

P R A C T I C E A P P L I C A T I O N

Lily, a nurse in a small city, became aware of the increased inci-

dence of respiratory diseases through contact with families in

the community and the local chapter of the American Lung As-

sociation. During family visits, Lily noted that many of the

parents were smokers. Because most of the families Lily visited

had small children, she became concerned about the effects of

secondhand smoke on the health of the infants and children

among her family caseload.

Further assessment of this community indicated that the

community recognized several problems, including school

safety and the risk for water pollution, in addition to the smok-

ing problem that Lily had identiied during her family visits.

Talks with community members revealed that they wanted each

of these identiied problems “ixed,” although these same com-

munity members also remained uncertain as to how to begin.

In deciding which of the three identiied problems to ad-

dress irst, which criterion would be most important for Lily to

consider?

A. The amount of money available

B. The level of community motivation to “ix” one of the three

identiied problems

C. The number of people in the community who expressed a

concern about one of the three identiied problems

D. How much control she would have in the process

Answers can be found on the Evolve website.

R E M E M B E R T H I S !

• A community is deined as a locality-based entity composed

of systems of formal organizations relecting societal institu-

tions, informal groups, and aggregates that are interdepen-

dent and whose function or expressed intent is to meet a

wide variety of collective needs.

• A community practice setting is an insuficient reason for saying

that practice is oriented toward the community client. When the

location of the practice is in the community but the focus of

the practice is the individual or family, the nursing client

remains the individual or family, not the whole community.

• Community-oriented practice is targeted to the community,

the population group in which healthful change is sought.

• Community health, as used in this chapter, is deined as the

meeting of collective needs through identifying problems

and managing interactions within the community itself and

between the community and the larger society.

• Most changes aimed at improving community health in-

volve, of necessity, partnerships among community resi-

dents and health workers from a variety of disciplines.

• Assessing community health requires gathering existing

data, generating missing data, and interpreting the database.

• Five methods of collecting data useful to the nurse are infor-

mant interviews, participant observation, secondary analysis

of existing data, surveys, and windshield surveys.

• Gaining entry or acceptance into the community is perhaps

the greatest challenge in assessment.

• The nurse is usually an outsider and often represents an es-

tablished health care system that is neither known nor

trusted by community members, who may react with indif-

ference or even active hostility.

• The planning phase includes analyzing and establishing pri-

orities among community health problems already identiied,

establishing goals and objectives, and identifying intervention

activities that will accomplish the objectives.

• Once high-priority problems are identiied, broad relevant

goals and objectives are developed.

• The goal, generally a broad statement of desired outcome,

and objectives, the precise statements of the desired out-

come, are carefully selected.

• Intervention activities, the means by which objectives are

met, are the strategies that clarify what must be done to

achieve the objectives, the ways change will be effected, and

the way the problem will be interpreted.

• Implementation, the third phase of the nursing process, is

transforming a plan for improved community health into

the achievement of goals and objectives.

• Simply deined, evaluation is the appraisal of the effects of

some organized activity or program.

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221

Case Management

Ann H. Cary

C H A P T E R

K E Y T E R M S

accountable care organizations, 222

advocacy, 222

afirming, 230

aggregate, 222

assertiveness, 232

autonomy, 227

beneicence, 233

care management, 222

CareMaps, 227

case management, 222

case manager, 222

case management plans, 227

collaboration, 229

conlict management, 229

constituency, 229

cooperation, 232

coordinating, 222

critical paths, 223

dashboard indicators, 222

demand management, 222

disease management, 222

informing, 230

information exchange process, 230

justice, 233

liability, 232

life care plan, 228

mediator, 229

negotiating, 231

nonmaleicence, 233

population management, 222

population manager, 222

problem-purpose-expansion

method, 231

problem solving, 230

promoter, 229

risk sharing, 227

social mandate, 222

supporting, 222

telehealth, 223

timelines, 233

use management, 223

veracity, 233

C H A P T E R O U T L I N E

Concepts of Case Management

Deinitions of Case Management

Healthy People 2020 and the Case Management Process

Case Management and the Nursing Process

Characteristics and Roles

Knowledge and Skill Requirements

Tools of Case Managers

Community Models of Case Management

Essential Skills for Case Managers

Advocacy

Conlict Management

Collaboration

Issues in Case Management

Legal Issues

Ethical Issues

O B J E C T I V E S

After reading this chapter, the student should be able to:

1. Deine continuity of care, care management, case manage-

ment, care coordination, transitional care, integrated care,

social determinants of health, and advocacy.

2. Describe the scope of practice, roles, and functions of a

case manager.

3. Identify the relationship between advocacy and case

management.

4. Compare and contrast the nursing process with the process

of case management and advocacy.

5. Identify methods to manage conlict, as well as the process

of achieving collaboration.

6. Deine and explain the legal and ethical issues confronting

case managers.

Since the Patient Protection and Affordable Care Act (ACA) was

initiated in 2010, the health care industry continues to reevalu-

ate systems that attempt to integrate inancing, management,

quality, and service delivery models. Challenges abound for

clients and providers as they attempt to coordinate care, transi-

tion clients among providers and systems, access and share

information and documentation about clients and communi-

ties, and navigate the complexity of integrated care to optimize

quality and access while managing costs. The new models of

health care inancing provide incentives to value care outcomes

over the volume of care provided. Delivery of care is now

organized through a network of providers, such as negotiated

222 PART 4 Issues and Approaches in Health Care Populations

contracts with hospitals and other levels of care, physicians,

nurse practitioners, pharmacies, ancillary health services, and

outpatient centers.

Managing the health of populations served by the integrated

systems is essential (Newman et al, 2014). These include

accountable care organizations (ACOs). Nurse case managers

and nurse care managers will play a pivotal role in innovative

systems of delivery (Institute of Medicine [IOM], 2011). Popu-

lation management includes the following:

• Wellness and health promotion

• Illness prevention

• Acute and subacute care

• Chronic disease

• Rehabilitation

• End-of-life care

• Care coordination

• Community engagement

Case managers are at the core of population health strate-

gies to improve community outcomes (Noonan, 2014). Popu-

lation health management can maintain and improve the

physical and psychosocial status of clients through cost-

effective and customized solutions, such as coordinating and

transitioning of care to reduce gaps and costs; supporting

evidence-based practices; selecting quality care that is cultur-

ally competent; and providing disease management and self-

management educational programming (Case Management

Society of America [CMSA], 2016; Noonan, 2014). Examples

include planning and health delivery strategies for adolescents

in a school system or the chronic disease management of elderly

individuals in a rural community (Huber, 2010; McKesson

Corporation, 2014). Like the earlier concept described by

the American Hospital Association (AHA, 2016), the ACA

endorses the use of integrated systems to attain the following

objectives:

• Emphasis on population health management across the con-

tinuum, rather than on episodes of illness for an individual

• Management shifting from inpatient care as the point of

management to primary care providers as points of entry

• Care management services and programs providing access

and accountability for the continuum of health

• Successful outcomes measured by systems performance and

pay for performance for providers to meet the needs of

populations

The contemporary focus of integrated health systems de-

ines the nature of the client as a population in addition to that

as an individual. In these systems, population management in-

volves the following activities:

• Assessing the needs of the client population through health

histories (and, in the future, genograms), claims, use-of-

service patterns, and risk factors; and communicating

through information systems to ascertain patterns, trends,

and responses to health programming in a population

• Creating beneits and network designs to address these needs

• Selecting dashboard indicators to measure performance

• Prioritizing actions to produce a desired outcome with avail-

able resources

• Selecting evidence-based programs related to wellness, preven-

tion, health promotion, and demand management; patient/

client engagement; and educating the population about them

• Instituting evidence-based care management processes that

assure transitional and coordinated care across the health

continuum for a population aggregate

• Deploying case managers within a variety of delivery and

insurance systems to clients and providers

• Evaluating provider patterns of performance and client

dashboard indicators for impact

Establishing a relationship between inancing, managing,

delivering, and coordinating services is critical to reach the goal

of population health management—that is, achieving health

outcomes at the population level. The Healthy People 2020 goals

are a social mandate for health care. In the second decade

of the twenty-irst century, case management will be an essen-

tial intervention to positively inluence the leading health indi-

cators, chronic disease outcomes, and focus areas of Healthy

People 2020.

Establishing evidence-based strategies for all functions is

critical to the success of case management for individuals

and populations. Using the current best evidence blended

with clinical expertise is a critical skill of the case manager

(American Nurses Association [ANA], 2013; Lamb, 2013;

CMSA, 2016). In their practice, nurse case managers have the

following core values:

• Increasing the span of healthy life

• Reducing disparities in health among Americans

• Promoting access to care and to preventive services

Many of the interventions nurses use with clients and health

care systems will further the Healthy People 2020 objectives.

These include case management interventions to minimize frag-

mented care and promote quality transitions of care; incorporate

standardized practice tools and adherence guidelines; improve

safety of care; and use interprofessional teams to deliver services.

In the intervention wheel model for public health nursing

practice, the nursing actions of case management, collaboration,

and advocacy comprise 3 of 17 evidence-based interventions for

individuals, families, and populations served by public health

nurses (Keller et al, 2004; see Appendix C.4). These three concepts

and practice arenas for public health nurses are more fully de-

scribed in this chapter. Case management incorporates many of

the Quad Council Competencies for Public Health Nursing (Quad

Council, 2011; see Appendix C.3) because it involves individual

and family care as well as community resources, population

health, interprofessional teams, and policy implementation.

CONCEPTS OF CASE MANAGEMENT

Case management is a strategy that is used in an overarching

process called care management. Care management is an en-

during process in which a population manager establishes

systems and monitors the health status, resources, and out-

comes for an aggregate—a targeted segment of the population

or a group. Care management strategies were initially devel-

oped by health maintenance organizations (HMOs) in the late

223CHAPTER 13 Case Management

1970s to manage the care of different populations while pro-

moting quality of care and ensuring appropriate use and costs.

Care management strategies include use management, critical

paths, disease management, demand management, and case

management (Box 13.1).

The population manager is the architect for the target

group’s health in the care management delivery process. The

building blocks used by the manager include the following

(Mullahy, 2017):

• Risk analysis

• Data mapping

• Data monitoring for health processes, indicators, and unex-

pected illnesses

• Epidemiological investigation of unexpected illnesses

• Multidisciplinary development of action plans and programs

• Identifying case management triggers or events that pro-

mote earlier referrals of high-risk clients when prevention

can have dramatic results

Case management, in contrast to care management, in-

volves activities implemented with individual clients in the

system. The case manager builds on the basic functions of

the traditional role and adapts new competencies for manag-

ing the transition from one part of the system to another or

to home.

Deinitions of Case Management A historical focus on collaboration is seen in the Commission

for Case Manager Certiication deinition:

A collaborative process that assesses, plans, implements, co-

ordinates, monitors and evaluates the options and services

required to meet the client’s health and human services

needs. It is characterized by advocacy, communication, and

resource management and promotes quality and cost-effective

interventions and outcomes

(Mullahy, 2017, p. 33).

Case management is deined in public health nursing as

the ability to “optimize self-care capabilities of individuals

and families and the capacity of systems and communities

to coordinate and provide services” (Minnesota Department

of Health, 2003, p 93). Case management is viewed as

only one competency, or skill, that nurses need to have to

provide quality care. Case management is identiied as one of

17 interventions in the scope of practice of nursing in the

community (Minnesota Department of Health, 2003). The

following knowledge and skills are required to achieve this

competency (Mullahy, 2017):

• Knowledge of community resources and inancing methods

• Written and oral communication and documentation

skills

• Negotiation and conlict-resolution skills

• Critical thinking processes to identify and prioritize prob-

lems from the view of the provider and client

• Application of evidence-based practices and outcome

measures

Case management practice is complex because of the

coordinating activities of multiple providers, payers, and

settings throughout a client’s continuum of care. Care by

multiple providers (the client, family, signiicant others, com-

munity organizations) must be assessed, planned, imple-

mented, adjusted, and based on mutually agreed-upon goals.

The nurse employed and located in one setting will be inlu-

encing the selection and monitoring of care provided in

other settings by formal and informal care providers. With

the use of electronic care delivery through telehealth activi-

ties, case management activities are now delivered via tele-

phone, e-mail, fax, and video visits in a client’s residence.

They may also be delivered to a global network of clients

located in different countries.

Although the activities in case management may differ

among providers and clients, the goals are as follows

(Mullahy, 2017):

• To promote quality services provided to clients

• To reduce institutional care while maintaining quality pro-

cesses and satisfactory outcomes

• To manage resource use through protocols, evidence-based

decision making, guideline use, and disease management

programs

• To control expenses by managing care processes and out-

comes (Mullahy, 2017)

A particularly challenging problem is the fragmenting of

services, which can result in overuse, underuse, gaps in care,

and miscommunication. This may ultimately result in costly

client outcomes. Case management in rural settings is more

complex because of the following:

• Fewer organized community-based systems

• Geographic distance to delivery

• Population density

• Finances

• Pace and lifestyle

• Values

• Social organization differences from the urban setting

• Use management attempts to redirect care and monitors the appropriate

use of provider care and treatment services for both acute and community

and ambulatory services (Leonard and Miller, 2012).

• Critical paths are tools that name activities that can be used in a timely

sequence to achieve the desired outcomes for care. The outcomes are

measurable, and the critical path tools strive to reduce differences in

client care.

• Disease management activities target chronic and costly disease condi-

tions that require long-term care interventions (e.g., diabetes). These

strategies address the entire cycle of a disease process, typically incorpo-

rating primary, secondary, and tertiary care interventions and self-care

activities (Huber, 2015).

• Demand management seeks to control use by providing clients with cor-

rect information to empower them to make healthy choices, use healthy

and health-seeking behaviors to improve their health status, and make

fewer demands on the health care system (Pawson et al, 2016).

BOX 13.1 Additional Deinitions of Case Management Strategies

224 PART 4 Issues and Approaches in Health Care Populations

Healthy People 2020 and the Case Management Process Nurse case managers in their practices have as core values the

goals of Healthy People 2020. Many of the interventions that

nurses use with clients, as well as the design of the health care

system and the number of covered lives in those systems, pro-

mote further progress in meeting the objectives of Healthy

People 2020. Case management strategies offer opportunities

for nurses to help meet the objectives for speciic population

targets listed in Healthy People 2020 (U.S. Department of Health

and Human Services, 2010).

ethnicity/race, low income, limited education, gender or sexual

orientation, those living in the inner city or rural areas, those

without health insurance, and the disabled or those experienc-

ing chronic disease.

This chapter guides the reader through the nature and pro-

cess of case management for individual and family clients. Case

management has had a rich tradition in public health nursing

and is frequently found in hospitals, transitional and long-term

care, home and hospice care, and health insurance companies.

Case management in public health nursing and in the commu-

nity dates back to Lillian Wald and the Henry Street Settlement

(Christopher et al, 2016). Nursing has maintained the leader-

ship among health care providers in coordinating resources to

achieve health care outcomes based on quality, access, and cost.

As health care delivery moves to chronic disease management

services, with an emphasis on pursuing the most eficient use of

services to manage client outcomes, case management emerges

to play a strong role.

Case Management and the Nursing Process Case management activities with individual clients and fami-

lies will reveal the larger picture of health services and health

status of the community. Through a nurse’s case management

activities, general community weaknesses in quality and quan-

tity of health services often are discovered. For example, the

management of a severely disabled child by a nurse case man-

ager may uncover the absence of respite services or parenting

support and education resources in a community. The com-

ponents of the nursing process are used when implementing

the functions of a case manager with clients. The spectrum of

case management consists of four activities: assessment, plan-

ning, facilitating, care coordination, evaluation, and advocacy

(CMSA, 2016).

While managing the disability and injury claims at an in-

dustry, the nurse may discover that referrals for home health

visits and physical therapy are generally underused by the

acute care providers in the community. Community assess-

ment, policy development, and assurance activities that frame

core functions of public health actions are often the logical

next steps for a nurse’s practice. When observing lack of care

or services at the individual and family intervention levels,

the nurse can, through case management, intervene at the

community level to make changes (Table 13.1). The case

management process involving client and nurse is depicted in

Fig. 13.1.

Characteristics and Roles Case management can be labor intensive, time-consuming, and

costly. Because of the rapid growth in the nature of complexity

in clients’ problems, the intensity and duration of activities re-

quired to support the case management function may soon

exceed the demands that the direct caregiver can meet. Manag-

ers and clinicians in community health are exploring methods

to make case management more eficient, including the use of

providers who can perform to the limit of their licenses, auxil-

iary case management providers/services, and evidence-based

practices.

EVIDENCE-BASED PRACTICE

The Effectiveness of a Registered Nurse Case

Manager

This retrospective case-control study sought to assess the effectiveness of a

registered nurse case manager’s (RNCM’s) certiied diabetes educator (CDE)

quality improvement case management program. The RNCMs provided chronic

care interventions, particularly for high-risk diabetes populations with glyco-

sylated hemoglobin (A1C) of 9% or higher. The RNCMs used protocols to

titrate medications and assess patients for medication adherence, diabetes

knowledge, and barriers to care. Researchers Watts and Sood (2016) reviewed

computerized patient records over a period of 10 years for patients seen at

11 different community outpatient clinics. Results indicated that a large

portion of high-risk patients with a baseline A1C of 9% or higher were seen

by the RNCM. Patients who were seen by an RNCM had a statistically signii-

cant reduction in A1C after 14 to 26 months of intervention (t-test, p ,0.001).

The RNCMs clinical intervention demonstrated a signiicant A1C reduction of

approximately 2%.

Nurse Use

Nursing case management can improve health outcomes for high-risk diabetes

populations. This inding may have additional implications for health care

policy makers for planning interventions with respect to long-term manage-

ment of diabetes mellitus.

From Watts SA, Sood A: Diabetes nurse case management: improving

glucose control: 10 years of quality improvement follow-up data. Appl

Nurs Res 29:202–205, 2016.

Case management strategies offer opportunities for nurses to help meet the

following Healthy People 2020 objectives for target populations:

• ECBP-14 and 14.1: Increase the inclusion of clinical prevention and popu-

lation content in undergraduate nursing, including counseling training for

health promotion and disease prevention

• SA-9: Increase the portion of persons who are referred for follow-up for

substance abuse problems

From U.S. Department of Health and Human Services: Healthy People

2020: a roadmap for health, Washington, DC, 2010, U.S. Government

Printing Ofice.

HEALTHY PEOPLE 2020

Objectives Achieved Using Case Management

Strategies

The target populations include those who do not have access

to health care and those whose lifestyle or health conditions may

limit the quality and length of healthy life; variables include

225CHAPTER 13 Case Management

Nursing Process Case Management Process Activities

Assessment Case inding Develop networks with the target population

Identiication of incentives for the target population Disseminate written materials

Screening and intake Seek referrals

Determination of eligibility Apply screening tools according to program goals and objectives

Assessment Use written and onsite screens

Apply comprehensive assessment methods (i.e., physical, social,

emotional, cognitive, economic, self-care capacity)

Obtaining consent for services if appropriate

Diagnosis Identiication of the problem or opportunity Hold interprofessional, family, and client conferences

Determine conclusions on the basis of assessment

Use an interprofessional team

Planning for outcomes Problem prioritizing Validate and prioritize problems with all participants

Planning to address care needs Develop goals, activities, time frames, and options

Identiication of resource match Gain the client’s consent to implement

Have the client choose options

Implementation Advocating of clients’ interests

Frequent monitoring to assess alignment with goals and changing

nature of client needs

Contact providers

Negotiate services and price

Adjust as implementation is needed

Document processes and monitor progress

Evaluation Measure attainment of activities and goals of service

delivery plan

Continued monitoring of clients during service

Reassessment

Bringing closure to care when client needs are achieved or change

Discharge appropriately

Ensure quality of transitional communication and coordinate of

service delivery

Monitor for changes in client or service status

Examine outcomes against goals

Examine needs against service

Examine costs

Examine the satisfaction of client, providers, and the case manager

Examine best practices and outcomes for this client

TABLE 13.1 The Nursing Process and Case Management

Clinical assessment

Research

Patient data

Point-of-care design

Best practice

Patient outcomes

Prespecification design

Clinician’s experiential knowledge

Research findings

TQM Evaluative

setting data

System management

System’s policies and resources

FIG. 13.1 Factors that require the attention of the nurse and client in the case management process.

In 1998, Cary described the roles that case managers assume

in the practice setting. These roles are clearly afirmed today in

the work of Leonard and Miller (2012) and by the Case

Management Society of America (CMSA, 2016) (Box 13.2).

The roles demanded of the nurse as case manager are vividly

inluenced by the forces at work in the employing agency.

Fig. 13.2 presents the continuum of care case management

model.

Knowledge and Skill Requirements Adopting the case management role for a nurse does not hap-

pen automatically with an agency position. Knowledge and

226 PART 4 Issues and Approaches in Health Care Populations

skills that are developed and reined are essential to success.

Knowledge domains useful for nurses in systems desiring

to implement quality case management roles are found in

Box 13.3 (Cary, 1998; Tahan et al, 2015; Treiger, 2013). If a nurse

seeks a case manager position, some of the skills and knowledge

areas will need to be developed through academic and continu-

ing education programs, literature reviews, orientation, and

mentoring experiences.

Tools of Case Managers The six “rights” of case management are right care, right time,

right provider, right setting, and right price/value, and right

outcomes. How does the nurse judge the effectiveness of case

management? Three tools are useful for case management prac-

tice: case management plans, disease management, and life care

planning tools. An underlying principle for use of each of these

tools is the need to use robust evidence as the basis for the selec-

tion of activities.

Telehealth is a contemporary intervention approach used by

case managers. It is an organized health care delivery approach

to triage and provides advice, counseling, and referral for a

BOX 13.2 Case Manager Roles

• Broker: Acts as an agent for provider services that are needed by clients

to stay within coverage according to the budget and cost limits of a health

care plan

• Consultant: Case manager who works with providers, suppliers, the com-

munity, and other case managers to provide case management expertise in

programmatic and individual applications

• Coordinator: Arranges, regulates, and coordinates needed health care

services for clients at all necessary points of services

• Educator: Educates the client, family, and providers about the case manage-

ment process, delivery system, community health resources, and beneit

coverage so that informed decisions can be made by all parties

• Facilitator: Supports all parties in work toward mutual goals

• Liaison: Provides a formal communication link among all parties concerning

the plan of care management

• Mentor: Case manager who counsels and guides the development of the

practice of new case managers

• Monitor and reporter: Provides information to parties on the status of

members and situations affecting patient safety, care quality, and patient

outcome and on factors that alter costs and liability

• Negotiator: Negotiates the plan of care, services, and payment arrange-

ments with providers; uses effective collaboration and team strategies

• Client advocate: Acts as an advocate, provides information, and supports

beneit changes that assist member, family, primary care provider, and capi-

tated systems

• Researcher: Case manager who uses and applies evidence-based practices

for programmatic and individual interventions with clients and communities,

participates in the protection of clients in research studies, and initiates and

collaborates in research programs and studies

• Standardization monitor: Formulates and monitors specific public

health nursing and disease management protocols that guide the type

and timing of care to comply with predicted treatment outcomes for

the specific client and conditions; attempts to reduce variation in re-

source use; targets deviations from standards so adjustments can

occur in a timely manner. These protocols are usually found in agency

policy books or in public health reference guides within governmental

agencies

• Systems allocator: Distributes limited health care resources according to a

plan or rationale

Client and case manager

Community

Communication

Health care team

Payer

Pl an

n in

F a c ilitation

Assessm e n t

A d vo

ca cy

C o o rd

in a tio

C o lla

b o ra

ti o n

FIG. 13.2 The Case Management Model.

• Standards of practice for case management

• Evidence-based practice guidelines for speciic health and disease condi-

tions and communities

• Knowledge of the health care inancial environment and the inancial

dimension of client

• Clinical knowledge, skill, and maturity to direct quality timing and sequenc-

ing of care activities

• Care resources for clients within institutions and communities: Facilitating

the development of new resources and systems to meet clients’ needs

• Transition planning for ideal timing and sequencing of care

• Management skills: communication, delegation, persuasion, use of power,

consultation, problem solving, conflict management, confrontation,

negotiation, management of change, marketing, group development,

accountability, authority, advocacy, ethical decision making, and profit

management

• Teaching, counseling, and education skills

• Program evaluation and research

• Performance improvement techniques

• Peer and team consultation, collaboration, and evaluation

• Requirements of eligibility and beneit parameters by third-party payers

• Legal and ethical issues

• Information management systems: clinical and administrative

• Health care legislation/policy

• Technical information skills, interoperable information systems, dashboard

monitoring, data management and analysis, predictive modeling software,

facile use of electronic health records (EHRs)

• Outcomes management and applied research

BOX 13.3 Knowledge Domains for Case Management

227CHAPTER 13 Case Management

client’s health problem using phones or computers with cam-

eras. The client is usually in the home, and the nurse is at an

ofice, health care facility, or phone bank location. Software is

being reined for use in documentation, decision making, dash-

board tools, predictive modeling, worklow, electronic medical

records, patient engagement strategies, and social media remote

monitoring as described earlier (Carneal and Pock, 2014;

Stricker, 2014; Treiger, 2013).

Case management plans have evolved through various

terms and methods (e.g., critical paths, critical pathways, Care-

Maps, multidisciplinary action plans, nursing care plans). To-

day the activities that involve developing individual plans for

clients are usually referred to as case management plans, Care-

Maps, or integrated clinical pathways. Regardless of the title

given, standards of client care, standards of nursing practice,

and clinical guidelines using evidence-based practices for case

management serve as core foundations of case management

plans. Likewise, in interprofessional action plans, core profes-

sional standards of each discipline guide the development of

the standard process.

Adaptation of the case management care plan to each client’s

characteristics is a crucial skill for standardizing the process

and outcome of care. It links multiple provider interventions to

client responses and offers reasonable predictions to clients

about health outcomes. Institutions report that sharing case

management plans with clients empowers the clients to assume

responsibility for monitoring and adhering to the plan of care.

Self-responsibility by clients incorporates autonomy and self-

determination as the core of case management. For the nurse

employed to function as a case manager, ample opportunity

exists to develop, test, and revise case management plan proto-

types for a target population experiencing acute and chronic

health problems.

Disease management is an organized program of coordi-

nated health care interventions and communications for

populations with conditions in which client self-care efforts

are critical (CMSA, 2016). This approach focuses on the

natural progression of a disease. Disease management pro-

grams may contain many of the following components

(Hisashige, 2012):

• Selection of high-risk patients, with a focus on a singular dis-

ease state (diabetes, asthma, congestive heart failure [CHF])

• Financial and risk sharing arrangements between payers

and providers

• Programs for monitoring the use of clinical paths and evidence-

based guidelines to assess outcomes and costs

• Protocols for clinical and administrative processes as well as

cost allocations

• Services to educate clients and promote self-management

skills

• Enhanced quality through evidence-based decision support

and other registry technologies

• Support for provider–client relationships and plans of care

• Evaluation of clinical, humanistic, and economic outcomes

to address the goal of improving overall health

The philosophy of disease management gives the clients

the tools needed to better manage their lives (CMSA, 2016;

Newman et al, 2014). Clients with chronic diseases beneit from a

disease management approach. The goals are to interrupt contin-

ued development of a disease and prevent future disease and

complications through secondary and tertiary prevention inter-

ventions. Promotion of wellness is necessary for success. For spe-

ciic client populations that consume a disproportionate share of

resources, disease management programs allocate the correct re-

sources in an eficacious manner (Berkowitz, 2016). Disease man-

agement programs also reduce emergency department visits and

result in fewer inpatient days, greater client satisfaction, and re-

duced school absences (Caloyeras et al, 2014). As the science of

disease management evolves to predict direct relationships between

outcomes and protocols of care, case managers will be able to en-

sure cost-effective, optimal clinical care across the continuum—a

goal of care management for populations. In fact, disease manage-

ment is viewed as a top strategy by employers. For case managers,

disease management strategies, which are part of the care man-

agement programs, shift the client interventions from speciic,

episodic care to holistic care functions that are proactive and

population based (American Hospital Association, 2016). The

Joint Commission (TJC) certiies and the American Accreditation

HealthCare Commission accredits disease management organiza-

tions and programs on the basis of their respective standards (visit

http://www.jointcommission.org and http://www.urac.org). This

may inluence the choice of programs a case manager selects to

use with clients. The Focus on Quality and Safety Education for

Nurses (QSEN) box emphasizes the importance of the interpro-

fessional team in the community. It is important that the nurse

understands roles and relationships and overlap in services to

become more eficient in providing quality and safe care.

FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES

Targeted Competency: Teamwork and Collaboration—Function effec-

tively within nursing and interprofessional teams, fostering open communica-

tion, mutual respect, and shared decision making to achieve quality client in-

terventions and outcomes.

Important aspects of teamwork and collaboration include the following:

• Knowledge: Describe scopes of practice and roles of health care team

members

• Skills: Clarify roles and accountabilities under conditions of potential

overlap in team member functioning

• Attitudes: Value the perspectives and expertise of all health team

members

Teamwork and Collaboration Question:

Observe a typical workday of a community health or public health nurse, noting

the types of activities that are done in coordination and case management and

the amount of time spent in these areas. Interview several staff members to

determine whether they perceive that the amount of their time spent in case

management is changing. To what degree are the staff members involved in

care management activities? Ask about common colleagues with whom case

managers collaborate. Besides primary care physicians, which health care team

members are often involved in managing clients’ care across time and across

settings? What skills are needed by the case management nurse to best facili-

tate these interdisciplinary teams?

Prepared by Gail Armstrong, DNP, ACNS-BC, CNE, Associate Professor,

University of Colorado Denver College of Nursing.

http://www.jointcommission.org

http://www.urac.org

228 PART 4 Issues and Approaches in Health Care Populations

The life care plan is another tool used in case management.

It assesses the current and future needs of a client for cata-

strophic or chronic disease over the life span. The life care

plan is a customized, medically based document that provides

assessment of all present and future needs (i.e., medical,

inancial, psychological, vocational, spiritual, physical, and

social), including services, equipment, supplies, and living

arrangements for a client (Leonard and Miller, 2012). These

plans may be used by either a plaintiff or defense lawyer to

analyze damages. They are also used to set inancial rewards,

which can be used to pay for care in the future and create a

lifetime care plan. Life care plans are typically used for clients

experiencing catastrophic illness or adverse events resulting

from professional malpractice. Another group of life care

planning beneiciaries involves those who have sustained in-

jury when younger and whose care requirements have changed

as a result of aging (Day et al, 2015; Rutherford-Owen and

Marini, 2012). A systematic process is used, and interprofes-

sional input is required. The irst phase of the plan is crafted

to include a thorough assessment of the client, inancial and

billing agreements, an information release signed by the cli-

ent, and a targeted date for report completion. Development

of the plan is the second phase. Case management plans are

based on several factors: social situation, leisure activities,

educational and employment status, medical history, physical

abilities, current status, and assistance required for complet-

ing the activities of daily living.

The plan includes projected costs and resources needed for

the frequency and duration of treatments, equipment, and sup-

plies. It also includes plans for future evaluations. The life care

plan seeks to portray the needs of a client that are consistent

with the changes in a client’s life over the predicted life span,

taking into account the injury or diagnosis (Apuna-Grummer

and Howland, 2013).

All of these tools and programs, in coordination, constitute

population health management strategies to educate clients and

promote self-management, provide nurse coaching support,

promote safe care transitions, improve care management and

coordination, and enhance quality (Kizer, 2015).

COMMUNITY MODELS OF CASE MANAGEMENT

Liberty Mutual Insurance Company has used case management

principles for more than 30 years in workers’ compensation

cases and has expanded services for employees whose conditions

were noted to be chronic or catastrophic. Box 13.4 lists examples

of case-managed conditions. Case managers coordinate all

providers, clients, and services to reduce excessive expenses

caused by lack of coordination, failure to use quality alternatives,

duplication, and fragmentation. Some states through their Med-

icaid programs are developing disease management programs

for high-cost chronic diseases, such as asthma and diabetes,

among their populations.

The Agency for Healthcare Research and Quality (AHRQ)

(2016) proiled the Elder Services of Merrimack Valley (ESMV),

an Area Agency on Aging in Northeastern Massachusetts, as a

service delivery innovation that included nursing case manage-

ment. ESMV followed recently discharged Medicare patients in

their homes and monitored them via telephone to identify and

address declines in health status that increase the risk for read-

mission. Patients received an in-home visit 48 hours after hos-

pital discharge and a weekly phone call. The nurse case manager

collaborated with the family’s assigned health coach. The nurse

care manager facilitated the provision of needed services, such

as primary care, specialty care, a change to the medication regi-

men, a home visit from a nurse, and/or an emergency depart-

ment visit. The program reported a signiicant reduction in

hospital readmissions among at-risk Medicare patients, which

also generated a substantial cost savings for the hospitals and

health care system.

Important guidance in developing a community-based case

management program can be found in the United States. Case

management is a key component of federally inanced and

many state-inanced health delivery options. The experiences of

states over the past two decades provide testimony to the im-

portance of case management for populations at risk. For older

clients, state-derived case management provides objective advice

and assistance with care needs. It also provides access to multi-

disciplinary providers and services. For payers (i.e., federal,

state, clients), case management serves as a way to ensure that

funds are allocated appropriately to those in greatest need. Case

management serves a policy assurance and accountability func-

tion for communities.

CHECK YOUR PRACTICE?

You are assisting the case manager in the chronic disease branch of the health

department. You have been asked to put together a life care plan for a client

who has been followed in the clinic for 5 years. This client has debilitating

uncontrolled diabetes. What type of information would you need to put to-

gether this plan?

• Acquired immunodeiciency syndrome

• Amputations

• Brain trauma

• Cerebrovascular accident

• Chronic diseases and disabilities (e.g., asthma, diabetes, mental illness,

behavioral health)

• High-risk neonates

• High usage of services

• Multiple fractures

• Psychiatric conditions

• Severe burns

• Spinal cord injury

• Substance abuse

• Terminal illness

• Transplantation

• Ventilator dependency

• Work-related injuries

BOX 13.4 Examples Of Case-Managed Conditions

229CHAPTER 13 Case Management

Within the states, the types of agencies designated to con-

duct case management are often district ofices of state

government, area agencies on aging, county social services

departments, and private contractors. States maintain the

oversight responsibilities for case management agencies to do

the following:

1. Ensure they are complying with program standards, con-

tracts, reporting, and iscal controls

2. Identify emerging problems and issues to be resolved by ad-

ditional state policies

3. Provide onsite technical assistance and consulting to im-

prove performance. States’ payment methods for case

management include daily and monthly rates, hourly and

quarterly rates, capped rates for services, and capped aggre-

gate rates to cover both case management and provider costs

(Mullahy, 2017).

ESSENTIAL SKILLS FOR CASE MANAGERS

Three speciic skills essential to the role performance of the case

manager are discussed: advocacy, conlict management, and

collaboration.

Advocacy Case managers report that they are irst and foremost client

advocates (CMSA, 2016; Sminkey and LeDoux, 2016; Tahan

et al, 2015). The deinition of nursing includes advocacy:

“Nursing is the protection, promotion and optimization of

health and abilities, prevention of illness and injury, alleviation

of suffering through the diagnosis and treatment of human

response, and advocacy in the care of individuals, families,

communities and populations” (ANA, 2010, p 6). For nurses,

advocacy involves various activities, ranging from exploring

self-awareness to lobbying for health policy. Advocacy is essen-

tial for practice with clients and their families, communities,

organizations, and colleagues on an interprofessional team. The

functions of advocacy require scientiic knowledge, expert com-

munication, facilitating skills, and problem-solving and afirm-

ing techniques. As the Code of Ethics for Nurses (ANA, 2015)

states, “Nurses consider the needs and respect the values of each

person in every professional relationship and setting” (p 1).

This means the nurse has the obligation to move beyond his or

her own personal feelings of agreement or disagreement to re-

spond compassionately. However, this goal is a contemporary

one; the perspective regarding the advocacy function has shifted

through time. The nurse advocate has been described in earlier

writings as one who acted on behalf of or interceded for the

client (Nelson, 1988). An example of the nurse interacting on

behalf of the client is the nurse who calls for a well-child ap-

pointment for a mother visiting the family planning clinic

when the mother is capable of making an appointment on her

own. The contemporary goal of advocacy would direct the

nurse to move clients toward making the call themselves.

The change over time in the advocacy role to that of media-

tor by the nurse advocate is described as a response to social

change, reimbursers, and providers in the health care system.

Mediation is an activity in which a third party attempts to

provide assistance to those who may be experiencing a conlict

in obtaining what they desire. The goal of the nurse advocate as

mediator is to help parties understand each other on many

levels so that agreement on an action is possible. In the example

of a nurse as case manager for an HMO, mediation activities

between an older client and the payer (i.e., the HMO) could

accomplish the following results: the client may understand the

options for community-based skilled nursing care, and the

payer may understand the client’s desires for a less restrictive

environment for care, such as the home. Although the case

manager as mediator does not decide the plan of action (in

contrast to the role of arbitrator), he or she facilitates the

decision-making process between the parties so that the desired

care can be reimbursed within the range of options available

to the client.

In today’s practice, the nurse advocate makes the client’s

rights the priority. The goal of promoter for the client’s au-

tonomy and self-determination may result in a high degree of

client independence in decision making. For example, when a

group of young pregnant women is the collective “client” (i.e.,

the aggregate), the nurse advocate’s role may be to inform the

group of the beneits and consequences of breastfeeding their

infants. However, if the new mothers decide on formula feed-

ing, the nurse advocate should support the group and continue

to provide parenting, infant, and well-child services.

A different perspective of the nurse advocate as promoter

holds that the nurse’s role as advocate may demand a variety of

functions that are inluenced by the client’s physical, psycho-

logical, social, and environmental abilities. The nurse adapts

the advocacy function to the client’s dynamic capabilities as the

client follows a path to a healthy status. Examples of advocacy

in such cases might include promoting a client group’s access to

onsite physical itness programs in the occupational setting or

supporting parents’ and students’ concerns about the high fat

content of vending machine food in the school system.

Process of Advocacy

The goal of advocacy is to promote self-determination in a

constituency or client group. It is often critical in promoting a

client’s self-determination. Table 13.2 compares the nursing

Nursing Process Advocacy Process

Assessment/diagnosis Exchange information

Gather data

Illuminate values

Planning/outcomes Generate alternatives and consequences

Prioritize actions

Implementation Make decisions

Support the client

Assure

Reassure

Evaluation Afirm

Evaluate

Reformulate

TABLE 13.2 Nursing Process and Advocacy Process

230 PART 4 Issues and Approaches in Health Care Populations

process with the advocacy process. The client may be an indi-

vidual, family, peer, group, or community. The classic process

of advocacy has been deined by Kohnke (1982), Mallik and

Rafferty (2000), Smith (2004), and Choi (2015) to include in-

forming, supporting, and afirming. All three activities are

more complex than they may initially seem, and they require

self-relection by the nurse as well as skill development. It is

often easier for the nurse to inform, support, and afirm another

person’s decision when it is consistent with the nurse’s values.

When clients make decisions within their value systems that are

different from the nurse’s values, the advocate may feel conlict

about contributing to the process of informing, supporting,

and afirming those decisions. Promoting self-determination

in others demands that the nurse have a philosophy of free

choice once the information necessary for decision making has

been discussed.

Informing. Knowledge is essential but not suficient to the

outcome of decision making. The interpreting of knowledge is

affected by the client’s values and the meaning the client assigns

to the knowledge. Informing clients about the nature of their

choices, the content of those choices, and the consequences to

the client is not a one-way activity. More active participation of

clients in conversations with providers has been linked to better

treatment compliance and health outcomes (Hibbard and

Greene, 2013). Although the exchange may be initiated at the

factual level, it will likely proceed to include the opinions of

both parties—the client and the nurse (see the How To box on

information exchange.

expresses a dedication to the client’s wishes; as a result, pur-

poseful exchange of new information may occur so that the

client’s choice remains viable.

The importance of afirming activities cannot be empha-

sized strongly enough. It is not the advocate’s role in the

decision-making process to tell the client which option is

“correct” or “right”; instead, the advocate’s role involves the

following:

• Providing the opportunity for information exchange, thus

giving clients the tools that can empower them in making

the best decision from their perspective.

• Enabling the client to make an “informed decision.” This is a

powerful tool for building self-conidence. It gives the client

the responsibility for selecting the options and experiencing

the success and consequences of the options based on cur-

rent data.

• Empowering clients in their decision making when they can

recognize events that are beyond their control and can link

events that occur by chance with predictable events to make

decisions they want.

Nurses can promote client decision making in the following

ways:

• Using the information exchange process

• Promoting the use of the nursing process

• Including written techniques (i.e., contracts, lists)

• Using relection and prioritizing decisions

• Using role playing to “try on” and determine the “it” of dif-

ferent options and consequences for the client

• Helping clients recognize the progression of activities they

experience as they build their “informed decision-making

base”

• Empowering clients with skills that can strengthen their

autonomy and conidence in the future

Advocacy is a complex process that maintains a delicate bal-

ance between “doing for” and “promoting autonomy.” The

process is inluenced by the client’s physical, emotional, and

social abilities. The goal of advocacy is to promote the maxi-

mum degree of client self-determination possible for the client

given the client’s current and potential status; for most clients,

this goal can be realized.

Skill Development

Skills needed by nurse advocates are not unique to their profes-

sion. Nursing demands scientiic, technical, relationship, and

problem-solving knowledge and skills. Advocacy applies nurs-

ing skills of communication and competency to promote client

self-determination.

Knowledge of nursing and other disciplines, as well as of hu-

man behavior, is essential for the advocacy role in establishing

authority, promoting authenticity, and developing skills. The

capacity to be assertive for personal rights and the rights of oth-

ers is essential.

Systematic Problem Solving

The nursing process—assessment, diagnosis, goal identiica-

tion, planning, implementation, and evaluation—constitutes

an example of a method of problem solving that can be used in

HOW TO Use the Information Exchange

Guidelines for exchanging information in the advocacy process include the

nurse’s responsibility to do the following:

1. Assess the client’s present understanding of the situation.

2. Provide correct information.

3. Communicate with the client’s literacy level in mind, making the information

as understandable as possible.

4. Use a variety of media and sources to increase the client’s comprehension.

5. Discuss other factors that affect the decision, such as inancial, legal, and

ethical issues.

6. Discuss the possible consequences of a decision.

Supporting. Upholding a client’s right to make a choice

and to act on the choice involves supporting. People who

become aware of clients’ decisions fall into three general

groups: supporters, dissenters, and obstructers. Supporters

approve and support the actions of the clients. Dissenters do

not approve of and do not support the actions of the clients.

Obstructers cause dificulties as clients try to implement their

decisions. There is the need for the nurse advocate to assure

clients that they have the right and responsibility to make

decisions and reassure them that they do not have to change

their decisions.

Affirming. Afirming is based on an advocate’s belief that a

client’s decision is consistent with the client’s values and goals.

The advocate validates that the client’s behavior is purposeful

and consistent with the choice that was made. The advocate

231CHAPTER 13 Case Management

the advocacy role. Advocates can be particularly helpful with

clients in illuminating values and generating alternatives as

described in the following sections.

Illuminating values. People’s values affect their behavior,

feelings, and goals. The advocate seeks to understand a client’s

values. The role of the advocate is to assist clients in discover-

ing their values, which can be particularly demanding in the

information exchange and afirming process. One way to help

clients state their values is through a process called clariica-

tion. A simple way to do this is to ask questions such as the

following:

• What are 10 things you enjoy doing?

• What are the most important things to you in life (e.g., family,

money, happiness, health, comfort, pleasure, recognition)?

• How do you spend a typical day?

Generating alternatives. Clients and advocates may feel lim-

ited in their options if they generate solutions before completely

analyzing the problems, needs, desires, and consequences. Several

techniques can be used to generate alternatives, including brain-

storming and a technique known as the problem-purpose-

expansion method (Box 13.5).

Impact of Advocacy

Advocacy empowers clients to participate in problem-solving

processes and decisions about health care. Clients try to under-

stand changing opportunities in the health care system for ac-

cess, use, and achieving continuity of care. Nurse advocates

promote client self-determination and management of behav-

ior as it relates to health and the adherence to therapeutic regi-

mens. Clients are part of larger systems: the family, the work

environment, and the community. Each system interacts with

the client to shape the available options through resources,

needs, and desires. Each system also has both conirming and

conlicting goals and processes that need to be understood for

client self-determination to be successful. For example, the

practice of advocacy among minority groups may involve the

ability to focus attention on the magnitude of problems caused

by diseases affecting minority clients. Whether the client is an

individual, family, group, or community, the advocacy function

can promote the interest of self-determination that character-

izes progressive societies.

Advocacy is not without opposition. Clients and advocates

may ind barriers to services, vendors, providers, and resources. A

community may experience a shortage in nursing home beds, a

childcare facility may experience stafing shortages, a family may

not have the inancial resources to keep a child at home, or a cli-

ent may ind that the school system cannot fund a full-time nurse

for its clinic. The reality of scarce resources creates a dificult bar-

rier for advocates. However, events such as these often stimulate

a community’s self-determination and lead to innovative actions

to correct gaps in service (see the Levels of Prevention box).

Brainstorming

1. The nurse, client, professionals, or signiicant others generate as many

alternatives as possible, without critical evaluation.

2. They examine the list for the critical elements the client seeks to preserve

(e.g., environmental preferences, degree of control).

3. They analyze the list for consequences, the probability of chance events

occurring, and the effect of the alternatives on self and others.

Problem-Purpose-Expansion Method

1. Restate the problem.

2. Expand the problem statement so different solutions can be generated. For

example, if the purpose of the problem statement is to convince the insur-

ance company to approve a longer hospital stay, the nurse and client

have narrowed their options. If the purpose of the problem statement is to

make the client’s convalescence as beneicial and safe as possible, several

solutions and options are available, as follows:

• Obtaining skilled nursing facility placement

• Obtaining home health skilled services

• Arranging physician home visits

• Paying for custodial care

• Paying for private skilled care

• Obtaining informal caregiving

BOX 13.5 Techniques of Generating Alternatives for Problem Solving

Primary Prevention

Use the information exchange process to increase the client’s understanding

of how to use the health care system and the health promotion strategies that

will maintain health.

Secondary Prevention

Use case inding to identify existing health problems in your caseload and the

population served by your agency. Timely, holistic assessments and interven-

tions can slow disease trajectories and promote healing and health.

Tertiary Prevention

Monitor the use of prescription medications and adherence to treatment to

reduce risk for illness complications. Use models such as the CSMA Case

Management Adherence Guidelines at (http://www.cmsa.org) to prevent sub-

sequent consequences of issues in medication compliance as part of the

treatment plan. Institutionalize this model in your agency.

LEVELS OF PREVENTION

Related to Case Management

Conlict Management Case managers help clients manage conlicting needs and scarce

resources. Mutual beneit with limited loss for everyone is a goal

of conlict management. Techniques for managing conlict in-

clude the following:

• Using a range of active communication skills directed to-

ward learning all parties’ needs and desires

• Detecting areas of agreement and disagreement

• Determining abilities to collaborate

• Assisting in discovering alternatives and valuable activities

for reaching a goal.

Negotiating is a strategic process used to move conlicting

parties toward an outcome. Parties must see the possibility of

achieving an agreement and the costs involved in not achieving

an agreement. Preparations must be made as to time, place, and

ground rules concerning participants, procedures, and coni-

dentiality. In a conlict situation, parties engage in behaviors

that relect the dimensions of assertiveness and cooperation.

http://www.cmsa.org

232 PART 4 Issues and Approaches in Health Care Populations

Assertiveness is the ability to present one’s own needs. Coop-

eration is the ability to understand and meet the needs of oth-

ers. Behaviors seen in conlict management are described in

Box 13.6. The Thomas-Kilmann categories of behaviors noted

in this box, although written some time ago, outline a variety of

behaviors that can be valuable in a given situation.

Clearly, lexibility in conlict management behavior can en-

courage an outcome that meets the client’s goals. Helping par-

ties navigate the process of reaching a goal requires effective

personal relations, knowledge of the situation and alternatives,

and a commitment to the process.

Collaboration In case management, the activities of many disciplines (e.g.,

social workers, nurses, physicians, insurers, physical therapists)

are needed for success. Clients, the family, signiicant others,

payers, and community organizations contribute to achieving

the goal. Collaboration is achieved through a developmental

process. It occurs in a sequence, yet it is reciprocal between

those involved.

The goal of communication in the collaborative development

process is to promote respect for, understanding of, and the ac-

curacy of all team members’ points of view. Although commu-

nication is an essential component in collaboration, it is not

suficient to result in or maintain collaboration. Although the

collaboration model recognizes the contributions inherent in

joint decision making, one member of the team should be held

accountable to the system and to the client. This team member

should be responsible for monitoring the entire process.

Teamwork and collaboration clearly demand knowledge and

skills about the following:

• Clients

• Health status

• Resources

• Treatments

• Community providers

• Clients’ and families’ complex needs

• Intrapersonal, interpersonal, medical, nursing, and social

dimensions

• Team member and leadership skills

• Competing: An individual pursues personal concerns at another’s

expense.

• Accommodating: An individual neglects personal concerns to satisfy the

concerns of another.

• Avoiding: An individual pursues neither personal concerns nor another’s

concerns.

• Collaborating: An individual attempts to work with others toward

solutions that satisfy the work of both parties.

• Compromising: An individual attempts to ind a mutually acceptable

solution that partially satisies both parties.

BOX 13.6 Categories Of Behaviors Used in Conlict Management

Modiied from Thomas KW, Kilmann RH: Thomas-Kilmann conlict

mode instrument, New York, 1974, Xicom. History and Validity of the

Thomas-Kilmann Conlict Mode Instrument (TKI). Mountain View, CA,

CPP, Inc. Retrieved January 2015 from: https://www.cpp.com/products/

tki/tki_info.aspx.

Through a nurse’s case management activities, general community deiciencies in

quality and quantity of health services are often discovered. When observing lack

of care or services at the individual and family intervention levels, the nurse can,

through case management, intervene at the community level to make changes.

George Stone is a nurse in community health practice working as a case

manager for the pediatric asthmatic population. He is studying the use of

service patterns among children with asthma. Mr. Stone would like to see if

the services offered for asthmatic children are being used and, if not, the

reasons they are underused.

Mr. Stone learns that many families without insurance are not using the free

inhalers and spacers that the local Lion’s Lodge provides to children without

insurance. In fact, the families do not know this service exists. Mr. Stone makes

it a priority to educate these families about this service so that they can save

money and still receive the necessary medication for their children. Through

school nurses, Mr. Stone identiies the current asthmatic students in the area

who are eligible for free inhalers and spacers. Flyers are sent to their homes

advertising the Lion’s Lodge service. Mr. Stone also visits the physicians in the

area who specialize in asthma. He educates the physicians and their staff about

who is eligible for the free inhalers and spacers and how to get the service for

their current and new clients. One year later, Mr. Stone collects new usage data

and compares them with his original indings. He inds a 50% increase in fami-

lies receiving inhalers and spacers from the Lion’s Lodge.

CASE STUDY

Deining Deiciencies through Case Management

Activities

ISSUES IN CASE MANAGEMENT

Legal Issues Liability concerns of case managers exist when the following

three conditions are met:

1. The provider had a duty to provide reasonable care.

2. A breach occurred through an act or omission to act.

3. The act or omission caused injury or damage to the client.

Case managers must strive to reduce risks, practice wisely

within acceptable standards, and limit legal defense costs

through professional insurance coverage (Box 13.7).

Legal citings related to case management and managed care

include the following:

• Negligent referrals

• Provider liability

• Payer liability

• Breach of contract

• Bad faith

As in any scope of nursing practice, proactive risk-management

strategies can lower the provider’s exposure to legal liability

(Box 13.8). When courts ind that cost considerations affect

decisions related to medical care, all parties to the decision,

such as the nurse, the agency, and all other health care provid-

ers, will be liable for any resulting damages.

Ethical Issues Case managers as nursing professionals are guided in ethical

practice by the Code of Ethics for Nursing (ANA, 2015) and the

It is unlikely that any single professional has the expertise

required in all of these. It is likely, however, that the synergy

produced by all involved can result in successful outcomes.

https://www.cpp.com/products/tki/tki_info.aspx

233CHAPTER 13 Case Management

Code of Professional Conduct for Case Managers (Commission for

Case Manager Certiication [CCMC], 2015), by performance

indicators for ethics in the Standards of Practice for Case

Management (CMSA, 2016), and by the contract expressed in

the Nursing’s Social Policy Statement:

Nursing is the protection, promotion, and optimization of

health and abilities, prevention of illness and injury, alle-

viation of suffering through the diagnosis and treatment of

human response, and advocacy in the care of individuals,

families, communities and populations

(ANA, 2010, p 2)

This contractual philosophy of nursing practice is ideally

suited to preserving the principles of autonomy, beneicence, and

justice in the case management processes. Leonard and Miller

(2012) and Sminkey and LeDoux (2016) describe how case man-

agers may confront dilemmas in each of these areas, as follows:

• Case management may hamper a client’s autonomy of indi-

vidual right to choose a provider if a particular provider is

not approved by the case management system. If a new pro-

vider must be found who can be approved for coverage,

continuity of care may be disrupted.

• Beneicence, or doing good, can be impaired when excessive

attention to containing costs supersedes or impairs the

nurse’s duty to improve health or relieve suffering.

• Justice, as an ethical principle for case managers, considers

equal distribution of health care with reasonable quality.

Tiers of quality and expertise among provider groups can be

created when quality providers refuse to accept reimburse-

ment allowances from the managed system, leaving less-

experienced or lower-quality providers as the caregiver of

choice for clients being managed.

• Nonmaleicence is “doing no harm.” When case managers

incorporate outcomes measures, evidence-based practice, and

monitoring progress in their plans of care, this principle is

addressed.

• Veracity, or truth telling, is absolutely necessary to the prac-

tice of advocacy and building a trusting relationship with a

client. Clients particularly complain that in the changing

health care system, payers do not seem to be able to provide

comprehensive yet inexpensive options for care.

Maintaining familiarity with ethical issues published in

the case management literature can offer speciic assistance

for practicing case managers.

BOX 13.7 Five General Areas Of Risk For Case Managers

1. Liability for managing care (Leonard and Miller, 2012; Sminkey and LeDoux,

2016)

• Inappropriate design or implementation of the case management system

• Failure to obtain all pertinent records on which case management actions

are based

• Failure to have cases evaluated by appropriately experienced and creden-

tialed clinicians

• Failure to confer directly with the treating provider at the onset of and

throughout the client’s care

• Substituting a case manager’s clinical judgment for that of the medical

provider

• Requiring the client or provider to accept case management recommenda-

tions instead of any other treatment

• Harassment of clinicians, clients, and family in seeking information and

setting unreasonable deadlines for decisions or information

• Claiming orally or in writing that the case management treatment plan is

better than the provider’s plan

• Restricting access to otherwise necessary or appropriate care because of cost

• Referring clients to treatment furnished by providers who are associated

with the case management agency without proper disclosure

• Connecting case managers’ compensation to reduced use and access

2. Negligent referrals (Leonard and Miller, 2012; Sminkey and LeDoux, 2016)

• Referral to a practitioner known to be incompetent

• Substituting inadequate treatment for an adequate but more costly option

• Curtailing treatment inappropriately when curtailment caused the injury

• Referral to a facility or practitioner inappropriate for the client’s needs

• Referral to another facility that lacks care requirements

3. Experimental treatment and technology (Sminkey and LeDoux, 2016)

• Failure to apply the contractual deinition of “experimental” treatment

found in the client’s insurance policy

• Failure to review sources of information referenced in the client’s insur-

ance policy (e.g., Food and Drug Administration determination, published

medical literature)

• Failure to review the client’s complete medical record

• Failure to make a timely determination of beneits in light of timelines of

treatment

• Failure to communicate to the insured client or participant how coverage

was determined

• Improper inancial considerations determining the coverage

4. Conidentiality (Leonard and Miller, 2012)

• Failure to deny access to sensitive information awarded special protection

by state law

• Failure to protect access allowances to computerized medical records

• Failure to adhere to regulations, such as the Health Insurance Portability

and Accountability Act of 1996 (HIPAA) and the Americans with Dis-

abilities Act

5. Fraud and abuse (Leonard and Miller, 2012)

• Making false statements on claims or causing incorrect claims to be

iled

• Falsifying the adherence to conditions of participation of Medicare and

Medicaid

• Submitting claims for excessive, unnecessary, or poor-quality services

• Engaging in payment, bribes, kickbacks, or rebates in exchange for referral

• Coding intervention requirements improperly

1. Clear documentation of the extent of participation in decision making and

the reasons for decisions

2. Records demonstrating accurate and complete information on interactions

and outcomes

3. Use of reasonable care in selecting referral sources, which may include

veriication of the provider licensure

4. Written agreements when arrangements are made to modify beneits other

than those in the contract

5. Good communication with clients

6. Informing clients of their rights of appeal

BOX 13.8 Elements That Reduce Risk Exposure

234 PART 4 Issues and Approaches in Health Care Populations

C L I N I C A L A P P L I C A T I O N

During her visit to the regularly scheduled blood pressure clinic in

a local apartment cluster, Mrs. Barnes, a 45-year-old woman, com-

plained of feeling dizzy and forgetful. She could not remember

which of her six medications she had taken during the past few

days. Her blood pressure readings on reclining, sitting, and stand-

ing revealed extreme elevations. The nurse and Mrs. Barnes dis-

cussed the danger of her present status and the need to seek medi-

cal attention. Mrs. Barnes called her physician from her apartment

and agreed to be transported to the emergency department.

While in the emergency department, Mrs. Barnes manifested

the progressive signs and symptoms of a cerebrovascular accident

(CVA, stroke). During hospitalization, she lost her capacity for

expressive language and demonstrated hemiparesis and loss of

bladder control. Her cognitive function became intermittently

confused, and she was slow to recognize her physician and neigh-

bors who came to visit. The utilization management nurse con-

tacted the case manager from the health department to screen and

assess for the continuum of care needs as early as possible because

Mrs. Barnes lived alone and family members resided out of town.

It became apparent that family caregiving in the community

could be only intermittent because members lived too far away.

Mrs. Barnes had residual functional and cognitive deicits that

would demand longer-term care.

As the case manager contracted by the plan, place the following

actions in the sequence needed to construct a case management plan:

A. Discuss with the family their schedule of availability to offer

care in the client’s home.

B. Call the client and introduce yourself as a prelude to work-

ing with her.

C. Obtain information on the scope of services covered by the

beneit plan for your client.

D. Arrange a skilled nursing facility site visit for the patient and

family.

Answers can be found on the Evolve website.

R E M E M B E R T H I S !

• An important role of the nurse in community health is that

of client advocate.

• The goal of advocacy is to promote the client’s self-

determination.

• When performing in the advocacy role, conlicts may emerge

regarding the full disclosure of information, territoriality,

accountability to multiple parties, legal challenges to client’s

decisions, and competition for scarce resources.

• The functions of advocacy and allocation can pose dilemmas

in practice.

• Skills important in fulilling the role of client advocate include

the helping relationship, assertiveness, and problem solving.

• Problem solving is a systematic approach that includes

understanding the values of each party and generating alter-

native solutions.

• Brainstorming and the problem-purpose-expansion method

are two techniques to enhance the effectiveness of problem-

solving skills.

• During conlict, negotiations can move conlicting parties

toward an outcome.

• Care management is a strategic program to maintain the

health of a population enrolled in a health care delivery system.

• Continuity of care is a goal of community health nursing

practice. It requires making linkages with services to improve

the client’s health status.

• As the structure of the health care system moves toward de-

livering more services in the community, the achievement of

continuity of care will present a greater challenge.

• Case management is typically an interdisciplinary process in

which the client is the focus of the plan.

• Documenting case management activities and outcomes is

essential to nursing practice in the community.

• Case management is a systematic process of assessment,

planning, service coordination, referral, monitoring, and

evaluation that meets the multiple service needs of clients.

• Nurses in community health have advocacy and case man-

agement functions within their scope of practice.

• Nurses functioning as advocates and case managers need to be

aware of the ethical and legal issues confronting their practice.

• Standardization of care for predictable outcomes can be

achieved through critical paths, disease management proto-

cols, and multidisciplinary action plans.

• Telehealth application provides new alternatives within re-

source delivery options but must be customized for clients.

APPLYING CONTENT TO PRACTICE

The clinical practice skill of advocacy is an inherent concept in the practice of case

management. Of the 16 interventions by public health nurses described in the

Wheel of Intervention model, both advocacy and case management are described

in accordance with best practices and operational deinitions of 3 of the 16 interven-

tions. Advocacy can be applied at the community, systems, individual, or family

level. In fact, when a public health nurse advocates for clients at any of these levels,

the source of conlict and collaboration will likely come from competing values, that

is, those of the client and any of the other levels of population values. For example:

• A client may want access to unlimited treatment, but inancial values may

pose a source of conlict as the system attempts to justify the comparative

effectiveness or costs.

• Family members may pose conlicting values for the nature of care they wish

a family member to receive, even as the client refuses care.

• Communities can divert budget allotments to needs that are in competition

for other population services such as community policing, health care access,

and environmental services.

The nurse as advocate must listen carefully to his or her client in order

to truly represent the interest of the client and encourage “win-win”

processes and outcomes for the client. Advocacy occurs in all three of

the core functions of public health: assessment, policy development, and

assurance.

235CHAPTER 13 Case Management

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236

C H A P T E R 14

Disaster Management

Sharon A. R. Stanley, Sharon L. Farra, Susan B. Hassmiller

chemical, biological, radiological,

nuclear, and explosive (CBRNE)

disasters, 241

community emergency response

team (CERT), 241

delayed stress reactions, 250

disaster, 236

disaster medical assistance teams

(DMATs), 241

Emergency Support Function 8:

Public Health and Medical

(ESF), 238

K E Y T E R M S

Disasters

Healthy People 2020 Objectives

The Disaster Management Cycle and the Nursing Role

Prevention (Mitigation)

C H A P T E R O U T L I N E

Preparedness

Response

Recovery

Future of Disaster Management

After reading this chapter, the student should be able to:

1. Discuss types of disasters, including natural and human-made.

2. Evaluate the effects of disasters on people and their

communities.

3. Describe the disaster management phases of prevent,

preparedness, response, and recovery, and explain the

nurse’s role in each phase.

O B J E C T I V E S

4. Describe the steps to take to initiate and maintain a disaster

clinic.

5. Identify how community groups and other organizations

such as the American Red Cross can work together to

prepare for, respond to, and recover from disasters.

Around the world, people are experiencing unprecedented

disasters from natural causes such as hurricanes, earth-

quakes, and tsunamis that can lead to nuclear power plant

meltdowns, human-made disasters (e.g., oil spills), and acts

of terrorism. Disasters occur suddenly and unexpectedly,

and they often cannot be prevented. However, communities

can be helped to prepare for, respond to, and recover from

disaster. This chapter describes management techniques to

be used in the prevention, preparedness, response, and re-

covery phases of disaster. The nursing role is discussed for

each phase.

DISASTERS

A disaster is any natural or human-made incident that causes

disruption, destruction, or devastation requiring external as-

sistance. Disasters can affect a single family or a small group, as

in a house ire, or they can kill thousands and have economic

losses in the millions, as with loods, earthquakes, tornadoes,

hurricanes, and bioterrorism. Disasters are expensive in terms

of lives affected and property lost or damaged. Although natu-

ral events such as earthquakes or hurricanes often trigger

disasters, predictable and preventable human-made factors can

Homeland Security Act of 2002, 238

human-made disasters, 236

Medical Reserve Corps (MRC), 241

mitigation, 239

National Health Security Strategy

(NHSS), 243

National Preparedness Guidelines

(NPG), 238

National Preparedness Goal, 238

National Response Framework

(NRF), 238

natural disasters, 237

Pandemic and All-Hazards

Preparedness Reauthorization

Act (PAHPRA), 238

preparedness, 240

Presidential Policy Directive 8:

National Preparedness, 238

prevention, 239

rapid needs assessment, 239

recovery, 250

response, 244

triage, 239

237CHAPTER 14 Disaster Management

increase the effect of the disaster. Each year hurricanes in the

United States batter the coasts and inland areas. A 9.0 magni-

tude earthquake struck Northeastern Japan on March 11, 2011.

The earthquake was quickly followed by a tsunami (Fig. 14.1).

These dual natural disasters caused an estimated death toll of

20,000, but there was a third, human-made component to com-

plete the incident triad: a nuclear reactor crisis. An independent

parliamentary investigation later found the Fukushima nuclear

disaster to be the result of a mix of several human-made factors

(Inajima et al, 2012). Box 14.1 lists examples of natural and

human-made disasters.

Unfortunately, developing countries experience a dispropor-

tionate burden from natural disasters. These countries are usu-

ally poor and have limited resources for dealing with the effects

of the disaster. To add to the misery, the governments of some

countries thwart the efforts of international aid workers to

bring relief to their people, as seen in recent years in Syria. Di-

sasters have political aspects in addition to the enormous losses

to the people. For example, some countries will not accept aid

from nations they do not consider their allies or supporters.

The urbanization and overcrowding of cities have increased

the danger of natural disasters because communities have been

built in areas that are vulnerable to disaster, such as in known

tornado zones or near rivers or lood plains. Increases in popula-

tion and developing for habitation of areas vulnerable to natural

disasters have led to major increases in insurance payouts in the

United States in every decade. Projections suggest that by 2050,

at least 46% of the world’s population will live in areas vulner-

able to natural loods, earthquakes, and severe storms.

In recent years, we have learned more about what is called a

“complex humanitarian emergency (CHE). These emergencies

result from a “humanitarian crisis in a country, region or soci-

ety where there is total or considerable breakdown of authority

resulting from internal or external conlict and which requires

an international response that goes beyond the mandate or

capacity of any single and/or ongoing UN country programme”

(Downes, 2015, p. 12). Downes developed a course at Emory

University in Atlanta, Georgia, to teach health care students to

learn how to respond when a CHE occurred. She used the ex-

ample of the Ebola outbreak in West Africa in 2015. She noted

that the countries most affected by the Ebola virus were those

with a long history of political instability and weak health sys-

tems. The students in the course learned not only about the

complexity of health care in an emergency setting, but they also

learned how central the nursing role was to dealing with the

emergency.

Overcrowding and urban development have also increased

human-made disasters. The stress caused by overcrowding

has caused civil unrest and riots. In some parts of the world,

modern wars waged over land rights and space have markedly

From U.S. Department of Health and Human Services: Healthy People 2020: a roadmap to improve all Americans’ health, Washington, DC, 2010,

USDHHS.

BOX 14.1 Types of Disasters

Natural

• Hurricanes

• Tornadoes

• Hailstorms

• Cyclones

• Blizzards

• Droughts

• Floods

• Mudslides

• Avalanches

• Earthquakes

• Volcanic eruptions

• Communicable disease epidemics

• Lightning-induced forest ires

• Tsunamis

• Thunderstorms and lightning

• Extreme heat and cold

Human-Made

• Conventional warfare

• Nonconventional warfare (e.g., nuclear, chemical)

• Transportation accidents

• Structural collapse

• Explosions and bombings

• Fires

• Hazardous materials incident

• Pollution

• Civil unrest (e.g., riots)

• Terrorism (e.g., chemical, biological, radiological, nuclear, explosives)

• Cyberattacks

• Airplane crashes

• Radiological incidents

• Nuclear power plant incidents

• Critical infrastructure failures

• Water supply contamination

FIG. 14.1 One week after the earthquake struck and tsunami

surged through northeastern Japan, a Japanese Red Cross

volunteer surveys the damage to Otsuchi in Iwate Prefecture.

(Courtesy of the American Red Cross Disaster Online News-

room, Washington, DC. Retrieved January 2015 from http://

newroom.redcross.org).

http://newroom.redcross.org

238 PART 4 Issues and Approaches in Health Care Populations

increased the risk for injury and death from disaster. In the

United States and other countries, school violence, a human-

made disaster, has increased in intensity and magnitude. Disas-

ter recovery efforts are expensive, and the costs are growing

because of the number of people involved and the amount of

technology that must be restored. People in industrialized

countries are becoming less self-suficient because they rely

heavily on technology and social and economic systems within

their community. People who live on the brink of disaster every

day, physically, emotionally, or economically, are among the

irst to be affected when disaster strikes.

Although the number of disasters worldwide continues to

grow, the number of lives lost has decreased. The increase in the

number of lives saved may be due to better disaster forecasting

and early warning systems that help people better prepare for

the impending disaster. Disaster disproportionably strikes at-

risk individuals, whether their day-to-day risk is physical, emo-

tional, or economic. Disasters in less developed communities

can also destroy decades of progress in a matter of hours, in a

manner that rarely happens in more developed countries. The

poor, elderly, ethnic minorities, people with disabilities, and

women and children in developing communities are excessively

affected and least able to rebound (World Health Organization,

2012). Economic losses from disasters such as tsunamis, cy-

clones, earthquakes and looding now reach an annual average

of US $250 to $300 billion. Also, the mortality and economic

loss associated with risk in low- and middle-income countries

are increasing. Unfortunately, by 2050, the percentages of popu-

lation areas more vulnerable to disasters will increase. Eighty

percent of the world’s population will live in developing coun-

tries, with 46% living in tornado and earthquake zones, near

rivers, and on coastlines (UNISDR, 2015; Dilley et al, 2005).

Although natural disasters cannot be prevented, much can

be done to prevent further increases in accidents, death, and

destruction after impact. A concise, realistic, and well-rehearsed

disaster plan is essential. Open, clear, and ongoing communica-

tion among involved workers and organizations is critical. Also,

many of the human-made disasters listed in Box 14.1 can be

prevented (e.g., major transportation accidents and ires result-

ing from substance abuse).

The U.S. Department of Homeland Security (DHS) was

created through the Homeland Security Act of 2002 (DHS,

2008a), consolidating more than 20 separate agencies.

Presidential Policy Directive 8: National Preparedness

(PPD-8) was signed and released by President Barack Obama

on March 30, 2011. PPD-8 replaced Homeland Security Presi-

dential Directive 8 from the Bush era, and guides how the

nation, from the federal level to private citizens, can “prevent,

protect against, mitigate the effects of, respond to, and recover

from those threats that pose the greatest risk to the security of

the Nation” (DHS, 2011). The National Preparedness Guide-

lines (NPG) (DHS, 2015) and the National Response Plan

(NRP), which provide a national doctrine for preparedness that

includes the National Response Framework [NRF]), was pro-

mulgated in January 2008. The second edition of the National

Response Framework, updated in 2013, provides context for

how the whole community works together and how response

efforts relate to other parts of national preparedness (DHS,

2013). Each of the ive frameworks covers one mission area:

Prevention, Protection, Mitigation, Response, or Recovery. In

that framework, there are also 15 emergency support functions.

Emergency Support Function 8: Public Health and Medical

provides coordinated federal assistance to supplement state,

local, and tribal resources in response to public health and

medical care needs (Federal Emergency Management Agency

[FEMA], 2016).

The National Preparedness Goal was irst released in Sep-

tember 2011, and the second edition in 2015 maintains the goal

of “A secure and resilient nation with the capabilities required

across the whole community to prevent, protect against, miti-

gate, respond to, and recover from the threats and hazards

that pose the greatest risk” (FEMA, 2015, p. 1). The ive mission

areas in the goal are the same ive frameworks in the National

Response Framework.

Homeland Security Presidential Directive 5 (HSPD 5) directed

the Secretary of Homeland Security to develop and administer

the National Incident Management System (NIMS), a uniied,

all-discipline, and all-hazards approach to domestic incident

management (FEMA, 2017). The NIMS was established to pro-

vide a common language and structure to help those involved

in disaster response to communicate together more effectively

and eficiently.

Two national preparedness documents speciically guide di-

saster health preparedness, response, and recovery: HSPD 21:

Public Health and Medical Preparedness and the National

Health Security Strategy (NHSS). HSPD 21 established a na-

tional strategy that enables a level of public health and medical

preparedness suficient to address a range of possible disasters.

It does so through four critical components of public health

and medical preparedness: (1) biosurveillance, (2) countermea-

sure distribution, (3) mass casualty care, and (4) community

resilience. The NHSS focuses on the national goals for protect-

ing people’s health in the case of disaster in any setting. The U.S.

system for homeland security includes public health prepared-

ness and response as a core part of its national strategies. Every

aspect of disaster management involves public health nursing.

The NHSS was directed by the 2006 Pandemic and All-Hazards

Preparedness Act (PAHPA). The goal of this act is to improve

the nation’s ability to detect, prepare for, and respond to a vari-

ety of public health emergencies. The PAHPA was reenacted

in 2013 and is now called the Pandemic and All-Hazards

Preparedness Reauthorization Act (PAHPRA). The PAHPRA

funds public health and hospital preparedness programs, medi-

cal countermeasures under the BioShield Project, and enhances

the authority of the Food and Drug Administration (FDA)

(USDHHS, 2017).

Healthy People 2020 Objectives Because disasters affect the health of people in many ways, they

have an effect on almost every Healthy People 2020 objective.

Disasters clearly affect the objectives that relate to unintentional

injuries, occupational safety and health, environmental health,

and food and drug safety. Disasters affect many of the objectives

in the areas of Access to Health Services and Public Health

239CHAPTER 14 Disaster Management

also includes human-made hazards and the ability to deter po-

tential terrorists, detect terrorists before they strike, and take

action to eliminate the threat (DHS, 2007). Prevention activities

may include heightened inspections; improved surveillance and

security operations; public health and agricultural surveillance

and testing; immunizations, isolation, or quarantine; and halt-

ing chemical, biological, radiological, nuclear, and explosive

(CBRNE) threats (DHS, 2007). The nurse should be familiar

with the region’s local cache of pharmaceuticals and how

the Strategic National Stockpile (SNS) will be distributed.

Nurses are involved in many aspects of prevention, including

the following:

• Awareness and education: Holding or attending commu-

nity meetings on disaster preparedness, including informing

the community about the many educational resources avail-

able to them. One resource is an in-depth citizen guide for

preparing for a disaster called “Are you ready?” The guide is

available at http://www.fema.gov.

• Organizing and participating in mass prophylaxis and vac-

cination campaigns to prevent, treat, or contain disease.

• Advocacy identifying environmental hazards, serving on the

public health team for mitigation work, supporting actions

and efforts for effective building codes and proper land use.

Because disasters are both natural and human-made, nurses

need to assess for and report environmental health hazards,

including unsafe equipment and faulty structures. They must

be aware of high-risk targets and current vulnerabilities

and what can be done to eliminate or mitigate the vulnerabil-

ity. Targets may include military and civilian government

facilities, health care facilities, international airports and other

transportation systems, large cities, and high-proile land-

marks. Terrorists might also target large public gatherings,

water and food supplies, banking and inance, information

technology, postal and shipping services, utilities, and corpo-

rate centers (DHS, 2007).

Preparedness Personal Preparedness Nurses who are disaster victims themselves and must provide

care to others will experience considerable stress. Conlicts

• EH-21: Improve the utility, awareness, and use of existing information sys-

tems for environmental health.

• FS-1: Reduce infections caused by key pathogens transmitted commonly

through food.

• HC/HIT-12: Increase the proportion of crisis and emergency risk messages,

intended to protect the public’s health, that demonstrate the use of best

practices.

• IID-12: Increase the percentage of children and adults who are vaccinated

annually against seasonal inluenza.

From Department of Health and Human Services (DHHS): Healthy

People 2020: Improving the Health of Americans. Retrieved February

2016 from http://www.healthypeople.gov.

HEALTHY PEOPLE 2020

Examples of Objectives Related to Disaster

Mitigation

Infrastructure (USDHHS, 2010). In the past few years, with the

many incidents and scares related to possible bioterrorism,

people have become even more aware of the importance of di-

saster preparedness and how the things they take for granted

such as safe food, water, and housing can be threatened. Public

health professionals study the effect that disasters have on

population health and develop new prevention strategies. Other

organizations, such as the American Red Cross (ARC), work

with communities in the preparedness, response, and recovery

phases of a disaster. The Healthy People 2020 box provides ex-

amples of objectives related to disaster mitigation.

THE DISASTER MANAGEMENT CYCLE AND THE NURSING ROLE

Disaster management includes four stages: prevention (includ-

ing mitigation and protection), preparedness, response, and

recovery. Fig. 14.2 shows the disaster management cycle. Nurses

have skills that enable them to work in all aspects of disasters,

such as assessment, priority setting, collaboration, health edu-

cation, disease screening, and mass clinic expertise. Nurses also

have the ability to provide essential public health services, make

referrals, serve as a liaison among organizations and health care

and social service providers, and provide psychological irst aid,

triage, and rapid needs assessment.

Re sponse

R e c o v e ry

re p a re

d n e s s

Mitigation

FIG. 14.2 Disaster management cycle. (From Ontario Agency

for Health Protection and Promotion [Public Health Ontario].

Public health emergency preparedness: an IMS-based work-

shop. Base scenario, Toronto, ON: Queen’s Printer for Ontario,

2015 July (p. 7).

Prevention (Mitigation and Protection) All-hazards mitigation (prevention) is an emergency manage-

ment term for reducing risks to people and property from

natural hazards before they occur. Prevention can include

structural measures, such as protecting buildings and infra-

structure from the forces of wind and water, and nonstructural

measures, such as land development restrictions. Prevention

http://www.redcross.org/flash/brr/english-html/default.asp

http://www.fema.gov

240 PART 4 Issues and Approaches in Health Care Populations

HOW TO Be Red Cross Ready

1. Get a Kit

Consider the following when assembling or restocking your kit to ensure

that you and your family are prepared for any disaster:

• Store at least 3 days of food, water, and supplies in your family’s

easy-to-carry preparedness kit. Keep extra supplies on hand at home in

case you cannot leave the affected area.

• Keep your kit where it is easily accessible.

• Remember to check your kit every 6 months and replace expired or

outdated items.

2. Make a Plan

When preparing for a disaster, always:

• Talk with your family.

• Plan.

• Learn how and when to turn off utilities and how to use life-saving tools

such as ire extinguishers.

• Tell everyone where emergency information and supplies are stored.

Provide copies of the family’s preparedness plan to each member of the

family. Always ensure that information is up to date and practice evacu-

ations, following the routes outlined in your plan. Don’t forget to identify

alternative routes.

• Include pets in your evacuation plans.

3. Get Informed

There are three key parts to becoming informed:

• Get Info: Learn the ways you would get information during a disaster or

an emergency.

• Know Your Region: Learn about the disasters that may occur in your area.

• Action Steps: Learn irst aid from your local ARC chapter.

Emergency Supplies That Nurses Should Have Ready

• Identiication badge and driver’s license

• Proof of licensure and certiication (e.g., RN, CPR/AED, First Aid)

• Pocket-size reference books (e.g., nursing protocols and intervention

standards)

Blood Pressure Cuff (Adult and Child) and Stethoscope

• Gloves, mask, and other personal protective equipment (PPE) for general

care

• First aid kit with mouth-to-mouth cardiopulmonary resuscitation (CPR)

barrier

• Radio with batteries and cell phone charger

• Cash, credit card

• Important papers and contact information in hard copy

• Sun protection

• Sturdy shoes with socks

• Medical identiication of allergies, blood type

• Medications for self

• Weather-appropriate clothing to include rain gear

• Toiletries

• Watch, cell phone, PDA with preentered emergency numbers

• Flashlight, extra batteries

• Record-keeping materials, including pencil/pen

• Map of area

between family and work-related duties are inevitable. For

example, a nurse who is also the mother of a young child

will not be able to participate fully, if at all, in disaster relief

efforts until she has made arrangements for her child. Ad-

vance personal and family preparation can help ease some

of the conlicts that arise and allow nurses to attend to

client needs sooner. In addition, the nurse assisting in

disaster relief efforts must be as healthy as possible, both

physically and mentally, to serve clients, families, and other

disaster victims.

Disasters require nurses to respond quickly. Public health

nurses need to have their own personal plans in place before

a disaster. Preparedness is multifaceted. The family of each

nurse must also be included and informed about the disaster

plan. One way a nurse can ensure that his or her family is

protected is by providing them with the skills and knowledge

to help them cope with a disaster. Long-term benefits will

come by involving children or adolescents in activities

such as writing preparedness or response plans, rehearsing

the plan, preparing disaster kits, becoming familiar with

their school emergency plan and where families should

reunite in the event of an emergency, finding out where the

evacuation shelters are located and identifying the evacua-

tion routes, and learning about the range of potential haz-

ards in their vicinity. Natural and human-made hazards,

including terrorism, should be discussed. Vulnerable types

of infrastructure such as dams, chemical plants, bridges, and

transportation should be pointed out. Discussion offers chil-

dren and adolescents an opportunity to express their feel-

ings. The ability to control as much as they can during each

phase of a disaster provides them with the ability to bounce

back (Figure 14.3). The How To box is an excellent guide for

developing and putting together the supplies needed for a

disaster plan.

FIG. 14.3 Personal preparedness. Public health nurses need to

develop their own disaster plan as a part of their community

disaster activities. (Courtesy of the Wichita Falls Health District,

Wichita Falls, TX. Retrieved January 2015 from http://tx-wichitafalls2.

civicplus.com/index.aspx?NID51301).

In addition to the items in the How To box, include these

items:

• A change of clothing and protective footwear per person and

one blanket or sleeping bag per person.

• A manual can opener

(Courtesy of the American Red Cross. Retrieved January 2016 from

http://www.redcross.org/lash/brr/english-html/default.asp).

http://tx-wichitafalls2.civicplus.com/index.aspx?NID=1301

241CHAPTER 14 Disaster Management

• A irst-aid kit that includes 1 week’s supply of your family’s

prescription medications and over-the-counter medications

you take. Make a list of your medications and dosages, aller-

gies, and physician names.

• Candles and matches.

• Sanitation supplies, including toilet paper, soap, feminine

hygiene items, and plastic garbage bags.

• Special items for infants, older adults, or disabled family

members.

• An extra pair of eyeglasses.

• Pet supplies if you have animals.

• Documents: Identiication, passport, birth certiicate, insur-

ance policies, family contact information, local maps with

marked evacuation routes, some money.

• Gather emergency supplies, and store them in a sturdy, easy-

to-carry container. Keep important documents in a water-

proof container.

Nurses should consider several contingencies for children

and seniors with a plan to seek help from neighbors in the event

of being called to a disaster. Many special-needs shelters en-

courage preregistration for physically or mentally challenged

people. Because most shelters do not allow pets other than

“pocket” pets, other arrangements will need to be made, such as

going to a special pet shelter or placing the pet in a bathroom

with suficient food and water. A note should be placed on

the front door for emergency personnel as to where the pet

might be found. Currently, many local emergency management

ofices are considering incorporating pets into the local disaster

plans. Useful sites for information about being prepared are as

follows:

Prepare for emergencies now: Information for people

with disabilities. https://www.fema.gov/media-library/assets/

documents/90360.

Professional Preparedness

One of the essentials for baccalaureate prepared nurses is to be

informed about disaster preparedness. Public health nurses

need to be aware of and understand the disaster plans at the

workplace and in the community. These nurses take time to

read and understand workplace and community disaster plans

and participate in disaster drills and community mock disas-

ters. Adequately prepared nurses can serve as leaders and enable

others to have a smoother recovery phase.

Disaster management in the community is about population

health, and the three core public health functions are used just

as in day-to-day operations. You would rely on assessment,

policy development, and assurance in disaster work. Although

disaster work is not highly technological, there is increasing

information provided in a wireless format. Fieldwork, includ-

ing shelter management, requires that nurses be creative

and willing to improvise in delivering care. All workers should

be certiied in irst aid and CPR. In addition, the ARC provides

a comprehensive program of disaster training for health profes-

sionals, to enable them to provide assistance within their

own communities and to other affected communities and

countries. The courses teach nurses how to adapt their existing

nursing skills to a disaster setting and to the scope of ARC

disaster nursing. Note that the knowledge the nurse will need

for chemical, biological, radiological, nuclear, and explosive

(CBRNE) disasters and those involving weapons of mass de-

struction (WMD) requires a base of specialized information.

Box 14.2 describes competencies for all public health workers in

the event of a disaster.

Nurses who want to know more about disaster management

and be more actively involved can become involved in several

community organizations. The National Disaster Medical Sys-

tem (NDMS) enables nurses to work on specialized teams such

as the Disaster Medical Assistance Team (DMAT). In a presi-

dentially declared disaster, including overseas war, the U.S.

Public Health Service can activate disaster medical assistance

teams (DMATs) to an area to supplement local and state medi-

cal care needs. DMATs can also be activated by the Assistant

Secretary for Health if requested to do so by a state health ofi-

cer. Teams of specially trained civilian physicians, nurses, and

other health care personnel can be sent to a disaster site within

hours of activation. DMATs can provide triage and continuing

medical care to victims until they can be evacuated to a national

network of hospitals prearranged by the NDMS (DHS, 2015).

Because of the nature of this country’s disasters since the initia-

tion of DMATs, these teams have been used primarily to staff

community health outpatient clinics in the affected areas. The

Medical Reserve Corps (MRC) and the Community Emer-

gency Response Team (CERT) provide opportunities for nurses

to support emergency preparedness and response in their local

jurisdictions. The ARC offers training in disaster health ser-

vices and disaster mental health for both response in local

jurisdictions and national deployment opportunities. After

participation in disaster training, nurses can take the follow-

ing steps: join a local disaster action team, act as a liaison with

local hospitals, determine health-services support for shelter

• Describe the public health role in emergency response in a range of emer-

gencies that might arise

• Describe the chain of command in emergency response

• Identify and locate the agency emergency response plan

• Describe functional role(s) in emergency response and demonstrate role(s)

in regular drills

• Demonstrate correct use of all communication equipment used for emer-

gency communication (e.g., phone, fax, radio)

• Describe communication role(s) in emergency response (i.e., within the

agency using established communication systems, with the media, with

the general public, personal [with family, neighbors])

• Identify limits to your own knowledge, skill, and authority and identify key

system resources for referring matters that exceed these limits

• Apply creative problem solving and lexible thinking to unusual challenges

within their functional responsibilities and evaluate effectiveness of all

actions taken

BOX 14.2 Bioterrorism and Emergency Readiness: Competencies for All Public Health Workers

From The Centers for Disease Control and Prevention: Bioterrorism

and emergency readiness: competencies for all public health workers,

2002. Retrieved March 2013 from http://training.fema.gov/emiweb/

downloads/BioTerrorism%20and%20Emergency%20Readiness.pdf?

https://www.fema.gov/media-library/assets/documents/90360

http://training.fema.gov/emiweb/downloads/BioTerrorism%2520and%2520Emergency%2520Readiness.pdf

242 PART 4 Issues and Approaches in Health Care Populations

sites, plan on a multidisciplinary team for optimal client

service delivery, address the logistics of health and medical

supplies, and teach disaster nursing in the community. A

list of education and training opportunities is shown in

Box 14.3.

The importance of being adequately trained and properly

associated with an oficial response organization to serve in a

disaster cannot be overstated. In a disaster, many untrained

and ill-equipped individuals rush in to help. Spontaneous

volunteer overload creates added burden on an already tense

situation to include role conlict, anger, frustration, and help-

lessness. Box 14.4 provides a list of volunteer opportunities in

disaster work.

Public Health Workforce Development Centers

• Centers for Disease Control and Prevention: https://www/slu.edu/public-

health-social-justice/training/center_heartlandphp

• Heartland Centers for Public Health and Community Capacity Development:

http://www.heartlandcenters.slu.edu/

• National Public Health Training Centers Network, HRSA: http://bhpr.hrsa.

gov/grants/publichealth/trainingcenters/index.html

• Northwest Center for Public Health Practice: http://www.nwcphp.org/

training

Government and Other Nurse-Speciic Courses

• American Red Cross Disaster Health and Sheltering Course for Nursing

Students: http://www.drc-group.com/library/exercise/osc/OSC-DHS-FactSheet.

pdf

• Emergency Management Institute: http://training.fema.gov/

• Federal Emergency Management Agency (FEMA) Training: http://www.

fema.gov/prepared/train.shtm

• National Nurse Emergency Preparedness Initiative: http://www.nnepi.org/

Public Health Organizations

• American Public Health Association (APHA): http://www.apha.org

• Association of Public Health Nurses (APHN): http://www.phnurse.org/

• Association of Schools and Programs of Public Health (ASPPH): http://

www.aspph.org/

• National Association of County and City Health Ofices (NACCHO): http://

www.naccho.org

• Public Health Foundation (PHF): http://www.phf.org

BOX 14.3 Websites Providing Education and Training Opportunities

American Red Cross (ARC): http://www.redcross.org

Buddhist Compassion Relief (Tzu Chi): http://www.tzuchi.org/

Certiied Emergency Response Team (CERT): https://www.citizencorps.gov/cert/

Citizen Corps: http://ready.gov/citizen-corps

Disaster Medical Assistance Team (DMAT): http://www.phe.gov/preparedness/

responders/ndms/teams/Pages.dmat.aspx

Medical Reserve Corps (MRC): mrc.hhs.gov

National Voluntary Organizations Active in Disaster (NVOAD): http://www.

nvoad.org

The Salvation Army: http://www.salvationarmyusa.org

BOX 14.4 Volunteer Opportunities in Disaster Work

Community Preparedness

The level of community preparedness for a disaster is only as

good as the people and organizations in the community make

it. Some communities stay prepared for a possible disaster by

having a written disaster plan and participating in yearly disas-

ter drills. Other communities are less prepared and depend on

luck and the fact that they are unlikely to experience a disaster.

Some organizations within the community may be more pre-

pared than others. For example, most health care facilities have

written disaster plans and require employees to perform annual

mock drills, but many businesses lack these requirements.

In recent years, hospitals and health departments in cities

with nursing, medical, and other health professional schools

have included their faculty in the disaster planning work so that

if a disaster occurs, faculty and students can easily be mobilized

to assist.

Presidential Policy Directive (PPD)-8 emphasizes that true

preparedness is a whole community event. PPD-8 urges the

strengthening of our nation’s security and resilience through an

integrated set of guidance, programs, and processes to imple-

ment the national preparedness goal, described earlier in this

chapter (DHS, 2011).

This planning and implementation require a coordinated

response that involves many stakeholders, including irst and

foremost the general public. Community preparedness also in-

volves all levels of government, public health agencies, hospi-

tals, irst responders, emergency management, health care

providers within the community, schools and universities, the

private sector, and business and nongovernmental organiza-

tions (NGOs) such as the ARC. Mutual aid agreements and

prior planning help to bridge perceived and actual barriers;

establish relationships before the incident at the local, regional,

state, and national levels; and ensure seamless service. Some-

times barriers involve regulatory authority and jurisdictional

boundaries; sometimes the barriers involve organizational con-

trol versus the common good.

Emergency management is responsible for developing and

coordinating emergency response plans within their deined

area, whether local, state, federal, or tribal. The Federal Emer-

gency Management Agency (FEMA) coordinates comprehen-

sive, all-hazard planning at the national level, assuring a menu

of exercises and plan templates to address plausible incidents in

any given community. Emergency management personnel at

the state and local levels work closely with their communities

and response partners, providing opportunities to train, exer-

cise, evaluate, and update disaster plans. Stronger predisaster

partnerships, which include all stakeholders, produce a more

coordinated response.

Disaster planning involves simplicity and realism with

backup contingencies because (1) the disaster will never be an

“exact it” for the plan, and (2) all plans must be implementa-

tion ready, no matter who is present to start them (DHS, 2015).

The following Quality and Safety Education for Nurses box

describes safety guidelines for the nurse’s family.

Finally, the community must have an adequate warning sys-

tem and a backup evacuation plan to remove those individuals

from areas of danger who hesitate to leave. Some people refuse

https://www/slu.edu/public-health-social-justice/training/center_heartlandphp

http://www.heartlandcenters.slu.edu/

http://bhpr.hrsa.gov/grants/publichealth/trainingcenters/index.html

http://www.nwcphp.org/training

http://www.drc-group.com/library/exercise/osc/OSC-DHS-FactSheet.pdf

http://training.fema.gov/

http://www.fema.gov/prepared/train.shtm

http://www.nnepi.org/

http://www.apha.org

http://www.phnurse.org/

http://www.aspph.org/

http://www.naccho.org

http://www.phf.org

http://www.redcross.org

http://www.tzuchi.org/

https://www.citizencorps.gov/cert/

http://ready.gov/citizen-corps

http://www.phe.gov/preparedness/%0aresponders/ndms/teams/Pages.dmat.aspx

http://www.mrc.hhs.gov

http://www.phe.gov/preparedness/%0aresponders/ndms/teams/Pages.dmat.aspx

http://www.salvationarmyusa.org

243CHAPTER 14 Disaster Management

to leave their homes because they are afraid their possessions

will be lost or destroyed by the disaster or from looting after the

disaster. Law enforcement personnel or others in authority may

have to speak directly to these reluctant residents to convince

them to leave their homes and go to safer quarters. Also, some

people mistakenly believe that experience with a particular type

of disaster is enough preparation for the next one. People must

be convinced that predisaster warnings are oficial, serious, and

personally important before they are motivated to take action.

FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES

Targeted Competency: Safety—Minimize risk for harm to clients and providers

through both system effectiveness and individual performance. Selected knowl-

edge, skills, and attitudes are cited here to develop a disaster safety plan:

• Knowledge: Examine human factors and other basic safety design principles,

as well as commonly used unsafe practices (such as workarounds and dan-

gerous abbreviations). Speciic steps might be:

1. Learn how you can get information during the disaster or emergency.

• Determine what types of disasters are most likely to happen.

• Learn about warning signals in your community.

• Ask about postdisaster pet care (shelters usually will not accept pets).

• Review the disaster plans at your workplace, school, and other places

where your family spends time.

• Determine how to help older adult or disabled family members or neighbors.

• WHAT should you do?

• Skills: Demonstrate effective use of strategies to reduce risk for harm to self

or others.

1. Create a disaster plan:

• Talk with your family and create two places to meet, including outside

your home and outside your neighborhood. Give each member of the

family a copy of the plan.

• Discuss the types of disasters that are most likely to happen, and

review what to do in each case and make a plan.

• Choose an out-of-state friend to be your family contact; this person will

verify the location of each family member. After a disaster, it may be

easier to call long distance than to make local calls.

• Review evacuation plans, including care of pets. Have alternative

routes for evacuation.

1. Complete this checklist:

• Post emergency phone numbers next to telephones.

• Teach everyone how and when to call 9-1-1.

• Determine when and how to turn off water, gas, and electricity at the

main switches.

• Check adequacy of insurance coverage for yourself and your home.

• Locate and review the use of ire extinguishers.

• Install and maintain smoke detectors.

• Conduct a home hazard hunt, and ix potential hazards.

• Stock emergency supplies, and assemble a disaster supplies kit.

• Acquire irst aid and cardiopulmonary resuscitation (CPR) certiication.

• Locate all escape routes from your home. Find two ways out of each

room.

• Find safe spots in your home for each type of disaster.

2. Practice and maintain your plan:

• Review the plan every 6 months.

• Conduct ire and emergency evacuation drills.

• Replace stored water every 3 months and stored food every 6 months.

• Test and recharge ire extinguishers according to manufacturer’s

instructions.

• Test your smoke detectors monthly, and change the batteries at least

once a year.

3. What more should you do?

• Attitudes: Appreciate the cognitive and physical limits of human

performance.

• Monitor your personal reactions to the disaster, and seek assistance if

the stress of the losses and the potential work to reestablish a new

normal seem overwhelming. Monitor also the reactions of your col-

leagues and the clients you serve, and provide or refer to others anyone

who needs stress-management intervention.

Safety Question: To prepare more effectively for the event of a future disaster,

list the steps that you would take to ensure the safety of your family, including

any pets you may have.

The National Health Security Strategy

The purpose of the National Health Security Strategy (NHSS),

which was developed in 2009 with a goal to do a revision every

4 years, is to reconnect public health and medical preparedness,

response, and recovery strategies to ensure the nation’s resil-

ience in the face of health threats or incidents with potentially

negative health consequences. Outcomes of the NHSS include

community strengthening, integration of response and recov-

ery systems, and seamless coordination among all levels of the

public health and medical system (USDHHS, 2017). Commu-

nity resilience has become a central theme in disaster planning.

The NHSS is built on the premise that healthy individuals,

families, and communities with access to health care and

knowledge become some of our nation’s strongest assets in

disaster incidents. Healthier communities have better bounce-

back ability.

Disaster and mass casualty exercises. Although practice

will not ensure a perfect response to disaster, disaster and mass

casualty drills and exercises are extremely valuable components

of preparedness. After the exercise, the lessons learned through

after-action reports are used to update disaster plans and sub-

sequent operations. Exercise categories include discussion-

based simulations, or “tabletops,” and operations-based events,

such as drills and functional and full-scale exercises (FEMA,

2016). Operations-based events involve escalating scope and

scale testing of the disaster preparedness and response network

using a speciic plan.

National Level Exercise 2009 (NLE09) was the irst major

exercise conducted by the U.S. government that focused exclu-

sively on terrorism prevention and protection, as opposed to

incident response and recovery. NLE09 was designated a Tier I

National Level Exercise. These exercises started out as the Top

Oficials exercise series [TOPOFF]) but now incorporate the

whole community, with an understanding that the practice

must reach all levels of the public, private, and government sec-

tors to be effective.

The National Exercise Program (NEP) serves to test and vali-

date core capabilities. Participation in exercises, simulations, or

other activities, including real world incidents, helps organizations

244 PART 4 Issues and Approaches in Health Care Populations

validate their capabilities and identify shortfalls, pulling in their

partners and stakeholders including citizen participation (FEMA,

2014). An annual Capstone Exercise, formerly titled the National

Level Exercise (NLE), is conducted every 2 years as the inal com-

ponent of each NEP progressive exercise cycle. The Capstone

Exercise for 2014 examined the nation’s collective ability to coor-

dinate and conduct risk assessments and implement National

Frameworks and associated plans to deliver core capabilities

(FEMA, 2014).

The Homeland Security Exercise and Evaluation Program

(HSEEP) was developed to help states and local jurisdictions

improve overall preparedness with all natural and human-made

disasters. It provides a standardized methodology and terminol-

ogy for exercise design, development, conduct, evaluation, and

improvement planning and assists communities to create exer-

cises that will make a positive difference before a real incident

(FEMA, 2016). HSEEP is the national standard for all exercises.

Whether conducted as drills, tabletops, functional scenarios,

or full-scale scenarios, and whether the scope is local or na-

tional, nurses and other health care providers must be included

as a part of the exercise’s planning, response, and after-action

activities. Nurses, as client and community advocates, are es-

sential players in the exercise and preparedness arena.

disaster stretches local resources, the county or city emergency

management agency will coordinate activities through an emer-

gency operations center. Generally, local responders within a

county sign a regional or statewide mutual aid agreement to

allow the sharing of needed personnel, equipment, services, and

supplies.

The initial scope of disaster assessment is usually measured in

dollars, health risk and injury, and/or lives lost. The more de-

struction and lives at risk, the greater is the degree of attention

and resources provided at the local, regional, and state levels.

When state resources and capabilities are overwhelmed, gover-

nors may request federal assistance under a presidential disaster

or emergency declaration. If the event is considered an incident

of national signiicance (a potential or high-impact disaster),

appropriate response personnel and resources are provided.

National Response Framework

Once a federal emergency has been declared, the National

Response Framework (NRF) may take effect, depending on the

speciic needs arising from the disaster. The NRF was released

by the USDHS in January 2008 as a successor to the National

Response Plan. The NRF focuses on response and short-term

recovery and is seemingly less cumbersome to use than the

NRP. This framework “helps deine the roles, responsibilities,

and relationships critical to effective emergency planning,

preparedness, and response to any emergency or disaster”

(DHS, 2013). The online component, the NRF Resource Center

(http://www.fema.gov/emergency/nrf/), contains supplemental

materials, including annexes, partner guides, and other sup-

porting documents and learning resources. This information is

dynamic and is designed to change with lessons learned from

real-world events. The framework involves the entire commu-

nity and is scalable, lexible, and adaptable to the given situa-

tion. It is a living document that is revised every 18 months in

response to evolving conditions and real-world applications

(DHS, 2013).

This framework should be used by government executives,

private sector business, nongovernmental leaders, and emer-

gency management practitioners. It is built on these ive

principles: engaged partnerships; tiered response; scalable,

lexible, and adaptable operational capabilities; unity of effort

through uniied command; and readiness to act.

The NRF includes Emergency Support Functions (ESFs).

The 15 ESFs provide a mechanism to bundle federal resources

and capabilities to support the nation. Functions include trans-

portation, communications, public works and engineering,

ireighting, information and planning, mass care, emergency

assistance, temporary housing and human services, logistics,

public health and medical services, search and rescue, oil and

hazardous materials, agriculture and natural resources, energy,

public safety and security, long-term community recovery, and

external affairs/standard operating procedures (FEMA, 2014b)

and energy. Each ESF includes a coordinator function, and both

primary and support agencies that work together to coordinate

and deliver the full breadth of federal capabilities. The ESFs

provide the structure for coordinating federal interagency sup-

port for a federal response to an incident.

The Saber city disaster preparedness (DP) team wanted to coordinate a mock

terrorist attack to study the effectiveness of its disaster management plan.

The goal of the mock attack was to promote conidence, develop skills, coor-

dinate activities, and coordinate participants of the disaster management

team. The DP team planned a commonly seen terrorist attack: a bus carrying

important politicians would explode outside the federal courthouse in down-

town Saber. All participating organizations (including the health department,

hospital, police department, and ire department) were notiied of the date

the mock attack would be held. Volunteers were found to play the victims on

the scene.

After months of planning, the day of the mock attack came. The members of

the DP team watched how well the organizations worked together during the

events of the mock attack. At noon, reports of an exploded bus in front of the

courthouse came across police scanners: “Several people are dead and many

more injured.” Emergency medical response teams and hazardous material

response crews were called to the scene to care for the injured and attend to

the potential hazardous exposure. Police oficers quickly cleared the area of

people and established a barrier around the scene. Fireighters put out the ire

on the burning bus.

From the mock attack, the DP team learned that the city of Saber was pre-

pared for a terrorist attack. Communication among organizations lowed

smoothly, and the disaster management team was skillful in controlling the

situation. Participants in the mock attack stated they were happy to have the

practice and felt more conident in their ability to provide care in the case of a

major disaster.

CASE STUDY

Use of the Mock Attack Strategy to Prepare

for Potential Disasters

Response The irst level of disaster response occurs at the local level with

the mobilization of responders such as the ire department,

law enforcement, public health, and emergency services. If the

http://www.fema.gov/emergency/nrf/

245CHAPTER 14 Disaster Management

ESF 8 (described previously) is Public Health and Medical

Services. It provides guidance for medical and mental health

personnel, medical equipment and supplies, assessment of the

status of the public health infrastructure, and monitoring for

potential disease outbreaks. The ESF 8 primary agency is the

USDHHS; supporting agencies include the USDHS, the ARC,

the Department of Defense, and the Department of Veterans

Affairs.

The NDMS is part of ESF 8 and includes the DMATs. These

teams of specially trained civilian physicians, nurses, and other

health care personnel can be sent to a disaster site within hours

of activation (FEMA, 2017).

National Incident Management System

The National Incident Management System (NIMS) is the na-

tional platform for disaster response, and it includes universal

protocols and language. The NIMS identiies concepts and prin-

ciples that answer how to manage emergencies from prepared-

ness to recovery regardless of their cause, size, location, or com-

plexity. “NIMS provides a consistent, nationwide approach and

vocabulary for multiple agencies or jurisdictions to work to-

gether to build, sustain and deliver the core capabilities needed

to achieve a secure and resilient nation” (FEMA, 2017, p. 1).

No matter what type of nursing practice or which agency a

nurse chooses, he or she will come into direct contact with NIMS,

which includes the Incident Command System (ICS). The NIMS

includes varying levels of education and training, with many

organizations requiring a base level of familiarization to comply

with federal funding requirements. A well-developed training

program promotes nationwide NIMS implementation. The

training program also grows the number of adequately trained

and qualiied emergency management/response personnel.

Response to Bioterrorism

Biological or chemical terrorist attacks require a very different

response. An unannounced dissemination of a biological agent

may easily go unnoticed, and the victims may have left the area of

exposure long before the act of terrorism is recognized. The irst

signs that a biological agent has been released may not be appar-

ent for days or weeks, when the victims become ill and seek a

health evaluation. In this case the health care professionals, in-

cluding nurses, are considered the “irst on the scene.” The ive

components of a comprehensive public health response to out-

breaks of illness are (1) detecting the outbreak; (2) determining

the cause; (3) identifying factors that place people at risk; (4) im-

plementing measures to control the outbreak; and (5) informing

the medical and public communities about treatments, health

consequences, and preventive measures (Rotz et al, 2000).

People who experience or witness a terrorist attack may expe-

rience a stress response as well as one or more of the following

symptoms (International Council of Nurses, 2009): (1) repeated

thoughts about the attack; (2) immense fear of everything,

which may prevent them from even leaving their homes;

(3) survivor guilt or questioning why they lived and others did

not; (4) a sense of great loss; and (5) hesitation to express feelings.

Although many of the nursing actions for dealing with

terrorism are similar to those in any other disaster, the follow-

ing list summarizes key actions. The International Council of

Nurses Fact Sheet on terrorism and bioterrorism provides

useful details on each of the following actions:

• Help people cope with the aftermath of terrorism

• Allay public concerns and fears of bioterrorism

• Identify the feelings that you and others may be experiencing

• Assist victims to think positively and to move to the future

• Prepare nursing personnel to be effective in a crisis or emer-

gency situation

Identifying the chemical or biological agent is the irst priority.

Rapid identiication is vital to protect health care workers and any

others affected. Results of a biological release are hard to recognize

because many biological agent symptoms mimic inluenza or

other viral syndromes. Pathogens such as bacteria, viruses, and

toxins can be used to create biological weapons. Although an

aerosol release may be a likely vehicle for dissemination, certain

biological agents could also be released through the water and

food supply. Only about a dozen pathogens pose a major threat,

even though there are thousands of pathogens, some highly con-

tagious. Quarantine of those exposed to contagious agents may be

considered in some instances. A few vaccines have been developed

to combat bacterial pathogens. The Centers for Disease Control

and Prevention (CDC) provides an excellent source of biological

agent information to include the latest agent fact sheets for health

practitioners (CDC, 2014a.). Important information provided

includes the methods of transmission and communicability

period. Through the Pandemic and All-Hazards Preparedness

Reauthorization Act (PAHPRA), several biodefense programs ex-

ist to help public health professionals mount a proactive response

to these events (USHHS, 2017):

• BioWatch is an early warning system for biothreats that uses

an environmental sensor system to test the air for biological

agents in several major metropolitan areas.

CHECK YOUR PRACTICE?

Nurses working as members of a disaster assessment team need to provide

accurate information to others in the National Incident Management System

(NIMS) environment. A part of that communication involves the rapid and on-

going needs assessment. Accurate information helps in providing the most

appropriate and needed resources. In a time of crisis or great uncertainty, there

is a crucial need for accurate and timely information. Health care personnel are

the best sources of essential health information, especially technical informa-

tion. The NIMS approach uses public affairs spokespersons for formal com-

munication. The Public Information Oficer (PIO) is a person with the authority

and responsibility to communicate information to the public. Nurses are con-

sidered highly trustworthy, and they are often asked by members of the media

for an interview. If the nurse is asked for an interview, what is the best irst

approach?

1. Set up a time for the interview later in the day after you prepare your

notes.

2. Refer the media to the PIO representing the agency.

3. Politely say that you are extremely busy dealing with victims of the

disaster and you do not have time for an interview.

Furthermore, terrorists are capable of spreading fear by sending explosives

or chemical and biological agents through the mail. The nurse should also

observe for and report any psychological or sociological health hazards such as

overcrowding, extreme disrespect, and anger in vulnerable populations that

could lead to unrest and violence.

246 PART 4 Issues and Approaches in Health Care Populations

• BioSense is a data-sharing program to facilitate surveillance

of unusual patterns or clusters of diseases in the United

States. It shares data with local and state health departments

and is a part of the BioWatch system.

• Project BioShield is a program to develop and produce new

drugs and vaccines as countermeasures against potential

bioweapons and deadly pathogens.

• Cities Readiness Initiative is a program to aid cities in in-

creasing their capacity to deliver medicines and medical

supplies during a large-scale public health emergency such

as a bioterrorism attack or a nuclear accident.

• Strategic National Stockpile (SNS) is a CDC-managed pro-

gram with the capacity to provide large quantities of medi-

cine and medical supplies to protect the American public in

a public health emergency to include bioterrorism. The SNS

is deployed through a combination of state level request and

the public health system.

Some of the most common lessons from exercises as well as

live incidents involve communication. In an effort to keep the pub-

lic health community informed, the CDC developed the Public

Health Information Network (PHIN). The PHIN provides for the

electronic exchange of information among governmental agencies.

It focuses on six components that help ensure information access

and sharing: early event detection, outbreak management, connect-

ing laboratory systems, countermeasure and response administra-

tion, partner communications and alerting, and cross-functional

components, and is critical to information exchange (CDC, 2014b).

How Disasters Affect Communities

The pain and suffering of people who lose their possessions, are

injured, or lose loved ones are immeasurable. When disaster

hits, people in a community will be affected physically and

emotionally, depending on the type, cause, and location of the

disaster; its magnitude and extent of damage; the duration; and

the amount of prewarning provided.

The irst goal of any disaster response is to reestablish sanitary

barriers as quickly as possible (Veenema, 2012). Water, food, waste

removal, vector control, shelter, and safety are basic needs. Difi-

cult weather conditions such as extreme heat or cold can hamper

efforts, especially if electricity is affected. Continuous monitoring

of the environment proactively addresses potential hazards. Dis-

ease prevention is an ongoing goal, especially if there is an inter-

ruption in the public health infrastructure. Infectious disease

outbreaks occur in the recovery phase of disasters, and occasion-

ally disaster workers introduce new organisms into the area.

The psychological effects of September 11, 2001, were dif-

ferent from those of more contained, single-event disasters.

The attack was totally unexpected and of great magnitude,

with much uncertainty and fear about what might happen

next. Not knowing when or if a subsequent attack will occur

may prevent individuals from moving beyond their fear and

anger (ARC, 2002).

Also, Hurricane Katrina, which started as a natural disaster,

had its consequences compounded by a human-made disaster

caused by looding from levee failure. Later followed by

Hurricane Rita, Hurricane Katrina affected the Gulf Coast and

the nation in ways that will be felt for generations to come. It is

the costliest U.S. disaster ever, with economic estimates of more

than $125 billion (National Oceanic and Atmospheric Adminis-

tration, 2017). The hurricane, loods, and more than 1800 con-

irmed deaths created traumatic stress that rose to unbearable

levels in New Orleans, resulting in a tense and sometimes violent

aftermath (Reagan, 2005). New Orleans was typically described

as a war zone in the weeks after the disaster, as was the Gulfport-

Biloxi coastline in Mississippi, where 90% of the buildings were

demolished. Hundreds of thousands of people lost access to their

homes and their jobs as a result of Hurricane Katrina, and the

rebuilding has been slow and costly.

Stress reactions in individuals. A traumatic event can cause

moderate to severe stress reactions. Individuals react to the

same disaster in different ways depending on their age, cultural

background, health status, social support structure, and general

ability to adapt to crisis. Symptoms that may require assistance

are listed in Box 14.5.

*The tips in Box 14.5 are not an entire list. For further details, see Substance Abuse and Mental Health Services Administration. Tips for survivors

of a disaster or other traumatic event: Managing stress, 2013. Retrieved from http://www.disasterdistress.samhsa.gov.

BOX 14.5 Tips for Survivors of a Disaster or Other Traumatic Event: Managing Stress*

You may feel emotionally:

• Anxious, fearful, or sad

• Extreme sense of urgency or panic

• Angry, especially if the event involved violence

• Guilty, even when you had no control over the traumatic event

• Heroic, like you can do anything

• Like you have too much energy or no energy

• Disconnected, not caring about anything or anyone

• Numb, unable to feel either joy or sadness

You may have physical reactions such as:

• Stomachaches and diarrhea

• Headaches or other physical pains for no obvious reason

• Eating too much or too little

• Sweating or having chills

• Having tremors or muscle twitches\being jumpy or easily startled

Behavior reactions may include:

• Trouble remembering things, thinking, making decisions, or concentrating

• Feeling confused or numb

• Worrying excessively

• Trouble talking about what happened and listening to others

• Trouble sleeping

• Increase or decrease in energy or activity levels

• Feeling sad or crying often

• Using alcohol, tobacco, illegal drugs, or prescription medicines to reduce distress

• Having outbursts of anger, or feeling irritated and blaming others or to forget

• Having dificulty helping others and accepting help or making decisions when

around people

• Being reluctant to abandon property

Children

• Regressive behaviors (e.g., bedwetting, thumb sucking, crying, clinging to parents)

• Fantasies that disaster never occurred

• Nightmares

• School-related problems, including inability to concentrate and refusal to go

back to school

http://www.disasterdistress.samhsa.gov

247CHAPTER 14 Disaster Management

People who are affected by a disaster often have an exacerba-

tion of an existing chronic disease. For example, the emotional

stress of the disaster may make it dificult for people with dia-

betes to control their blood glucose levels. Grief results in

harmful effects on the immune system. It reduces the function

of cells that protect against viral infections and tumors. Hor-

mones produced by the body’s light-or-ight mechanism also

play a role in mediating the effects of grief.

Older adults’ reactions to disaster depend a great deal on

their physical health, strength, mobility, independence, and

income. They can react deeply to the loss of personal posses-

sions because of the sentimental value attached to the items

and their irreplaceable value. Their need for relocation de-

pends on the extent of damage to their home or their compro-

mised health. They may try to conceal the seriousness of their

health conditions or losses if they fear loss of independence.

Box 14.6 lists other populations at higher risk for serious dis-

ruption after a disaster. Many of them are the same popula-

tions who are also at risk for adverse health effects before a

disaster.

The effect of disasters on young children can be especially

disruptive (National Institute of Mental Health [NIMH], 2015)

(Fig. 14.4). Regressive behaviors such as thumb sucking, bed-

wetting, crying, and clinging to parents can occur. Children

tend to reexperience images of the traumatic event or have re-

curring thoughts or sensations, or they may intentionally avoid

reminders, thoughts, and feelings related to disaster events.

Children may have arousal or heightened sensitivity to sights,

sounds, or smells and may experience exaggerated responses or

dificulty with usual activities. Children not immediately af-

fected by a disaster also can experience effects from it. The

constant bombardment of disaster stories on television can

cause fear in children. They may believe that the event could

happen to them or their family, believe someone will be injured

or killed, or think they will be left alone. It is best to turn off the

television news and engage in activities with family, friends, and

neighbors. The parents’ reaction to a disaster greatly inluences

children (NIMH, 2015).

One special population that may be overlooked is children

in childcare facilities. Children are cared for in many different

locations, ranging from freestanding buildings to provider

homes. They tend to have little, if any, security against a disaster,

and people come in and go out of the facility all day. Also, if a

disaster occurs, a plan must be in place for how the children can

be reunited with their parents. Because of their small size, they

may have to be helped to leave the facility. In addition, they are

more vulnerable to chemical and biological agents because of

their immature physiological and psychological development,

and they have less luid reserve than adults so are more suscep-

tible to dehydration. With all populations, review individual

strategies, including available speciic resources, in the event of

an emergency. The following actions are recommended regard-

ing childcare emergency supplies (Gaines and Leary, 2004):

• Put together a family readiness kit and disaster supply kit

(see the American Academy of Pediatrics at http://www.

aap.org).

• Gather the supplies recommended by the ARC (http://www.

redcross.org).

• Store things such as irst-aid supplies, emergency blankets,

medications, ice packs, and nonperishable food in backpacks

or rolling containers.

• Put copies of each child’s medical information, parent con-

tact information, and local emergency telephone numbers in

a portable container.

• Take with you the attendance list of children and some

comfort items such as games, toys, blankets, crayons, and

paper.

Public health nurses should help those in the affected com-

munity talk about their feelings, including anger, sorrow, guilt,

and perceived blame for the disaster or the outcomes of the

disaster. Community members should be encouraged to engage

• Disabled

• Older adults

• Visually or hearing impaired

• Health care providers and irst responders

• Women

• Pregnancy

• Children

• Diabetes

• American Indians

• Latino Communities

BOX 14.6 Populations at Greatest Risk for Disruption After Disaster

From National Institutes of Health, National Library of Medicine:

Special populations: emergency and disaster preparedness,

Washington, DC, 2014, NIH. Retrieved January 2016 from http://sis.

nlm.nih.gov/outreach/specialpopulationsanddisasters.html.

FIG. 14.4 The effects of disaster on children can be especially

disruptive. In 2013, 1 week after Typhoon Haiyan made landfall,

residents of Tanauan, the Philippines, struggle to cope amid

the devastation. Every house in the city of 50,000 was badly

damaged or destroyed. The effects of a disaster on young

children can be especially disruptive. (Courtesy of the American

Red Cross Photo Library. Photo by Patrick Fuller/International

Federation of Red Cross and Red Crescent Societies, Geneva,

Switzerland. Retrieved January 2015 from: http://media.redcross.

org/sites/.)

http://media.redcross.org/sites/

http://www.aap.org

http://www.redcross.org

http://sis.nlm.nih.gov/outreach/specialpopulationsanddisasters.html

248 PART 4 Issues and Approaches in Health Care Populations

in healthy eating, exercise, rest, daily routine maintenance, lim-

ited demanding responsibilities, and time with family and

friends.

Stress reactions in the community. Communities relect the

individuals and families living in them, both during and after a

disaster incident. Four community phases are commonly recog-

nized: (1) heroic, (2) honeymoon, (3) disillusionment, and (4)

reconstruction. The irst two phases—the heroic and honey-

moon phases—are most often associated with response efforts.

The latter two phases—disillusionment and reconstruction—

are most often linked with recovery. For purposes of continuity,

all phases will be discussed in this response section.

During the heroic phase, there is overwhelming need for

people to do whatever they can to help others survive the disas-

ter. First responders, who include health and medical personnel,

will work hours on end with no thought of their own personal

or health needs. They may ight needed sleep and refuse rest

breaks in their drive to save others. Moreover, imported re-

sponders may be unfamiliar with the terrain and inherent dan-

gers. Those with oversight responsibilities may need to order

helpers to take necessary breaks and attend to their health

needs. Exhausted, overworked responders present a danger to

themselves and the community served.

In the honeymoon phase, survivors may be rejoicing that

their lives and the lives of loved ones have been spared. Survi-

vors will gather to share experiences and stories. The repeated

telling to others creates bonds among the survivors. A sense of

thankfulness over having survived the disaster is inherent in

their stories.

The disillusionment phase occurs after time elapses and

people begin to notice that additional help and reinforcement

may not be immediately forthcoming. A sense of despair re-

sults, and exhaustion starts to take its toll on volunteers, rescu-

ers, and medical personnel. The community begins to realize

that a return to the previous normal is unlikely and that they

must make major changes and adjustments. Nurses need to

consider the psychosocial impact and the consequent emo-

tional, cognitive, and spiritual implications. Public health

nurses should identify groups and population segments par-

ticularly at risk for burnout and exhaustion, to include re-

sponders and volunteers involved in rescue efforts. They may

need breaks and reminders for nourishment. In addition, those

in shock and those consumed by grief related to loss of loved

ones will need compassionate care, with possible referrals to

mental health counseling resources.

The last phase—reconstruction—is the longest. Homes,

schools, churches, and other community elements need to

be rebuilt and reestablished. The goal is to return to a new

state of normalcy. Because the scope of human need may

still be extensive, the nurse will continue to function as

a member of the interprofessional team to provide and en-

sure provision of the best possible coordinated care to the

population.

Role of the Nurse in Disaster Response

The nurse’s role during a disaster depends largely on the nurse’s

experience, professional role in a community disaster plan,

specialty training, and special interest. Flexibility is essential

because the only certainty is that there will be continuing

changes (Stanley et al, 2008). Nurses serve in many roles in the

community. They advocate for a safe environment. They also know

that disasters are both natural and human-made, so they assess

for and report environmental health hazards. For example,

the nurse should be aware of and report unsafe equipment,

faulty structures, and the beginning of disease epidemics such

as measles or inluenza. The public health nurse brings leader-

ship, policy, planning, and practice expertise to disaster pre-

paredness and response (Association of Public Health Nurses

[APHN], 2014).

Assessment is a major nursing role during a disaster. In com-

pleting an assessment, use the skills of interview, observation,

individual physical examinations, health and illness screening,

surveys (i.e., sample and special health), and records (i.e., cen-

sus, school, vital statistics, disease reporting). The traditional

model of community assessment presents the foundation for

the rapid community assessment process. The acute needs of

populations in disaster turn the community assessment into

rapid appraisal of a sector or region’s population, social sys-

tems, and geophysical features. Elements of a rapid needs

assessment include determining the magnitude of the incident,

deining the speciic health needs of the affected population,

establishing priorities and objectives for action, identifying ex-

isting and potential public health problems, evaluating the

capacity of the local response, including resources and logistics,

and determining the external resource needs for priority

actions (Stanley et al, 2008). Also, assessments in sudden-

impact disasters, such as tornadoes and earthquakes, are more

concerned with ongoing hazards, injuries and deaths, shelter

requirements, and clean water. Triage should begin immedi-

ately and is the process of separating casualties and allocating

treatment on the basis of the individuals’ potentials for survival.

Highest priority is given to individuals with life-threatening

injuries, but also those who have a high probability of survival

once they are stabilized (Veenema, 2012). Second priority is

given to victims with injuries that have systemic complications

that are not yet life threatening and could wait 45 to 60 minutes

for treatment. Last priority is given to those victims with local

injuries without immediate complications and who can wait

several hours for medical attention.

Assessments in gradual-onset disasters, such as famines, are

most concerned with mortality rates, nutritional status, immu-

nization status, and environmental health.

Nurses also should understand what the available community

resources will be after a disaster strikes, and, most important,

how the community will work together. A community-wide

disaster plan serves as a roadmap for what “should” occur

before, during, and after the response and the role of each par-

ticipant in the plan. As shown in Box 14.4, there are a variety of

community organizations in which nurses can become involved

to assist in a disaster.

There may be times when the nurse is the irst to arrive on

the scene of a disaster. If so, the more usual skills of community

assessment, case inding and referring, prevention, health edu-

cation, surveillance, and working with aggregates will be put

249CHAPTER 14 Disaster Management

aside temporarily so that the nurse can deal with life-threatening

problems. Once rescue workers arrive on the scene, plans for

triage should begin immediately.

Nurses can help initiate or update the agency’s disaster plan,

provide educational programs and materials regarding disasters

speciic to the area, and organize disaster drills. Nurses also can

provide an updated record of vulnerable populations within the

community. When calamity strikes, disaster workers must know

what kinds of populations they are attempting to assist. For

example, if a tornado strikes a retirement village, the needs are

quite different from those seen after the tornado hits a church

illed with families or a center for the physically challenged. In

addition to knowing where special populations exist, the nurse

can educate groups about what effect the disaster might have on

them. Nurses should review individual strategies, including

available speciic resources, in the event of an emergency.

Lack of or inaccurate information regarding the scope of the

disaster and its initial effects contributes to the misuse of re-

sources. Often, too many volunteers who lack oficial sponsor-

ship convene at the site of disaster and are disappointed when

their help cannot be used. Similarly, well-meaning people may

send clothes and food to disaster sites that lack storage and

distribution abilities. Contributions that add to the stress of

coping with the disaster can be a burden. Local and regional

emergency management and public health resources need to be

readjusted as assessment reports continue to come in. Estab-

lishing a priority of needs that beneit the largest aggregate of

affected individuals with the most correctable problems is con-

sistent with the basic tenets of triage.

Ongoing assessments or surveillance reports are just as im-

portant as initial assessments. Surveillance reports indicate the

continuing status of the affected population and the effective-

ness of ongoing relief efforts. They continue to inform relief

managers of needed resources. Nurses involved in ongoing sur-

veillance can use the methods listed in the “How To” box to

gather information. Surveillance continues into the recovery

phase of a disaster.

type of facility is most appropriate. Although initially physical

health needs are the priority, especially among older adults and

the chronically ill, many of the predominant problems in shel-

ters revolve around stress. The shock of the disaster itself, the

loss of personal possessions, the fear of the unknown, living in

proximity to total strangers, and even boredom can cause stress.

Nurses working in shelters, in addition to providing assess-

ments, also provide referrals and meet health care needs such as

helping clients get prescription glasses, medications, irst aid,

and appropriate diet adjustments; keeping client records; en-

suring emergency communications; and providing a safe envi-

ronment (ARC, 2013). The ARC provides training for shelter

support and use of appropriate protocols and partners with

other agencies such as the MRC and local public health agencies

to ensure adequate health care to those in shelters. Nurses can

use common-sense approaches to help shelter residents. These

measures include listening to victims tell and retell their disas-

ter story and current situation; encouraging residents to share

their feelings with one another if it seems appropriate to do so;

helping residents make decisions; delegating tasks (e.g., reading,

crafts, playing games with children) to teenagers and others to

help combat boredom; providing the basic necessities (i.e.,

food, clothing, rest); attempting to recover or get needed items

(e.g., prescription glasses, medication); providing basic com-

passion and dignity (e.g., privacy when appropriate and if pos-

sible); and referring to a mental health counselor or other

source of help.

EVIDENCE-BASED PRACTICE

Veenema and Thornton (2015) reviewed the disasters at Chernobyl, Three

Mile Island, and the Fukushima Daiichi nuclear power plant to develop the

information that would be useful to inform nurses in preparedness efforts. In

reviewing these historic power plant disasters, they found that nurses played

a signiicant role in the response and recovery phases of the disasters. Nurses

screened individuals for exposure to radiation, decontaminated victims, pro-

vided clinical care to those experiencing radiation syndrome symptoms, and

provided mental health counseling and emotional support to both individuals

and communities. Their review reinforced the belief that nurses can only pro-

vide quality care to others when they are safe. Some of the speciic care that

nurses and other health care personnel provide include triage, screening, treat-

ment including decontamination, transporting, and referring.

Nurse Use:

It is important for nurses and public health preparedness workers to learn the

key expectations if they are to be called to provide care during a radiological

disaster. They will need to understand the basic effects of high-level radiation

exposure, how they should intervene, and, equally important, how to protect

themselves from exposure.

Veenema TG, Thornton CP: Understanding nursing’s role in health

systems response to large-scale radiological disasters. J Radiol Nurs

34:63–72, 2015.

HOW TO Gather Disaster Information

1. Interview

2. Observation

3. Individual physical examinations

4. Health and illness screening

5. Surveys (sample and special health)

6. Records (census, school, vital statistics, disease reporting)

From Landesman L: Public health management of disasters: the prac-

tice guide, Washington, DC, 2001, American Public Health Association.

Shelter Management

Shelters are generally the responsibility of the local ARC chap-

ter, although in massive disasters the military may set up “tent

cities” or bring in trailers for the masses who need temporary

shelter. Nurses, because of their comfort with delivering aggre-

gate health promotion, disease prevention, and emotional sup-

port, make ideal shelter managers and team members. Each

person who comes to the shelter is assessed to determine what

Nurses need to be aware of the surrounding medical facili-

ties and services provided in their area, including special needs

shelters. Individuals who are medically dependent and not

acutely ill but have varied physical, cognitive, and psychological

conditions should be directed to a special needs shelter. The

federal government provides assistance to special needs shelters

250 PART 4 Issues and Approaches in Health Care Populations

through one of the emergency support functions (ESF 8) of the

National Response Plan, which provides assessment of public

health and medical needs, health surveillance, supplies, and

medical care personnel, such as teams from the National Disas-

ter Medical System (DHS, 2015).

Special needs shelters reduce the surge demands on hospitals

and long-term care facilities that often occur during disasters.

Although helpful in reducing surge, too many referrals can cre-

ate tension among the special needs shelters, the regular shel-

ters, and the health care facilities as roles and responsibilities

become blurred and overall resources and personnel are lim-

ited. Careful preplanning for a community’s special needs popu-

lations is essential.

International Relief Efforts

Disasters occur throughout the world, and people suffer from

natural disasters and human-made disasters. Civil strife leads

to war, famine, and communicable disease outbreaks. Some-

times disaster or relief workers are sent to these international

disasters at the request of the affected country’s government.

At other times, workers are not welcomed but instead may go

with the support of the United Nations. When workers are not

welcomed, their lives may be in danger, even though they go as

peacekeeping agents of the Federation of the Red Cross and

Red Crescent societies and the International Committee of the

Red Cross or as health representatives from the World Health

Organization. International disaster or relief workers generally

have intensive training and preparation before embarking on a

mission.

Psychological Stress of Disaster Workers

Disaster relief work can be rewarding because it provides an

opportunity to have a profound and positive impact on the lives

of those who may be experiencing their greatest time of need.

However, the work is also challenging and stressful. During an

assignment, responders may be exposed to chaotic environ-

ments, long hours, rapidly changing information and directives,

long wait times before getting to work, noisy environments, and

living quarters that are less than ideal. According to the Na-

tional Institute of Occupational Health and Safety (NIOSH,

2013), responders may not recognize the need for self-care, and

to monitor their own emotional and physical health. As recov-

ery efforts span time frames of weeks to months, there is in-

creasing risk for adverse effects to responders.

No one who experiences a disaster either personally or in a

professional capacity is untouched by it. Nurses who work with

survivors of disasters may be at risk for stress reactions. Self-

care is as important as the care that is provided to community

members. Symptoms that may signal a need for stress manage-

ment assistance include: being reluctant or refusing to leave the

scene until the work is inished; denying needed rest and recov-

ery time; feeling overriding stress and fatigue; engaging in

unnecessary risk-taking activities; having dificulty communi-

cating thoughts, remembering instructions, making decisions,

or concentrating; engaging in unnecessary arguments; having a

limited attention span; and refusing to follow orders (ARC,

2013). Physical symptoms such as tremors, headaches, nausea,

and colds or lulike symptoms can also occur. Suppressing feel-

ings of guilt, powerlessness, anger, and other signs of stress will

eventually lead to symptoms such as irritability, fatigue, head-

aches, and distortions of bodily functions. It is normal to expe-

rience stress, but it must be dealt with. The worst thing anyone

can do is to deny that it exists.

The nurse should understand that everyone reacts differ-

ently after a disaster assignment. Most reactions are consid-

ered normal and are temporary, resolving in days to a few

weeks. For some workers, disasters bring forth strong thoughts

and emotions, both positive and negative. Other workers may

experience mild reactions or hardly any reaction at all. There

are some common strategies that will help individuals return-

ing from the incident: rest and recovery time, focusing on

accomplishments, using calming strategies such as relaxation

techniques or working on hobbies, and concentrating on self-

care to include healthy food and drink, exercise, and sleep,

take time to debrief (ARC, 2013). Delayed stress reactions, or

those that occur once the disaster is over, include exhaustion

and an inability to adjust to the slower pace of work or home

(Bryce, 2001).

Workers may be disappointed if family members and friends

do not seem as interested in what they have been through and

if coming back home, in general, does not live up to expecta-

tions. Also, they may feel frustration and conlict if their needs

seem inconsistent with those of their family and co-workers or

if they have left the disaster site thinking that so much more

could have been done (Bryce, 2001). Issues or problems that

once seemed pressing may now seem trivial. Anger may emerge

as others present problems that seem trivial in contrast to those

faced by the victims who were left behind. Disaster workers may

fantasize about returning to the disaster site if they think their

actions are appreciated more there than at home or the ofice.

Mood swings are common and serve to resolve conlicting feel-

ings. Feelings or actions that persist or that the worker perceives

are interfering with daily life should be dealt with by a trained

mental health professional.

Recovery Recovery is about returning to the new normal with the goal of

reaching a level of organization that is as near the level before

the disaster as is possible. This is often the hardest part of the

disaster. During the recovery period, all involved agencies pull

together to restore the institutions and properly rebuild. For

example, the government takes the lead in rebuilding efforts,

whereas the business community tries to provide economic

support. Many religious organizations help with rebuilding ef-

forts as well. The Internal Revenue Service educates victims as

to how to write off losses, and the Housing and Urban Develop-

ment Department provides grants for temporary housing. The

CDC provides continuing surveillance and epidemiological

services. Voluntary agencies continue to assess individual and

community needs and meet those needs as they are able. When

housing is destroyed, groups such as Habitat for Humanity play

a valuable role in the rebuilding. The best time to start thinking

about the lessons learned from a recent disaster is during the

recovery phase of the disaster cycle.

251CHAPTER 14 Disaster Management

Role of the Nurse in Disaster Recovery

The role of the nurse in the recovery phase of a disaster is as

varied as in the prevention, preparedness, and response phases,

and the three levels of prevention are used (see the Levels of

Prevention box). Flexibility is essential in the recovery opera-

tion. Community cleanup efforts can cause many physical and

psychological problems. For example, the physical stress of

moving heavy objects can cause back injury, severe fatigue, and

even death from heart attacks. Nurses also must continue to

teach proper hygiene and make sure immunization records are

current given the threat of disease.

The reality of the recovery effort is that the rapid needs as-

sessment continues into an ongoing community needs assess-

ment. To determine effective interventions to ensure the best

possible outcomes, it is essential to have ongoing accurate data

about the population. Some conditions are manifest only after

time elapses. A major advantage of the recovery community

assessment efforts is that they can be more in-depth, with

greater conidence in the results. Some examples of community

data points in the recovery phase include the following: ongo-

ing illness and injuries related to the disaster; diseases related to

disruption of environmental or health services; health facility

infrastructure in terms of adequate personnel, beds, medical

and pharmaceutical supplies; and environmental health assess-

ment to include water quantity and quality, sanitation, shelter,

solid waste disposal, and vector populations.

Other examples of community data points to watch for dur-

ing the recovery phase include ongoing illnesses and injuries

related to the disaster, disease and acute respiratory infections

related to disruption of environmental health services, health

facility infrastructure in terms of adequate personnel, beds, and

medical and pharmaceutical supplies (Landesman, 2006).

The hurricanes in the United States over the past several

years changed how the health care system prepares for, re-

sponds to, and recovers from a disaster. People have learned

how critical it is for communities to have a well-organized

plan and for key players to know their roles and be lexible and

collaborative. The value of an electronic medical record be-

came more apparent in recent years when hospitals, clinics,

and health departments lost records during a disaster and

when people were relocated for substantial periods of time

without access to their medications or their medical records

(Cary, 2008).

It is important to have a realistic perspective related to how

long recovery may take. It will take months or years to return to

a semblance of normal, and this new normal may be different

from the predisaster state. Also, postdisaster cleanup may lead

to unintentional injuries, including those resulting from falls,

contact with live wires, accidents while cutting items, heart

attacks from overexertion and stress, and auto accidents caused

by road conditions and absent trafic signals. Nurses need to

educate the community about the hazards described earlier, as

well as hazards related to carbon monoxide poisoning from

using lanterns, gas ranges, or generators or from burning

charcoal to heat an enclosed area.

Nurses play a key role in helping survivors by providing

psychological support. Acute and chronic illness may become

worse after a disaster. The psychological stress of loss, cleanup,

or moving can lead to feelings of hopelessness, depression, and

grief in the disillusionment phase. Referrals to mental health

professionals should continue throughout the recovery phase

and as long as the need exists. The role of the nurse in case

inding and referral remains critical during this phase. In the

end, it is the concept of community resilience that will lead

the community to its new normal. The public health nurse is

the community and client advocate who ensures that resilience

is supported in partnership with the population.

FUTURE OF DISASTER MANAGEMENT

In the last several years, the terrorist events of September 11,

2001, Hurricane Katrina, the H1N1 pandemic, the Haiti earth-

quake of 2010, the earthquake and tsunami in Japan, and the

civil war in Syria continued to underscore the need for nursing

involvement at every step of the disaster management cycle. To

fully participate in this mission, nurses must continue to plan

and train in an all-hazards environment, regardless of their

specialty practice. Public health nurses are especially critical

members of the multidisciplinary disaster health team given

their population-based focus and specialty knowledge in epide-

miology and community assessment. Although sophisticated

technology and surveillance will continue to advance in re-

sponse to both human-made and natural disasters, the nature

LEVELS OF PREVENTION

Related to Disaster Prevention Management

Primary Prevention

Participate in developing a disaster management plan for the community.

Secondary Prevention

Assess disaster victims and triage for care.

Tertiary Prevention

Participate in home visits to uncover dangers that may cause additional injury

to victims or cause other problems (e.g., house ires from faulty wiring).

Disruption of the public health infrastructure, including

water and food supply, the sanitation system, the vector control

program, and access to primary and mental health care, can

lead to increased disease and community dysfunction. Nurses

will engage in ongoing community assessments during the re-

covery phase. It is important to be alert for environmental

health hazards during the recovery phase of a disaster. During

home visits, nurses may uncover situations such as a faulty

housing structure or lack of water or electricity. Objects that

have been blown into the yard by a tornado or that loated in

from a lood may be dangerous and must be removed. Also, the

nurse should assess the dangers of live or dead animals and

rodents that are harmful to a person’s health. An example of

this would be inding poisonous snakes in and around homes

once the waters from a lood start to recede. Case inding and

referral are critical during the recovery phase and may continue

for a long time.

252 PART 4 Issues and Approaches in Health Care Populations

of disasters will retain the element of unpredictability. That

unpredictability and the medical and public health surge re-

quirements in disaster makes prevention and preparedness ac-

tivities on the part of individuals and communities even more

important. Disaster information changes rapidly because of the

learning that occurs during and after each incident, producing

progressive best practices. Staying current in disaster training

requires the public health nurse’s commitment in community

planning activities, exercise participation, and actual disaster

work.

APPLYING CONTENT TO PRACTICE

Throughout this chapter, how nurses work in disaster management is applied

to standards of public health nursing and the core competencies of health

professionals in disaster work. Other applicable areas include discussion

about the continuous processes of assessment, planning, implementation,

evaluation, collaboration, and cooperation. The role of the nurse in disaster

management relates to both standards of nursing and public health practice.

Speciically, the nurse must irst assess, then plan, implement, and evaluate

while simultaneously working with a variety of other concerned and involved

agencies and individuals.

C L I N I C A L A P P L I C A T I O N

R E M E M B E R T H I S !

Paula Miller, a nurse in a medium-sized public health depart-

ment in Lincoln, Nebraska, was called to serve on her irst na-

tional disaster assignment. Her disaster skills were tested when

a level 1 hurricane hit Miami and its surrounding areas.

Ms. Miller left Lincoln to help manage a shelter in an elemen-

tary school cafeteria in Homestead, Florida, near Miami.

The devastation that she saw en route to the school had a

negative effect on her. Assigned to help with client intake, she pa-

tiently listened to the disaster victims, referred many of her most

distraught clients to the mental health counselor, and set priorities

for other needs as they arose. For example, she found that many

of her clients had left their medications behind and needed ther-

apy. Other needs included diapers and formula for infants, pre-

scription eyeglasses, and clothing. By identifying their needs,

Ms. Miller helped ensure that the master “needs list” was complete.

• The number of disasters, both human-made and natural,

continues to increase, as does the number of people affected

by them.

• The cost to recover from a disaster has risen sharply because

of the amount of technology that must be restored.

• Professional preparedness involves an awareness and under-

standing of the disaster plan at work and in the community.

• Nurses are increasingly getting involved in disaster planning,

response, and recovery through their local health depart-

ment or local government.

• Disaster health and disaster mental health training from an

oficial agency such as the ARC can prepare nurses for the

many opportunities that await them in disaster prevention,

preparedness, response, and recovery.

• Being knowledgeable about community resources available

to vulnerable populations before a disaster incident ensures

a more coordinated response and recovery.

• Helping clients maintain a safe environment and advocating

for environmental safety measures in the community are key

roles for the nurse during all phases of disaster management.

• People in a community react differently to a disaster de-

pending on the type, cause, and location of the disaster; its

magnitude and extent of damage; its duration; and the

amount of warning that was provided.

As the days went on, the stress level in the shelter grew. The

crowded living conditions and lack of privacy took its toll

on the residents. Around the tenth day of her assignment,

Ms. Miller began to experience pounding headaches and had

dificulty concentrating. She thought she would be ine, but the

mental health counselor said that she was experiencing a stress

reaction.

Which of the following actions would probably be the most

useful for this nurse to take?

A. Share her feelings with the onsite mental health counselor

on a regular basis.

B. Call home to share her feelings with family members.

C. Meet the needs of her clients to the best of her ability, and

accept the fact that stress is a part of the job.

Answers can be found on the Evolve website.

• People react differently to disasters depending on factors

such as their age, cultural background, health status,

social support structure, and general adaptability to

crisis.

• The stress of nurses is compounded if they are both victims

and caregivers in a disaster.

• Disaster shelter nurses are exposed to a variety of physical

and emotional complaints, including stress. Stress may be

instigated by the shock of the disaster, the loss of personal

possessions, the fear of the unknown, living in proximity to

strangers, and boredom.

• The degree of worker stress during disasters depends on the

nature of the disaster, the worker’s role in the disaster, indi-

vidual stamina, noise level, adequacy of workspace, potential

for physical danger, stimulus overload, and, especially, being

exposed to death and trauma.

• Symptoms of worker stress during disasters include minor

tremors, nausea, decreased concentration, dificulty thinking

and remembering, irritability, fatigue, and other somatic

disorders.

• A key attribute in aiding disaster victims is lexibility.

• The stage of disaster known as recovery occurs as all in-

volved agencies pull together to restore the economic and

civic life of the community.

253CHAPTER 14 Disaster Management

W H A T W O U L D Y O U D O ?

1. If you thought a hurricane might affect your community,

what steps would you take to adequately prepare for

the possible disaster? What steps would you take to ensure

safety and preparedness for your family and for the clients

for whom you care? Whose help would you enlist?

To whom would you go for advice? Talk with two class-

mates, and compare your answers; then prepare an action

plan.

2. Assume your community has the potential to be hit by a

tornado. List the groups who would be most vulnerable.

What steps could you take in advance to reduce their vulner-

ability? What community resources are available?

3. If you and your classmates saw a tornado moving across the

street in a small town as you drove to your clinical site, what steps

would you take to determine whether people were injured? What

would you do irst? Who else would you involve? Discuss your

replies with a classmate and come up with a consolidated plan.

4. Describe the role of the nurse in the preparedness, response,

and recovery stages of disaster. Does all of this make sense

to you?

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Security Strategy of the United States of America, 2017. Retrieved

July 27, 2017 from http://www.phe.gov/nhss.

U.S. Department of Health and Human Services: Public Health Emer-

gency Pandemic and All-Hazards Preparedness Reauthorization Act

of 2013, 2017. Retrieved July 27, 2017 from https://www.phe.gov/

Preparedness/legal/pahpra/Pages/pahpra.aspx.

Veenema TG: Disaster Nursing and emergency preparedness for chemical,

biological, and radiological terrorism and other hazards, New York,

2012, Springer Publishing.

Veenema TG, Thornton CP: Understanding nursing’s role in health

systems response to large-scale radiologic disasters, Radiol Nurs

34(2):63–72, 2015.

Vinter S, Lieberman DA, Levi J: Public health preparedness in a

reforming health care system, Harv Law Policy Rev 4:339–360, 2010.

http://www.disasterdistress.samhsa.gov

https://www.phe.gov/Preparedness/legal/pahpra/Pages/pahpra.aspx

http://www.phe.gov/nhss

255

biological terrorism, 256

chemical terrorism, 256

common source outbreak, 261

disease surveillance, 255

endemic, 261

epidemic, 261

event, 256

holoendemic, 261

K E Y T E R M S

Disease Surveillance/Public Health Surveillance

Deinitions and Importance

Uses of Public Health Surveillance

Purposes of Surveillance

Collaboration Among Partners

Nurse Competencies

Data Sources for Surveillance

National Notiiable Diseases

State Notiiable Diseases

Types of Surveillance Systems

C H A P T E R O U T L I N E

Passive System

Active System

Sentinel System

Special Systems

The Investigation

Investigation Objectives

Patterns of Occurrence

When to Investigate

Interventions and Protection

After reading this chapter, the student should be able to:

1. Deine public health surveillance.

2. List types of surveillance systems.

3. Identify steps in planning, analyzing, interviewing, and

evaluating surveillance.

4. Recognize sources of data used when investigating a disease

or condition outbreak.

O B J E C T I V E S

5. Describe the role of the nurse in surveillance and outbreak

investigation.

6. Relate the nurse’s role in investigation to the national core

competencies for public health nurses.

C H A P T E R 15

Surveillance and Outbreak Investigation

Marcia Stanhope

Disease surveillance has been a part of public health protection

since the 1200s during the investigations of the bubonic plague

in Europe. The Constitution of the United States provides for

“police powers” necessary to preserve health safety as well as

other events (see Chapter 7). These powers include public

health surveillance. State and local “police powers” also provide

for surveillance activities. Health departments usually have the

legal authority to investigate unusual clusters of illness as well

(Shannon, 2015).

DISEASE SURVEILLANCE/PUBLIC HEALTH SURVEILLANCE

DEFINITIONS AND IMPORTANCE

Disease surveillance is “the ongoing systematic collection,

analysis, interpretation and dissemination of speciic health

data for use in public health” (Lee et al, 2010; McNabb et al,

2016; Centers for Disease Control and Prevention [CDC],

2015a). Surveillance provides a means for nurses to monitor

hyperendemic, 261

intermittent or continuous

source, 261

mixed outbreak, 261

National Notiiable Disease

Surveillance System

(NNDSS), 258

outbreak, 261

outbreak detection, 261

pandemic, 261

point source outbreak, 261

propagated outbreak, 261

sentinel, 260

sporadic, 261

syndromic surveillance

systems, 260

256 PART 4 Issues and Approaches in Health Care Populations

disease trends to reduce morbidity and mortality and improve

health (McNabb et al, (2016) also use the term public health

surveillance as “the systematic collection of health informa-

tion for the purpose of monitoring, preventing, or controlling

the spread of disease in a population (p. 13).” The Centers for

Disease Control and Prevention indicates that public health

surveillance is the foundation of public health practice (2015a).

Surveillance is a critical role function for nurses practicing in

the community. It is important because it generates knowledge

of a disease or event outbreak patterns (including timing, geo-

graphic distribution, and susceptible populations).

Although surveillance was initially devoted to monitoring

and reducing the spread of infectious diseases, it is now used to

monitor and reduce chronic diseases and injuries, as well as

“environmental and occupational exposures” (McNabb et al,

2016) and personal health behaviors. Surveillance systems help

nurses and other professionals monitor emerging infections

and bioterrorist outbreaks (McNabb et al, 2016) and personal

health behaviors. Bioterrorism is one example of an event cre-

ating a critical public health concern that involves environ-

mental exposures that must be monitored. This event also

requires serious planning to be able to respond quickly and

effectively. Biological terrorism is “the deliberate release of

viruses, bacteria, or other germs (agents) used to cause illness or

death in people, animals, or plants” www.emergency.cdc.gov/

bioterrorism/overview.asp (CDC, 2012a). Chemical terrorism

is the intentional release of hazardous chemicals into the envi-

ronment for the purpose of harming or killing (U.S. Depart-

ment of Homeland Security, n.d.). In the event of a bioterrorist

attack, imagine how dificult it would be to control the spread of

biological agents such as botulism or anthrax or chemical agents

such as sarin or ricin if no data were available about these agents,

their resulting diseases or symptoms, and their usual incidence

(new cases) patterns in the community. (See Box 15.1 for a sum-

mary of the features of surveillance.)

USES OF PUBLIC HEALTH SURVEILLANCE

Public health surveillance can be used to facilitate the following

(CDC, 2014):

• Estimate the magnitude of a problem (disease or event)

• Determine the geographic distribution of an illness or symptoms

• Portray the natural history of a disease

• Detect epidemics and deine a problem

• Generate hypotheses and stimulate research

• Evaluate control measures

• Monitor changes in infectious agents

• Detect changes in health practices

• Facilitate planning

PURPOSES OF SURVEILLANCE

Surveillance helps public health departments identify trends

and unusual disease patterns, set priorities for using scarce

resources, and develop and evaluate programs for commonly

occurring and universally occurring diseases or events

(Box 15.2).

Surveillance activities can be related to the core functions of

public health—assessment, policy development, and assurance.

Disease surveillance helps establish baseline (endemic) rates of

disease occurrence and patterns of spread. Surveillance makes it

possible to initiate a rapid response to an outbreak of a disease

or event that can cause a health problem. Surveillance data are

assessed and analyzed, and interpretations of these data analy-

ses are used to develop policies that better protect the public

from problems such as emerging infections, bioterrorist bio-

logical and chemical threats, and injuries from problems such

as motor vehicle accidents. Surveillance makes it possible to

have ongoing monitoring in place to ensure that disease and

event patterns improve rather than deteriorate. It can also make

it possible to study whether the clinical protocols and public

health policies that are in place can be enhanced based on cur-

rent science so that disease rates actually decline.

Surveillance data are very helpful in determining whether a

program is effective. Such data make it possible to determine

whether public health interventions are effective in reducing

the spread of disease or the incidence of injuries.

COLLABORATION AMONG PARTNERS

A quality surveillance system requires collaboration among

various agencies and individuals: federal agencies, state and lo-

cal public health agencies, hospitals, health care providers,

medical examiners, veterinarians, agriculture, pharmaceutical

agencies, emergency management, and law enforcement agen-

cies, as well as 9-1-1 systems, ambulance services, urgent care

• Is organized and planned

• Is the principal means by which a population’s health status is assessed

• Involves ongoing collection of speciic data

• Involves analyzing data on a regular basis

• Requires sharing the results with others

• Requires broad and repeated contact with the public about personal health

issues

• Motivates public health action as a result of data analyses to:

• Reduce morbidity

• Reduce mortality

• Improve health

BOX 15.1 Features of Surveillance

• Assess public health status

• Deine public health priorities

• Plan public health programs

• Evaluate interventions and programs

• Stimulate research

BOX 15.2 Purposes of Surveillance

From Centers for Disease Control and Prevention (CDC): Introduction

to public health. In: Public Health 101 Series, Atlanta, GA, 2014, U.S.

Department of Health and Human Services, CDC. Available at: http://

www.cdc.gov/publichealth101/surveillance.html.

http://www.emergency.cdc.gov/bioterrorism/overview.asp

http://www.cdc.gov/publichealth101/surveillance.html

257CHAPTER 15 Surveillance and Outbreak Investigation

and emergency departments, poison control centers, nurse

hotlines, schools, and industry. Such collaboration promotes

the development of a comprehensive plan and a directory of

emergency responses and contacts for effective communication

and information sharing. The type of information to be shared

includes the following:

• How to use algorithms to identify which events should be

investigated (i.e., using a precise step-by-step plan outlining

a procedure that in a inite number of steps helps identify the

appropriate event)

• How to investigate

• Whom to contact

• How and to whom information is to be disseminated

• Who is responsible for appropriate action

Nurses are often in the forefront of responses to be made in

the surveillance process whether working in a small rural

agency or a large urban agency; within the health department,

school, or urgent care center; or on the telephone performing

triage services during a disaster. It is the nurse who sees

the event irst (Association of Public Health Nurses, 2014;

Veenema, 2013).

NURSE COMPETENCIES

The national core competencies for public health nurses

were developed from the work of the Council on Linkages

Between Academia and Public Health Practice (2014) and

by the Quad Council of Public Health Nursing Organizations

(2011). These competencies are divided into eight practice

domains: analytic assessment skills, policy development/

program planning skills, communication skills, cultural

competency skills, community dimensions of practice

skills, public health sciences skills, financial planning and

management skills, and leadership and systems thinking

skills.

To be a participant in surveillance and investigation activi-

ties, the staff nurse must have the following knowledge related

to the core competencies:

1. Analytic assessment skills

• Deining the problem

• Determining a cause

• Identifying relevant data and information sources

• Partnering with others to give meaning to the data

collected

• Identifying risks

2. Communication

• Providing effective oral and written reports

• Soliciting input from others and effectively presenting

accurate demographic, statistical, and scientiic infor-

mation to other professionals and the community at

large

3. Community dimensions of practice

• Establishing and maintaining links during the investigation

• Collaborating with partners

• Developing, implementing, and evaluating an assessment

to deine the problem

4. Basic public health science skills

• Identifying individual and organizational responsibilities

• Identifying and retrieving current relevant scientiic

evidence

5. Leadership and systems thinking

• Identifying internal and external issues that have an effect

on the investigation

• Promoting team and organizational efforts

• Contributing to developing, implementing, and monitor-

ing of the investigation

Whereas the staff nurse participates in these activities, the

advanced practice public health nurse should be proicient in

applying these competencies.

The Minnesota Model of Public Health Interventions: Ap-

plications for Public Health Nursing Practice (Center for Public

Health Nursing, 2001, pp 15, 16) suggests that surveillance is

one of the interventions related to nursing practice in public

health. The model provides seven basic steps of surveillance for

nurses to follow:

1. Consider whether surveillance as an intervention is appro-

priate for the situation.

2. Organize the knowledge of the problem, its natural course of

history, and its aftermath.

3. Establish clear criteria for what constitutes a case.

4. Collect suficient data from multiple valid sources.

5. Analyze the data.

6. Interpret and disseminate the data to decision makers.

7. Evaluate the impact of the surveillance system.

DATA SOURCES FOR SURVEILLANCE

Clinicians, health care agencies, and laboratories report cases to

state health departments. Data also come from death certii-

cates and administrative data such as discharge reports and

billing records (McNabb et al, 2016). The following are select

sources of mortality and morbidity data:

1. Mortality data are often the only source of health-related

data available for small geographic areas. Examples include

the following:

• Vital statistics reports (e.g., death certiicates, medical

examiner reports, birth certiicates)

2. Morbidity data include the following:

• Notiiable disease reports

• Laboratory reports

• Hospital discharge reports

• Billing data

• Outpatient health care data

• Specialized disease registries

• Injury surveillance systems

• Environmental surveys

• Sentinel surveillance systems

A good example of a process in place to collect morbidity

data is the National Program of Cancer Registries. This pro-

gram provides for monitoring of the types of cancers found in

a state and the locations of the cancer risks and health problems

in the state.

258 PART 4 Issues and Approaches in Health Care Populations

monitoring preventable deaths; and examining cause and effect

factors in diseases. Vital statistics can be used to plan programs

and monitor programs to meet Healthy People 2020 goals.

The sentinel surveillance system provides for the monitoring

of key health events when information is not otherwise avail-

able or for calculating or estimating disease morbidity in vul-

nerable populations (McNabb et al, 2016).

NATIONAL NOTIFIABLE DISEASES

Box 15.3 shows the national notiiable infectious diseases. Re-

porting of disease data by health care providers, laboratories,

and public health workers to state and local health departments

is essential if trends are to be accurately monitored.

The data provide the basis for detecting disease outbreaks, for

identifying person characteristics, and for calculating incidence,

geographic distribution, and temporal trends. They are used to

initiate prevention programs, evaluate established prevention

and control practices, suggest new intervention strategies, iden-

tify areas for research, document the need for disease control

funds, and help answer questions from the community. (https://

wwwn.cdc.gov/nndss/conditions/notiiable/2016/)

(CDC, 2016a)

The CDC and the Council of State and Territorial Epidemi-

ologists have a policy that requires state health departments to

report certain diseases to the CDC National Notiiable Disease

BOX 15.3 Infectious Diseases Designated as Notiiable at the National Level: United States, 2016

• Anthrax

• Arboviral neuroinvasive and nonneuroinvasive diseases

• California serogroup virus disease

• Chikungunya virus disease

• Eastern equine encephalitis virus disease

• Powassan virus disease

• St. Louis encephalitis virus disease

• West Nile virus disease

• Western equine encephalitis virus disease

• Babesiosis

• Botulism

• Botulism, foodborne

• Botulism, infant

• Botulism, other

• Botulism, wound

• Brucellosis

• Campylobacteriosis

• Cancer

• Carbon monoxide poisoning

• Chancroid

• Chlamydia trachomatis infection

• Cholera

• Coccidioidomycosis/ Valley fever

• Congenital syphilis

• Cryptosporidiosis

• Cyclosporiasis

• Dengue virus infections

• Dengue

• Dengue-like illness

• Severe dengue

• Diphtheria

• Ehrlichiosis/anaplasmosis

• Anaplasma phagocytophilum infection

• Ehrlichia chaffeensis infection

• Ehrlichia ewingii infection

• Undetermined human ehrlickiosis/Anaplasmosis

• Foodborne disease outbreak

• Giardiasis

• Gonorrhea

• Haemophilus inluenzae, invasive disease

• Hansen’s disease/leprosy

• Hantavirus infection, non-Hantavirus pulmonary syndrom

• Hantavirus pulmonary syndrome (HPS)

• Hemolytic uremic syndrome, post-diarrheal (HUS)

• Hepatitis A, acute

• Hepatitis B, acute

• Hepatitis B, chronic

• Hepatitis B virus, perinatal infection

• Hepatitic C, acute

• Hepatitis C, past or present

• HIV infection (AIDS has been reclassiied as HIV stage III) (AIDS/HIV)

• Inluenza-associated pediatric mortality

• Invasive pneumococcal disease (IPD)/Streptococcus pneumoniae, Invasive disease

• Lead, elevated blood levels

• Lead, elevated blood levels, adult (16 years)

• Lead, elevated blood levels, children (,16 years)

• EH-5: Reduce waterborne disease outbreaks arising from water intended

for drinking among persons served by community water systems.

• FS-2: Reduce infections associated with foodborne outbreaks from patho-

gens commonly transmitted through food.

• GH-1: Reduce the number of cases of malaria reported in the United States.

• IID-16: (Developmental) Increase the scientiic knowledge on vaccine

safety and adverse events.

• PHI-2: Increase the proportion of tribal, state, and local public health agen-

cies that incorporate core competencies for public health professionals into

the job.

• PHI-7: Increase the proportion of population-based Healthy People 2020

objectives for which national data are available for all population groups

identiied for the objective.

HEALTHY PEOPLE 2020

Surveillance Objectives

From U.S. Department of Health and Human Services: Healthy People

2020: a roadmap to improve all Americans’ health, Washington, DC,

2010, U.S. Government Printing Ofice.

Each of the data sources has the potential for underreporting

or incomplete reporting. However, if there is consistency in the

use of surveillance methods, the data collected will show trends

in events or disease patterns that may indicate a change needed

in a program or a needed prevention intervention to reduce

morbidity or mortality (CDC, 2014).

Mortality data assist in identifying differences in health sta-

tus among groups, populations, occupations, and communities;

https://wwwn.cdc.gov/nndss/conditions/notifiable/2016/

259CHAPTER 15 Surveillance and Outbreak Investigation

Surveillance System (NNDSS). The data for nationally noti-

iable diseases from 50 states, the US territories, New York

City, and the District of Columbia are published weekly in

the Morbidity and Mortality Weekly Report (MMWR). Data

collection about these diseases and revision of statistics

are ongoing. Annual updated inal reports are published

in the CDC Summary of Notiiable Diseases: United States

(CDC, 2016a).

STATE NOTIFIABLE DISEASES

Requirements for reporting diseases are mandated by law or

regulation. Although each state differs in the list of report-

able diseases, the usefulness of the data depends on “unifor-

mity, simplicity, and timeliness.” Because state requirements

differ, not all nationally notifiable diseases are legally man-

dated for reporting in a state. For legally reportable diseases,

states compile disease incidence data (new cases) and trans-

mit the data electronically, weekly, to the CDC through the

National Electronic Disease Surveillance System (NEDSS)

(CDC, 2015b) (https://wwwn.cdc.gov/nndss/nedss.html).

To determine which of the national notifiable diseases are

Modiied from Centers for Disease Control and Prevention: Nationally notiiable infectious diseases: United States, Atlanta, 2016, CDC. Retrieved

July 2016 from https://wwwn.cdc.gov/nndss/conditions/notiiable/2016/.

BOX 15.3 Infectious Diseases Designated as Notiiable at the National Level: United States, 2016—cont’d

• Legionellosis/ Legionnaire’s disease or Pontiac fever

• Leptospriosis

• Listeriosis

• Lyme disease

• Malaria

• Measles/ Rubeola

• Meningococcal disease

• Mumps

• Novel inluenza A virus infections

• Pertussis/ Whooping cough

• Pesticide-related illness and injury, acute

• Plague

• Poliomyelitis, paralytic

• Poliovirus infection, nonparalytic

• Psittacosis/ ornithosis

• Q fever

• Acute

• Chronic

• Rabies, animal

• Rabies, human

• Rubella/ German measles

• Rubella, congenital syndrome (CRS)

• Salmonellosis

• Severe acute respiratory syndrome–associated coronavirus disease (SARS)

• Shiga toxin-producing Escherichia coli (STEC)

• Shigellosis

• Silicosis

• Smallpox/ Variola

• Spotted fever rickettsiosis

• Streptococcal toxic shock syndrome (STSS)

• Syphilis

• Early latent

• Late latent

• Late with clinical manifestations (including late benign syphilis and

cardiovascular syphilis)

• Primary

• Secondary

• Stillbirth

• Tetanus/c. tetani

• Toxic shock syndrome (other than streptococcal) (TSS)

• Trichinellosis/ trichinosis

• Tuberculosis (TB)

• Tularemia

• Typhoid fever

• Vancomycin-intermediate Staphylococcus aureus (VISA)

• Vancomycin-resistant Staphylococcus aureus (VRSA)

• Varicella/ Chickenpox

• Varicella deaths

• Vibriosis

• Viral hemorrhagic fevers (VHF)

• Crimean-Congo hemorrhagic fever virus

• Ebola virus

• Lassa virus

• Lujo virus

• Marburg virus

• New World arenaviruses (Gunarito, Machupo, Junin, and Sabia viruses)

• Waterborne disease outbreak

• Yellow fever

• Zika virus disease

• Zika virus, congenital infection

FOCUS ON QUALITY AND SAFETY EDUCATION FOR NURSES

Targeted Competency: Safety—Minimizes risk for harm to clients and

providers through both system effectiveness and individual performance.

• Knowledge: Discuss potential and actual impact of national client safety

resources, initiatives, and regulations.

• Skill: Use national resources for own development and to focus attention

on safety in the community.

• Attitude: Value relationships between national safety campaigns and im-

plementation in locales, times and settings.

Safety Question

The Quad Council competency for communication skills indicates that the

public health nurse uses a variety of methods to disseminate public health

information to populations within a community and provides a presentation of

targeted health information to multiple audiences at a local level: groups,

professionals, and agency peers.

How would the nurse use the national sentinel surveillance system to

identify health conditions and risks in the community? What types of data

sources in this system would the nurse collect? After careful analysis of the

data sources, what would the nurse include in a presentation to multiple

audiences?

https://wwwn.cdc.gov/nndss/conditions/notifiable/2016/

https://wwwn.cdc.gov/nndss/nedss.html

260 PART 4 Issues and Approaches in Health Care Populations

reportable in your state, go to your state health department

website.

TYPES OF SURVEILLANCE SYSTEMS

Informatics is essential to the mission of protecting the public’s

health. Surveillance systems are designed to assist public health

professionals in the early detection of disease and event outbreaks to

intervene and reduce the potential for morbidity or mortality or

to improve the public’s health status (CDC, 2014). Surveillance sys-

tems in use today are deined as passive, active, sentinel, and special.

PASSIVE SYSTEM

In the passive system, case reports are sent to local health depart-

ments by health care providers (i.e., physicians, nurses) or labora-

tory reports of disease occurrence are sent to the local health de-

partment. The case reports are summarized and forwarded to the

state health department, national government, or organizations

responsible for monitoring the problem, such as the CDC or an

international organization such as the World Health Organization.

ACTIVE SYSTEM

In the active system, the nurse, as an employee of the health

department, may begin a search for cases through contact with

local health care providers and agencies. In this system, the

nurse names the disease or the event and gathers data about

existing cases to try to determine the magnitude of the problem

(how widespread it is).

SENTINEL SYSTEM

In the sentinel system, trends in commonly occurring diseases

or key health indicators are monitored (Healthy People 2020). A

disease or an event may be the sentinel, or a population may be

the sentinel. In this system a sample of health providers or agen-

cies is asked to report the problem. The system is useful because

it helps monitor trends in commonly occurring diseases and

events.

SPECIAL SYSTEMS

Special systems are developed for collecting particular types

of data; these may be a combination of active, passive, or sen-

tinel systems. As a result of bioterrorism, newer systems called

syndromic surveillance systems are being developed to

monitor illness syndromes or events. This approach requires

the use of automated data systems to report continued (real

time) or daily (near real time) disease outbreaks (CDC,

2016b) (Box 15.4).

The CDC’s Syndromic Surveillance website discusses the

impact of increasing electronic health record systems: “Public

health syndromic surveillance using inpatient and ambula-

tory clinical care electronic health record (EHR) data is a

relatively new practice. As eligible health professionals and

hospitals adopt, implement, and upgrade their EHR systems

• Health Alert Network: http: //emergency.cdc.gov

• The Emerging Infections program http://www.cdc.gov

• Epidemiology and Laboratory Capacity program (ELC) http://cdc.gov

• Hazardous substances Data Bank. TOXNET.gov

• Inluenza surveillance in the United States

Community Emergency Response Systems (check local health department)

BOX 15.4 Bioterrorism and Response Networks

EVIDENCE-BASED PRACTICE

Cancer Screening Interventions for Surveillance

An analysis was conducted to identify uses of spatial analysis in cancer

screening interventions. Researchers used a spatial analysis tool called

cluster detection to identify geographic areas with populations at

high risk for colorectal cancer. Specifically, the investigators used the

free cluster detection software application SaTScan to map the at-risk

population. The researchers sought to identify which spatial analysis

method was most successful in identifying at-risk populations. Various

methods were used to detect areas in Florida where the population

was at high risk. Although no single method emerged as being able

to detect all significant clusters, all methods did detect one area as

high risk. This area could be seen as a priority area to implement a

screening intervention to improve early identification of disease and early

treatment.

Nurse Use

Cluster detection is a surveillance tool that public health nurses can use to

determine geographic priority areas for health promotion and disease

prevention interventions. Being able to focus on a specific area would

enable the nurse to use public health resources in an efficient manner and

provide outreach to the populations at highest risk for disease.

From Sherman RL, Henry KA, Tannenbaum SL, et al: Applying spatial

analysis tools in public health: an example using SaTScan to detect

geographic targets for colorectal cancer screening interventions.

Prev Chronic Dis 11:130264, 2014. DOI: http://dx.doi.org/10.5888/

pcd11.130264. Sherman RL, Henry KA, Tannenbaum SL, et al: Applying

spatial analysis tools in public health: an example using SaTScan to

detect geographic targets for colorectal cancer screening interventions.

Prev Chronic Dis 11:130264, 2014. DOI: http://dx.doi.org/10.5888/

pcd11.130264

through the Centers for Medicare and Medicaid services EHR

Incentive programs (Meaningful Use programs), there is an

opportunity for public health agencies (PHAs) to routinely

receive health data from settings other than emergency

departments and urgent care centers. Given the number of

factors and complex relationships that affect EHR data

quality, a collaborative approach that includes public health,

healthcare, and EHR technology developers is the best

way to determine how EHR data can be meaningfully used

for surveillance.” (http://www.cdc.gov/ehrmeaningfuluse/

syndromic.html

Although all of the systems are important, the public health

nurse is most likely to use the active or passive systems. A passive

system may use the state reportable disease system to complete

a community assessment or Mobilizing for Action through

http://www.cdc.gov/ehrmeaningfuluse/syndromic.html

http://dx.doi.org/10.5888/pcd11.130264

http://emergency.cdc.gov"

http://cdc.gov

http://www.TOXNET.gov

261CHAPTER 15 Surveillance and Outbreak Investigation

THE INVESTIGATION

INVESTIGATION OBJECTIVES

Any unusual increase in disease incidence (new cases) or an un-

usual event in the community should be investigated. The system

used for investigation depends on the intensity of the event, the

severity of the disease, the number of people or communities

affected, the potential for harm to the community or the spread

of disease, and the effectiveness of available interventions (CDC,

2012b). The objectives of an investigation are as follows:

• To control and prevent disease or death

• To identify factors that contribute to the outbreak of the

disease and the occurrence of the event

• To implement measures to prevent occurrences

Deining the Magnitude of a Problem or an Event The following deinitions provide a way to describe the level of

occurrence of a disease or an event for purposes of communi-

cating the magnitude of the problem. A disease or an event

found to be present (occurring) in a population is deined as

endemic if there is a persistent (usual) presence with a low to

moderate number of cases of the disease or event. The endemic

levels of a disease or an event in a population provide the base-

line for establishing a public health problem. For example,

foodborne botulism is endemic to Alaska. The baseline must be

known to determine the existence of a change or increase in the

number of cases from the baseline. If a problem is considered

hyperendemic, there is a persistently (usually) high number of

cases. An example is the high cholera incidence rate among

Asians and Paciic Islanders. Sporadic problems are those with

an irregular pattern with occasional cases found at irregular

intervals. Epidemic means that the occurrence of a disease

within an area is clearly in excess of expected levels (endemic)

for a given time period. This is often called the outbreak. Pan-

demic refers to the epidemic spread of the problem over several

countries or continents (e.g., severe acute respiratory syndrome

[SARS] outbreak). Holoendemic in a population implies a

highly prevalent problem that is commonly acquired early in

life. The prevalence of this problem decreases as age increases

(Nmadu et al, 2015). Outbreak detection, or identifying an

increase in the frequency of disease above the usual occurrence

of the disease, is the function of the investigator (CDC, 2015c).

Patterns of Occurrence Patterns of occurrence can be identiied when investigating a dis-

ease or event. These patterns are used to deine the boundaries of

a problem to help investigate possible causes or sources of the

problem. A common source outbreak refers to a group exposed

to a common noxious inluence such as the release of noxious

gases (e.g., ricin in the Japanese subway system several years ago

and more recently in a water system in the United States) (Merrill,

2017). In a point source outbreak, all persons exposed become ill

at the same time, during one incubation period. A mixed out-

break is “when a victim of a common source epidemic has

person-to-person contact with others and spreads the disease,

further propagating the health problem” (Merrill, 2017, p. 316), as

in the spreading of inluenza. Intermittent or continuous source

cases may be exposed over a period of days or weeks, as in the

recent food poisonings at a restaurant chain throughout the

United States as a result of the restaurant’s purchase of contami-

nated green onions. A propagated outbreak does not have a com-

mon source and spreads gradually from person to person over

more than one incubation period, such as the spread of tubercu-

losis from one person to another.

Causal Factors From the Epidemiological Triangle Factors that must be considered as causes of an outbreak are

categorized as agents, hosts, and environmental factors (see

Chapter 9). The belief is that these factors may interact to cause

the outbreak and therefore the potential interactions must be

examined. Box 15.5 presents deinitions used to classify agents in

an attack. Box 15.6 lists the types of agent factors that may be

present. The host factors associated with cases may be age, sex,

race, socioeconomic status, genetics, and lifestyle choices (e.g.,

cigarette smoking, sexual practices, contraception, eating habits).

BOX 15.5 Classiication of Agents

Infectivity: Refers to the capacity of an agent to enter a susceptible host and

produce infection or disease

Pathogenicity: Measures the proportion of infected people who develop the

disease

Virulence: Refers to the proportion of people with clinical disease who

become severely ill or die

BOX 15.6 Types of Agent Factors

1. Biological

• Bacteria (e.g., tuberculosis, salmonellosis, streptococcal infections)

• Viruses (e.g., hepatitis A, herpes)

• Fungi (e.g., tinea capitis, blastomycosis)

• Parasites (e.g., protozoa-causing malaria, giardiasis; helminths [round-

worms, pinworms]; arthropods [mosquitoes, ticks, lies, mites])

2. Physical

• Heat

• Trauma

3. Chemical

• Pollutants

• Medications/drugs

4. Nutrients

• Absence

• Excess

5. Psychological

• Stress

• Isolation

• Social support

Planning and Partnerships (MAPP) (see Chapters 12 and 16).

The active system is used when several school children become

ill after eating lunch in the school cafeteria or at the local hot dog

stand, to investigate the possibility of food poisoning, or to fol-

low up with the contacts of a client newly diagnosed with tuber-

culosis or a sexually transmitted disease (STD) at the local

homeless shelter (CDC, 2014).

262 PART 4 Issues and Approaches in Health Care Populations

The environmental factors that may be related to a case are physi-

cal (e.g., weather, temperature, humidity, physical surroundings)

or biological (e.g., insects that transmit the agent). Some of the

socioeconomic factors that might affect the development of a

disease or an event are behavior (e.g., terrorist behaviors), person-

ality, cultural characteristics of the group, crowding, sanitation,

and the availability of health services.

WHEN TO INVESTIGATE

An unusual increase in disease incidence should be investigated.

The amount of effort that goes into an investigation depends on

the severity or magnitude of the problem, the numbers in the

population who are affected, the potential for spreading the dis-

ease, and the availability and effectiveness of intervention mea-

sures to resolve the problems. Most of the outbreaks of diseases

(or increased incidence rates) occur naturally or are predictable

compared with the consistent patterns of previous outbreaks of a

disease such as inluenza, tuberculosis, or common infectious

diseases. When a disease or an event outbreak occurs as a result of

the purposeful introduction of an agent into the population, then

the predictable patterns may not exist. Sobel and Watson (2009)

provide clues to be used when trying to determine the existence of

bioterrorism. These clues are simpliied and appear in Box 15.7.

INTERVENTIONS AND PROTECTION

Remember that disease and event surveillance systems exist

to help improve the health of the public through the sys-

tematic and ongoing collection, distribution, and use of

health-related data. A nurse can contribute to such systems

and best use the data collected through such systems to help

manage endemic health problems and those that are emerg-

ing, such as evolving infectious diseases and bioterrorist

(human-made) health problems. The functions of surveil-

lance and investigation include detecting cases, estimating

the impact of disease or injury, showing the natural history

of a health condition, determining the distribution and

spread of illness, generating hypotheses, evaluating pre-

vention and control measures, and facilitating planning

(McNabb et al, 2016). Response to bioterrorism or to a

large-scale infectious disease outbreak may require the use

of emergency public health measures such as quarantine,

isolation, closing public places, seizing property, mandatory

vaccination, travel restrictions, and disposal of the de-

ceased. Suggestions for protecting health care providers

from exposure include the use of standard precautions

when coming into contact with broken skin or body fluids,

the use of disposable nonsterile gowns and gloves followed

by adequate hand washing after removal, and the use of a

face shield (CDC, 2016c).

Primary Prevention

Develop an approach for mass immunizations of citizens to prevent the occur-

rence of H1N1 (H1N2 or H3N3) in the community.

Secondary Prevention

Investigate an outbreak of lulike illness in a local school.

Tertiary Prevention

Provide health care and treatment for those infected by H1N1 or the new

strains of the virus.

LEVELS OF PREVENTION

For Surveillance Activities

• Large numbers of ill persons with a similar disease or syndrome

• Large numbers of unexplained disease, syndrome, or deaths

• Unusual illness in a population

• Higher morbidity and mortality than expected with a common disease or

syndrome

• Failure of a common disease to respond to usual therapy

• Single case of the disease caused by an uncommon agent

• Multiple unusual or unexplained disease entities coexisting in the same

person without any other explanation

• Disease with an unusual geographic or seasonal distribution

• Multiple atypical presentations of disease agents

• Similar genetic type among agents isolated from temporally or spatially

distinct sources

• Unusual, atypical, genetically engineered, or antiquated strain of agent

• Endemic disease with an unexplained increase in incidence

• Simultaneous clusters of similar illness in noncontiguous areas, domestic

or foreign

• Atypical aerosol, food, or water transmission

• Ill people presenting at about the same time

• Deaths or illness among animals that precedes or accompanies illness or

death in humans

• No illness in people not exposed to common ventilation systems, but illness

among those people in proximity to the systems

BOX 15.7 Epidemiological Clues that may Signal a Covert Bioterrorism Attack

HOW TO Conduct an Investigation

• Conirm the existence of an outbreak.

• Verify the diagnosis and/or deine a case.

• Estimate the number of cases.

• Orient the data collected to person, place, and time.

• Develop and evaluate a hypothesis.

• Institute control measures and communicate indings.

From the Centers for Disease Control and Prevention (CDC): Steps to

Investigation Retrieved January 2015 from http://www.cdc.gov.

WHAT WOULD YOU DO?

You have joined the community emergency response team to investigate a

suspected disease outbreak in the area. How would you determine the exis-

tence of an unusual outbreak?

The How To box provides a brief guide to conducting the

investigation.

263CHAPTER 15 Surveillance and Outbreak Investigation

P R A C T I C E A P P L I C A T I O N

As a clinical project the health department asked the public

health nursing class at the university to develop a community

service message to air on local radio about the potential of a

pandemic lu.

What does the message need to contain to help the community

prepare?

Answers can be found on the Evolve website.

R E M E M B E R T H I S !

• Disease surveillance has been a part of public health protec-

tion since the 1200s during the investigations of the bubonic

plague in Europe.

• Surveillance provides a means for nurses to monitor disease

trends to reduce morbidity and mortality and to improve health.

• Surveillance is a critical role function for nurses practicing in

the community.

• Surveillance is important because it generates knowledge of

a disease or event outbreak patterns.

• Surveillance focuses on the collection of process and out-

come data.

• Although surveillance was initially devoted to monitoring

and reducing the spread of infectious diseases, it is now used

to monitor and reduce chronic diseases and injuries, as well

as environmental and occupational exposures.

• Surveillance activities can be related to the core functions of

public health assessment, policy development, and assurance.

• A quality surveillance system requires collaboration among

agencies and individuals.

• The Minnesota Model of Public Health Interventions: Ap-

plications for Public Health Nursing Practice (Center for

Public Health Nursing, Ofice of Public Health Practice,

2001) suggests that surveillance is one of the interventions

related to public health nursing practice.

• Clinicians, health care agencies, and laboratories report cases

to state health departments. Data also come from death cer-

tiicates and administrative data such as discharge reports

and billing records.

• Each of the data sources has the potential for underreporting

or incomplete reporting. However, if there is consistency in

the use of surveillance methods, the data collected will show

trends in events or disease patterns that may indicate a

change needed in a program or a needed prevention inter-

vention to reduce morbidity or mortality.

• The sentinel surveillance system provides for the monitoring

of key health events when information is not otherwise

available or for calculating or estimating disease morbidity

in vulnerable populations.

• Reporting of disease data by health care providers, laboratories,

and public health workers to state and local health depart-

ments is essential if trends are to be accurately monitored.

• Requirements for reporting diseases are mandated by law or

regulation.

• Surveillance systems in use today are deined as passive,

active, sentinel, and special.

• Any unusual increase in disease incidence (i.e., new cases) or

an unusual event in the community should be investigated.

• Patterns of occurrence can be identiied when investigating

a disease or event. These patterns are used to deine the

boundaries of a problem to help investigate possible causes

or sources of the problem.

• Factors that must be considered as causes of outbreak are

categorized as agents, hosts, and environmental factors.

• An unusual increase in disease incidence should be

investigated.

• Functions of surveillance and investigation include detecting

cases, estimating the impact of disease or injury, showing the

natural history of a health condition, determining the distri-

bution and spread of illness, generating hypotheses, evaluat-

ing prevention and control measures, and facilitating plan-

ning.

APPLYING CONTENT TO PRACTICE

Remember that disease and event surveillance systems exist to help improve

the health of the public through the systematic and ongoing collection, distribu-

tion, and use of health-related data. A nurse can contribute to such systems and

best use the data collected through such systems to help manage endemic

health problems and those that are emerging, such as evolving infectious dis-

eases and bioterrorist (human-made) health problems. The functions of surveil-

lance and investigation include detecting cases, estimating the impact of

disease or injury, showing the natural history of a health condition, determining

the distribution and spread of illness, generating hypotheses, evaluating pre-

vention and control measures, and facilitating planning (McNabb et al, 2016).

Response to bioterrorism or to a large-scale infectious disease outbreak may

require the use of emergency public health measures such as quarantine, isola-

tion, closing public places, seizing property, mandatory vaccination, travel re-

strictions, and disposal of the deceased. Suggestions for protecting health care

providers from exposure include the use of standard precautions when coming

in contact with broken skin or body luids, the use of disposable nonsterile

gowns and gloves followed by adequate hand washing after removal, and the

use of a face shield (CDC, 2016c). This chapter focuses on the importance of

using informatics to identify, monitor, and intervene in unusual occurrences and

events to protect the public and to keep communities safe. Informatics the use

of information and technology to communicate, manage knowledge, mitigate

error, and support decision making. The knowledge requirement for the public

health nurse and student is to explain why information and technology skills are

essential for safety. The skill to be developed is the seeking of education about

how information is managed in the setting before providing an intervention.

This chapter applies this by looking at trends of occurrences and events before

investigating the situation and deciding on an intervention. It is also important

to be able to use the databases and the tools of investigation to ensure safe

processes of care. The attitude of engaging in continuous learning and the

development of new technology skills is essential.

264 PART 4 Issues and Approaches in Health Care Populations

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EVOLVE WEBSITE

http://evolve.elsevier.com/Stanhope/foundations

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