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CommunityPublicHealth_TheFutureofHealthCare.pdf
CHAPTER 1 Populations as Clients By Sue Z. Green
“We often think of nursing as giving meds on time, checking an X-ray to see if the doctor needs to be called, or taking an admission at 2:00 a.m. with a smile on our faces. Too often, we forget all the other things that make our job what it truly is: caring and having a desire to make a difference.”—Erin Pettengill (National CPR Association, n.d.)
Essential Questions ● How does expanding knowledge of population, community, and public health nursing
improve the nurse’s practice? ● What are expected competencies for the nurse practicing within population groups? ● How does the nurse apply the nursing process and collaborate with others to conduct a
population’s health assessment? ● Which community resources are useful during planning and interventions for a
population’s health?
Introduction Nursing care of populations involves working with larger groups of people and their corresponding multiple health care needs. Community and public health nurses consider the effect of ethnicity, culture, spiritual values, and geographic and socioeconomic conditions on the wellness of the population. Diverse populations have various health disparities and health inequities that affect their ability to maintain health and meet health care needs. A greater understanding of historical and theoretical concepts provides a foundation for the nurse’s approach to care of populations. The role of the public health nurse and the essential function of public health services are explored in this chapter. The nursing process is applied as an
approach to assess a community or specific population. Impediments to effective practice are discussed to aid the nurse’s awareness of barriers to overcome.
Population Health
● Population health is defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (Kindig & Stoddart, 2003, p. 381). Population health has a goal of measuring, intervening, and improving health disparities among groups, as well as the distribution of health, all of which is driven by assessment and statistical data. Public health, a subcomponent of population health, is the practice of protecting and promoting quality of life and holistic health of persons and communities through the use of science, research, and direct care. The American Public Health Association (APHA) defines public health nursing as “the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences” (American Public Health Association [APHA], 2013, p. 2). Interdisciplinary public health practices aim to prevent disease outbreaks, injuries, and poor health while promoting cost-effective measures that improve quality of life and health as well as reduce environmental hazards (APHA, n.d.; Centers for Disease Control and Prevention Foundation, 2017).
Development of the Public Health Nursing Role
●
The historical path leading to the discipline of public/community health nursing began more than a century ago. Several nursing pioneers fashioned programs that led to the development of organized public health delivery.
● Florence Nightingale initiated “health visitors” in 1892, a group composed of lay female missionaries with specialized training for instruction of health (Buhler-Wilkinson, 1985). Much of the focus was teaching women about caring for themselves and their children. This was the foundation of England’s district nursing today.
● Lillian Wald established the term public health nurse with a focus on treating social and economic problems along with illness. In 1893, Wald and Mary Brewster put this belief into practice on the Lower East Side tenements of New York. Two years later, this led to the establishment of the Henry Street Settlement and, later, the development of the Visiting Nurses Association (VNA) (Fee & Bu, 2010).
● Mary Breckinridge introduced nurse midwifery to the United States in 1925. She traveled on horseback to deliver modern health care to the most inaccessible and poorest areas of Appalachia in Kentucky (Frontier Nursing Service, 2015). This lead to the subsequent development of the Frontier Nursing Service (FNS) and the expansion of public health nursing into remote rural areas (Frontier Nursing University, n.d.).
Policy Reform The public health profession continues to evolve. Various policy reforms in the United States have shaped public health nursing to become what it is today. Public health needs drive development of programs to improve public health. Sanitation reforms occurred as public health nursing emerged. Public health education, improved waste disposal methods, and clean-water policies reinforced the importance of the environment to the nation’s health. In 2004, a presidential order, signed by President George W. Bush, established the Office of National Coordinator for Health Information Technology, which included incentives for providers using health information technology (HIT), motivating them to utilize electronic medical records (Bush, 2004; DeSalvo, Dinkler, & Stevens, 2015). Timely and efficient access to patient-related information ushered in a new era of health informatics and population health. The 2010 Affordable Care Act (ACA) reinforced the importance of the use of HIT. Gradual transition of services to outpatient or community settings further reinforce the nurse’s role in population health management and health information technology.
From public health nursing, subspecialties have emerged, including school nursing, industrial and occupational health nursing, child health nursing, tuberculosis nursing, rural nursing, and the American Red Cross. Born from the rise of nursing specialty interest groups, the National Organization of Public Health Nursing (NOPHN) emerged with Lillian Wald as the first president. Many groups have since formed to address the varying needs of nurses across settings and clinical specialties, including the American Nurses Association (ANA). The ANA, the largest nursing organization, represents nurses across the United States, reinforcing the role of public health nursing. The ANA recognizes and promotes the Quad Council Coalition of Public Health Nursing Organizations (QCC or Quad Council) and public health nursing’s scope and standards of practice. The ANA also supports nursing involvement in public health advocacy, education, and policy, along with evolving health issues (American Nurses Association [ANA], n.d.).
Quad Council Coalition
The QCC comprises four nursing organizations serving public health nursing. Current
members include the Alliance of Nurses for Healthy Environments (ANHE), Public
Health Nursing Section of the American Public Health Association (PHN Section of
APHA), the Association of Community Health Nurse Educators (ACHNE), and the
Association of Public Health Nurses (APHN) (Quad Council Coalition of Public Health
Nursing Organizations [QCC], n.d.).
The QCC is the vehicle for guiding and developing current critical components and
competencies. Beginning in 2011, the QCC competencies were aligned to the Core
Competencies for Public Health Professions, a guiding document the QCC developed to
bridge academic and public health practice (Public Health Foundation, n.d.; QCC, n.d.;
Swider, Krothe, Reyes, & Cavetz, 2013). This alignment provided a mechanism to
promote nursing evidence-based competencies congruent with other public health
professions and academic practices. The nursing competencies span three tiers of
practice over various skill domains with competencies. The three tiers categorize
practice as:
● Tier 1-basic or generalist ● Tier 2-specialist or midlevel ● Tier 3-executive and/or multi-systems level (Swider et al., 2013).
Those at the Tier 1 level work directly with the diverse populations to promote health
and prevent disease, collect and analyze data, plan programs, and conduct outreach
activities to reduce health disparities (QCC, n.d.). Tier 2 public health nurses are in
management or supervisory roles and assist in implementation of public health
programs (QCC, n.d.). Tier 3 competencies are for senior management or nurse
executive roles. Tier 3 public health nurses are responsible for administration,
organization, and operation of public health programs (QCC, n.d.).
Today’s Community and Public Health Nurses
● Health promotion and care for the community and population at large reflect public/community health nurses’ mission, vision, and commitments. Community health nursing and public health nursing are terms synonymous for the role of the nurse outside institutional settings; however, the terms are distinct from each other. Community health nursing has traditionally focused on nursing care for acute and chronic conditions outside the traditional hospital setting, primarily involving restorative care. Now, community health nursing involves health promotion of individuals and families, providing care in settings such as occupational or educational systems. Public health nursing addresses health promotion beyond an individual’s or family’s needs, incorporating community aspects and global or environmental concerns. Public health nursing focuses on groups, populations, or the health of an entire geographical sector (Canales & Drevdahl, 2014; Kulbok, Thatcher, Park, & Meszaros, 2012; Reifsnider & Garcia, 2015). Public health nursing is a population-focused practice. This practice concentrates on the defined population’s needs for prevention of illness and health improvement (Association of Public Health Nurses [APHN], n.d.; ANA, n.d.; APHA, 2013). A public health nurse (PHN) incorporates dynamics extending to small groups, or aggregates, and beyond for improvement of a population’s overall health. In turn, this improves the health of individuals and families’ living, employment, and recreational environments (Swider & Kulbok, 2015). Aggregates are persons who are grouped together because of common characteristics or location. The PHN’s educational background is traditionally a baccalaureate or advanced practice level (Reifsnider & Garcia, 2015). To a nurse providing inpatient or primary care, a population means the patients who are within that setting, but for a PHN, the population is inclusive of the entire aggregate living in the community or a larger geographic sector. The PHN’s population shares commonalities of disease and risk and, unlike patients in an inpatient setting, the population
comprises all persons irrespective of whether they request services (Reifsnider & Garcia, 2015). Most nurses practice at individual and interpersonal levels of a community, but PHNs practice at the organizational, community, and public policy levels as well. The PHN collaborates with other disciplines and key community stakeholders. These stakeholders are persons who are both involved and directly affected by the plans, actions, and outcomes of population health care. For example, stakeholders may be local government officials, community groups, faith-based organizations, or local business owners.
The PHN’s practice involves the use of epidemiology. Epidemiology is the health science that studies the incidence and prevalence of disease in large populations. Incidence rates denote the emergence of a new illness. Prevalence rates reflect, in a given timeframe, the presence or pervasiveness of disease in a population compared to the overall health of the population at large. Epidemiologists aim to detect the source and cause of epidemics resulting from the pervasive presence of infectious diseases.. These scientists seek to understand patterns associated with the spread of communicable diseases and identify methods to minimize incidence or prevent outbreak. Programs in public health originate from data obtained through epidemiological research and focus on addressing infective agents, safeguarding biological or human hosts, and controlling the environment to prevent the spread of disease.
Aspects of the Public Health Nursing Role
● Advocates for the health of populations. ● Establishes credibility with the community. ● Concentrates on an aggregate or groups to improve the health of all. ● Seeks prevention of illness. ● Acts as a role model for leadership in provisions of health. ● Fosters community organization. ● Applies the ethical theory of utilitarianism—making choices for “the greater
good.” ● Incorporates epidemiologic knowledge and methods. ● Conducts health assessment for entire populations for prevalence of disease,
risk factors, self-perceived health status, functional ability, and psychological stressors.
● Demonstrates versatility in dynamic collaborative environments. ● Exhibits cultural competence with diverse populations. ● Designs interventions for specific populations. ● Evaluates outcomes of interventions (Harkness & DeMarco, 2015; Joyce,
O’Brien, Belew-LaDue, Dorjee, & Smith, 2014; Kulbok, Thatcher, Park, & Meszaros, 2012).
The 10 Essential Public Health Services The Centers for Disease Control and Prevention (CDC) (n.d.) identifies three functions and 10 essential public health services (see Figure 1.1). Note the cyclical nature of Figure 1.1, indicating that assessment, policy development, and assurance are ongoing. System management features all the functions and essentials and incorporates the essential service of research. The discipline of nursing has the ability to be involved in every aspect of the wheel.
Figure 1.1
The 10 Essential Public Health Services
Note. Adapted from “The Public Health System & the 10 Essential Public Health Services,” by the Centers for Disease Control and Prevention, 2017.
Assessment The assessment function incorporates the essential services of monitoring health status and diagnosis and investigation of community health problems and hazards (see Figure 1.1). PHNs are involved in data collection, community health assessment, and maintenance of data banks on population health statistics. The PHNs use the information to identify health risks and disparities, determine health service needs, and locate health care assets and resources to support health and quality of life improvements (Centers for Disease Control and Prevention [CDC], 2014). This health monitoring and identification process includes using technology, such as geographic informational systems (GIS) to map the population for groups at higher risk than the overall population (CDC, 2014). The monitoring and diagnosis essential service of the assessment function involves timely identification and investigation of health threats; use of diagnostic resources, such as state public health laboratories; and development of plans to reduce health threats (CDC, 2014). The PHN is involved in epidemiologic investigations of disease outbreaks, patterns of infections, environmental hazards, chronic diseases, injuries, and any additional threat to the population, as well as developing plans for health care interventions (see Table 1.1).
Policy Development The development of public health policies address essential services and work to inform, educate, and empower the public about health concerns while mobilizing the community in support of key initiatives. (CDC, 2017b) (see Figure 1.1). The PHN builds knowledge and shapes attitudes about health through health education initiatives, informing the public of choices in health decision making, skills, and behaviors that contribute to a healthy quality of life. Health promotion and education is often supported through partnerships with employers, faith-based organizations, schools, and health care providers for implementation of initiatives and reinforcement of health information (CDC, 2014). Public service announcements are one mechanism in which media and marketing campaigns work to disseminate health information (see Table 1.1). Mobilization of community partnerships also aid in the identification of health problems and provide a source of both human and material resources. As public awareness increases, partnerships, coalitions, and alliances develop to support prevention, screening, and rehabilitation projects (CDC, 2014). The mobilization of partnerships serves as a foundation toward effective local public health governance. Policies and plans develop to support both individual and community efforts to protect health, further improve health, and prepare for emergency response to health threats (CDC, 2014). The PHN may be involved in the development of health policies, codes, regulations, and legislation that guide public health protections. PHN planning for health improvement occurs at both the local and state levels, including systematic alignment of resources for health improvement strategic planning.
Assurance
● The assurance function encompasses enforcing laws, linking people to care providers, assuring a competent workforce, and evaluating program effectiveness (CDC, 2014). The enforcement of laws and regulations are for the protection of health and safety. The PHN is involved in public health emergencies requiring reinforcement, such as a quarantine, use of best practices to achieve compliance with health regulations, and education of the public regarding laws and regulations. Linking people in need of care to service providers involves the PHN’s identification of barriers to care for various population aggregates and coordination of appropriate services to address, intervene, and overcome the barriers, including cultural, transportation, and language barriers. PHNs participate as members of the competent workforce by maintaining active licensure; using public health competencies, such as those from the QCC; and applying the concept of lifelong learning. PHNs assess, educate, and train other public health participants, such as students, volunteers, or lay community health workers. Measures for continuous quality improvements are adopted by PHNs while maintaining standards of care. PHNs seek opportunities for ongoing leadership development, cultural competence, and improvement of health disparities. PHNs evaluate the effectiveness, accessibility, and quality of individual and population-based public health services. This ongoing evaluation and review of effectiveness analyzes health status and service utilization data (CDC, 2014). This management of performance provides information toward allocation of resources and program revisions (CDC, 2014). The information should show how the needs of the population are met, which approaches are working, and what requires improvement.
System Management Research is an essential service contained throughout all three functions (CDC, 2014). This involves surveillance of the outcomes of research and development of links between public health practice and academic or research settings (CDC, 2014). Common research areas of focus include epidemiological studies, health policy analyses, and public health systems research (CDC, 2014). The PHN is involved in research activities, including initiation of research, participation of research by other entities, reporting results, and implementation of resulting evidence-based policies (see Table 1.1).
Table 1.1
Nursing Public Health Interventions
Intervention Definitions Examples
Assessment
● Surveillance ● Screening ● Case finding ● Investigation of disease
and health events
The continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice (World Health Organization [WHO], n.d.)
Screening used to detect risk factors for diseases or undiagnosed diseases
The systematic search for at risk persons
Track statistical data and clusters of health events for risk to the community and compliance with infection prevention/control measures
Tracking progress and spread of the Zika virus
Testing for tuberculosis in persons living with HIV
MRSA reported among several high school athletes
Policy Development
● Outreach ● Inform, educate,
empower ● Mobilize community
partnerships ● Develop policies
Providing information about health issues to the at risk groups, special interest populations, or the community at large
Public service announcement regarding influenza season and an upcoming flu immunization clinic
Check for Understanding
1. What aspects of national and global public health require enlarging the nurse’s perspective beyond the care of the individual and family?
2. How have nurses been instrumental in the creation of the current services in public health? 3. How do public health nurses meet the public’s need for services?
Theories to Inform Public Health Nursing Practice
●
Assurance
● Referral and follow up ● Enforce laws ● Link to and/or provide
care ● Ensure competent
workforce ● Evaluate
Assistance to identify and access necessary resources to resolve health issues
Referral for counseling to victim of intimate partner violence and encouragement for follow-up appointments
Childhood immunization monitoring
System Management
● Incorporated within all of the above
● The research aspects of all of the above
Provides intersection of health, information and communication technologies, and research to employ new perspectives and innovative solutions to care for health problems
Epidemiological studies
Methods of data input and quality monitoring
The nursing profession adopts theories and conceptual frameworks from other disciplines, such as behavioral change models, systems theories including family systems theories, concepts of distributive or social justice, and community organization models (see Table 1.2). When applying these concepts, the nurse seeks to discover the factors that influence the public to exchange unhealthy behaviors for healthier ones and seeks to determine how programs and revisions in community activities can promote and maintain health. Ethical care and general systems theory are discussed next to demonstrate further applications to nursing. Table 1.2
Psychosocial Theoretical Approaches for Community Health Care
Ethical Care Ethical concepts relating to population health focus on the interdependence of people and what is of benefit to the population, while maintaining respect for the individual (Barrett et al., 2016). This social justice concept aligns well with the utilitarian ethical concept of doing the greatest good for the greatest number. The concept of distributive justice, a component of social justice, emphasizes the need to equalize access to resources, assets, and services for all within a community (Devia et al., 2017). Social justice is at the foreground for combating health care
Concepts from Other Disciplines Application to Community/Public Health Nursing
Ethics, Distributive Justice, Social Justice First aid, food, and water distribution after a regional disaster
General Systems Theory, Family Systems Model
Assessment of the community
Behavioral Change Models:
● Transtheoretical Health Model ● Health Belief Model
Smoking cessation campaign and support groups
Community Organization Models:
● Mobilizing for Action Through Planning and Partnerships (MAPP)
● PRECEDE-PROCEED Model ● Community-Based Collaborative Action
Research (CBCAR)
Community and health care professionals collaborate to improve health through participatory decision making toward identification of key issues and strategies to develop and mobilize programs to achieve health goals
inequities and health disparities. Every human has a fundamental right to health and well-being (WHO, 2017). Health inequities and disparities promote disease transmission, poverty, illiteracy, contaminated air and water, inadequate nutrition, and other aspects affecting a person’s health. Nurses have knowledge, skills, and the duty to care in order to rebalance inequities and decrease health disparities. Nurses have access to numerous resources pertaining to nursing ethics and public health, including
● ANA’s Code of Ethics for Nurses with Interpretive Statements (2015) ● ANA’s The Nurse’s Role in Ethics and Human Rights (2016) ● ANA’s Public Health Nursing: Scope and Standards of Practice (2015) ● ANA’s Nursing’s Social Policy Statement (2010) ● The ICN Position Statement on Nurses and Human Rights (2006) ● The ICN Code of Ethics for Nurses (2012) ● CDC’s Public Health Ethics website ● Principle of the Ethical Practice of Public Health (2002) ● WHO Guidelines on Ethical Issues in Public Health Surveillance (2017) ● Public Health Ethics: Cases Spanning the Globe (2016)
The Public Health Leadership Society’s Principle of the Ethical Practice of Public Health (2002) contains 12 principles of ethical practice of public health, often referred to as the public health code of ethics (National Association of County and City Health Officials, n.d.). These principles are also used by the CDC, the APHA, and the National Association of County and City Health Officials.
Table 1.3
A Comparison of Clinical vs. Public Health Ethics Focus
Clinical Ethics Focus Public Health Ethics Focus
Individual autonomy is central; focus is on consent and privacy
Interdependence is central; autonomy can be restricted to protect the public
Treatment of individual disease Prevention of disease in population
Fiduciary relation to patient Public stewardship
Individual informed consent Community engagement
Individual patient benefit and harm
Populations and communities
Note. Adapted from Good Decision Making in Real Time: Public Health Ethics Training for Local Health Departments. Student Manual, by the Centers for Disease Control and Prevention, 2017.
General Systems Theory General systems theory is one approach to develop a broader understanding of population health. Ludwig von Bertalanffy proposed a way of studying components of systems by applying Aristotle’s view that a whole is greater than the sum of its parts. Suprasystems, or wholes, comprise a system, the environment around the system, and energy flowing from the system (see Figure 1.2). Multiple systems may be contained within a suprasystem. Assessing all of the components and the flow of energy exchanges provides a greater perspective of the suprasystem (Von Bertalanffy, 1972; Drack, 2009). The flow of energy and system components works to resist stressors to the system and keep equilibrium, which is a state of balance or stability (Eshlemann & Davidhizar, 2000). Changes in the suprasystem influence systems and subsystems. The change may be small but can yield a large impact on a subsystem. In reverse, small changes in one part of a subsystem or system can alter the other aspects of the system and result in larger changes in the system or suprasystem. Sometimes this is known as the “butterfly effect,” which refers to the analogy that a butterfly fluttering its wings in one country moves and stirs the air until subsequently there is a change in weather in another country, such as a hurricane or tornado (Andrews, 2010).
Nurses use the assessment components of the nursing process to gain a perspective of the larger whole, the individual, or family. Within the context of public health, nurses influence individuals, families, and communities to make measurable changes toward established health goals. Nurses observe external influences on persons, the interactions within persons and families, and the influences from persons and families on the surrounding environment. Through these observations, nurses gain a greater perspective of the persons’ or families’ health and life,
Individual benefit and harm Greatest net social good
Clinicians making medical interventions
Array of interventions and professionals
Authority based on doctor or profession
Authority based on police powers
Law more of an adversary than an ally
Law/Policy a key tool of the profession
Justice focus limited to access to care
Social justice and health equity central
stressors on the life, and resources to maintain or restore equilibrium. Through the assessment of needs, strengths, and barriers, nurses initiate steps to empower change across multiple levels: person, family, and the community.
Figure 1.2
General Systems Theory and Energy Flow
General Systems Theory
Premises of general systems theory include the following:
● A system consists of an overall whole called a susprasystem. ● Inside the susprasystem are three components:
○ A system with internal energy exchanges, known as throughput, ○ Input or environment energy influences around the system, and ○ Output or energy exchanges coming from the system.
● Studying the input, throughput, and output of the parts of the susprasystem creates a greater perspective of the whole susprasystem (Von Bertalanffy, 1972; Drack, 2009).
Nursing Theoretical Approaches The theoretical and conceptual foundations of nursing practice incorporate the concepts of humans, environment, health, and nursing. The relationship of these concepts to one another reflect the exchange between members of the locus of care. The nurse interacts with individual clients, who in turn engage with environmental influences, socioeconomic and cultural factors, and unique attributes that inform health and well-being. Prominent nursing theoretical approaches and general premises pertaining to health and wellness have application in population health care (see Table 1.4).
Table 1.4
Nursing Theoretical Approaches for Population Health Practice
Nursing Concepts Premise Application to Population Health Practice
Anderson’s Client As Partner Community populations are those directly affected; known as stakeholders; are partners in health care
● Community involvement as a partner, stakeholder, and collaborator in the assessment of healthy after-school activities for local teens
● Grant writing to increase availability of resources
King’s Theory of Goal Attainment
Purposeful, quality interactions between people, groups, and community for community functioning, development, and health maintenance
Community nurses use resources such as pamphlets, to educate the public of the dangers of carbon monoxide poisoning with generator use, helping to significantly reduce the number of deaths the following winter
Leininger’s Transcultural Nursing
Understanding diverse cultural health beliefs aids in support of human health choices and care
Respect and support of alternative health practices
Neuman’s System Theory Continuous interaction of humans with each other and with environmental stimuli; expanded awareness and competence to function and maintain balance and harmony in presence of stressors and defend against threats
● Presence of stressors associated with aging noted, such as isolation from others
● Community network is established for reducing isolation of the elderly through friendly visitors and community yoga exercise groups
Orem’s Self Care Deficit Theory
Concept of empowerment; clients have deficits in ability to provide health care for themselves; nurses assist client with restoration/rehabilitation of health
The nurse provides education, advocacy, and skilled interventions that assist the community to obtain healthy lives and empowers the community to take charge of its health
Check for Understanding
Orlando’s Nursing Process Assessment, planning, implementation, and evaluation as an organized approach to nursing care delivery
● Community assessment of high suicide rates among local teenagers
● Planning and implementing suicide prevention education for a local school district
● Evaluation of subsequent suicide rates among local teens of the school district
Pender’s Health Promotion Model
Factors and relationships contribute to health-promoting behavior, health enhancement, and quality of life
Interpersonal influences of community health helps smokers commit to smoking-cessation program
Roy’s Adaptation Model Process of adaptation to the environment/external stimuli
● Advocacy for increasing physical accessibility to public places
● Advocacy for changing school lunch menus and vending machines to healthy nutritional choices
Watson’s Caring Healthy community is holistic integration of social, spiritual, and personal resources to attain or maintain health for members’ body, mind, and spirit
Caring and compassion shown in aiding the homeless population
1. Which nursing theoretical foundation that applies to individuals can be expanded to apply to population health?
2. How do nursing theoretical concepts enhance the nurse’s approach to population health care?
Community Assessment and the Nursing Process
● Communities have three components: the population, a location, and a social system; therefore, nurses assessing the communities consider the people within, the boundaries of the location, and the general environment where the community exists. Narrowing the focus begins by establishing boundaries or parameters in which to examine members of a community and the environment. Professionals can also narrow the focus by defining sets of factors, or variables, and analyzing population sets in various databases.
Population of Focus Defining and describing characteristics of the population of focus is the first step in population-focused assessment. The population may reside in a large metropolis, a small rural community, or in a particular geographical region in which members of the population are influenced by unique social, economic, and political circumstances. Certain health care conditions and disparities are more prevalent in locations with larger population size, density, and composition of characteristics. Over time, populations can grow or decline, and population characteristics can change. Demographic characteristics, including culture, gender, educational level, marital status, occupation, and income, form the basis for assessing population needs and gaps in health.
Geopolitical Place Environmental factors relevant to the geographic location affect the health of the community. One means of examining the environmental conditions influencing the quantity and quality of life for a given population is to evaluate the geopolitical location of a population. A geopolitical place consists of community boundaries, transportation infrastructure, geographic features, climate, vegetation, animals, and human-made homes and facilities. The nurse may begin by defining the place in terms of natural geographic boundaries. Various mountain ranges may surround the
community. A river or rivers may dissect the area, or border the region. Injury and natural disasters that occur are also associated with geographic location. This can include animal influences on health (e.g., kicking, bites, or attack), poisonous vegetation, outdoor recreational activities common in the area, geological activity, temperature extremes, and other adverse weather activity.
Constructed geopolitical boundaries include ZIP codes, census tracts, voting districts, suburb dimensions, school districts, health districts, and other legal or political boundaries. Man-made structural boundaries, such as streets, bridges, airports, and transportation tracks, complete the picture. Epidemiologic studies use data from specified geopolitical places to determine population demographics, diversity, health services, and resources, including structural facilities.
GIS tracking can assist health professionals in defining geographical or population boundaries. Additionally, GIS can be used as a framework to organize health patterns, disparities, and behaviors related to geographic overlay. In other words, GIS helps to determine where there are disparities, health behaviors, or health deficits in an environment related to the geography of the area. The organizing system of GIS can help professionals in population health informatics to track and analyze data, define problem areas, and assess populations, so intervention can be determined and implemented.
Phenomenological Place Phenomenological place is a relational or psychological location rather than a geographical location. A phenomenological place centers on history, culture, economics, education, spiritual beliefs, values, common characteristics, or similar goals. These independent and interdependent relationships create a context in which members of the community experience belonging. An individual may belong within various phenomenological places. For example, one person may belong to a church organization, cultural heritage group, library-reading group, and a political activism group. Another person may belong to an animal shelter volunteer group, online graphic novel interest group, and a veterans’ group. Social interactions, common interests, goals, and various other characteristics assessment and analysis aids determination of health status and health needs.
The community components discussed in this chapter are foundational to understanding community assessment. Demographic characteristics of the population of focus determine the size of population for assessment and the characteristics of the population. Geopolitical and phenomenological place aid in the development of geographical, political, and psychosocial context that guides population assessment.
Assessment Approach A community assessment involves researching the safety and quality aspects of a community to understand the interactions among the population, environment, and resources. Pertinent informatics and community data retrieval from various resources measure behaviors and health status of the population. Much like conducting a health assessment, the nurse undertakes a
sequence of steps to discover subjective and objective information and then analyzes the findings. Based on the findings, the nurse identifies needs, priority outcomes, a plan, intervention, and a means to evaluate the intervention outcomes. Much like an individual health assessment, the community or population assessment happens in an organized manner to avoid overlooking subtle positive and negative findings. The process may take weeks or months and may halt the prioritization of needs while funding and resources, such as people, assemble.
The first step in a community assessment is refining the focus to a particular targeted population group or location. Although an extensive community assessment is possible, usually an initial assessment occurs on a smaller scale. When conducting a community assessment, the nurse determines what population and location will be assessed and if assistance of others or key stakeholders are needed for the assessment. The assessment process includes the gathering of data and observing the given group of people and their location for physical, psychological, sociological, economic, spiritual, and lifestyles that reveal the current health status, problems, or barriers to priority needs. Quantitative (numerical) and qualitative (explanatory or descriptive) data are utilized as resources for a community assessment. Both are collected from both primary and secondary sources of information.
Primary Sources of Data Primary sources of data include the critical assessment resources of the defined community. The people conducting the assessment directly collect the information. The components include, but are not limited to, the people/population, geopolitical or phenomenological place, health information systems, and the observable social interactions. These sources provide information that the nurse and other group members obtain directly through means such as observation and surveys. A population has parameters of variables or factors that define the assessment or analysis.
The nurse can inspect the location of and listen to the population by conducting a walking or windshield survey. A windshield survey occurs when someone drives through a defined community’s geographical location, making observations of the locale. The person seeks impressions of what life is like for the population in the neighborhood(s) and what those in the heart of the area need. Housing age and general condition, availability of public transportation, noise levels, general condition of motor vehicles, street or road conditions, traffic flow, types of businesses, sources of recreation, education, police, fire department, and health care accessibility are noted, along with natural boundaries, terrain, and climate. Observations provide evidence of spiritual beliefs, architecture style, decay or renewal, and open spaces, such as parks or vacant lots, to help form a picture of the life there. Signs of life may include notices and posters (Mengistu & Misganaw, 2006). If walking through the area, the person assessing the area may engage in conversations with people on the street, asking questions about the area. An imprint or mental snapshot forms about what the population encounters day to day. A sense of the area or people’s history, demographics, ethnicity, values, and beliefs forms. Walking and windshield surveys provide firsthand impressions of the physical environment, economy, political and governmental activity, recreation, availability of transportation, education, safety, health, social services, and communication venues (Anderson & McFarlane, 2015). Because walking or windshield surveys are not always feasible, the nurse is likely to use a secondary
resource, such as data from databases or health warehouses, to analyze the extent and significance of health status or disparities.
Secondary Sources of Data The nurse gleans pertinent data from secondary sources including research conducted by others at a previous time. Websites and public documents are resources for gathering this information. Data warehouses of epidemiological information can reveal current issues and help with trending. GIS surveys can use computer information systems to overlay information such as health variables, access to health care, transportation systems, neighborhoods, food availability, or other available data to get a clear picture of how variables interact to increase or decrease health outcomes. Further assessment continues through research of additional primary and secondary sources of data and use of technology. The results of public forums and focus groups provide additional material. These forums and focus groups are a venue for people to answer some predetermined questions about a particular topic, permitting those who would not ordinarily express an opinion an opportunity to provide input (Rotary International, n.d.).
The assessment uses a holistic approach and identifies sources of spiritual support in the community. The aim is to uncover the biological, spiritual, and psychosocial factors that compose the population studied (CDC, 2010). The nurse can detect the effect humanitarian and spiritual mission-based groups have on the community. For example, Habitat for Humanity creates safe, affordable shelters with long-lasting, life-changing effects. Support groups and counseling services may have a spiritual-based background, such as local Alcoholic Anonymous groups, bereavement groups, equine or pet therapy programs, and divorce or single parent support groups. Food banks, homeless shelters, and clothing centers operate as mission-based services. Interfaith organizations join to form larger programing, such as Interfaith Hospitality Network’s mission to provide food and temporary shelter for families. The nurse assesses the organizations’ impact on the reduction of health inequities and disparities. If an organization is not available to provide a service or discontinues a service, the nurse assesses for gaps and other possible interventions. Likewise, spiritual resources can aid nursing interventions that reduce health inequities and disparities.
The desired outcome of studying both primary and secondary sources is to form an understanding of the populations, creating a complete picture of the defined population in the community, their health status, and their health behaviors. The understanding includes awareness of community history, organizations or groups among the population, and social, political, and economic changes for the population. Comparisons to other like populations provide further understanding through the compare/contrast processes (YMCA, 2012). Health problems become more prominent. During this process, the nurse may align with community leaders who are stakeholders in the outcome or persons who become partners in the pursuit of health improvement. The terminology, partner in care, indicates that an individual or a group within the population or community becomes a partner and collaborator in the public health arena, with a voice in determining the approach to care.
●
Table 1.5
Primary and Secondary Sources of Data
Primary Sources of Assessment Data Examples
People ● Structured interviews of key individuals or stakeholders who have knowledge of particular alterations or situations
○ People in the situation ○ Volunteers ○ Workers with knowledge ○ Spiritual groups
Environment ● Feedback from the environment of the communities functioning physically and socially
● Determination of assets and resources
Boundaries Statistics or description of the population’s parameters
Demographics ● Observations ● Key interviews
Observation ● Walking or windshield survey ● Group dynamics
Secondary Sources of Assessment Data Examples
National Sources ● U.S. Census Bureau ● Government publications of data
State Sources ● Birth, deaths, and disease statistics ● Climate statistics ● Air quality ● Health department
Local Sources Public school finances, school enrollment, levels of education, day care facilities, tax records, housing starts, government housing, shelters, employment rates, occupations, fire and police protection, publication of local history media (radio, television, newspapers, city website), waste disposal and sanitation, water sources and treatment, hospitals and clinics, health department, counseling services, religious groups and facilities, sources for food and clothing, food pantry, welfare services
Survey ● Random or sample selection of members from particular groups within the population
● Responses may provide a picture of the larger population
Interviews and Presentations ● Testimonies from key community members or experts
● Presentations to/from groups
Check for Understanding
1. What nursing perceptions of the client expand when applied to a population? 2. How do primary sources enlighten the nurse’s perspective of a population? 3. How does use of secondary sources enhance the assessment of the community?
Analysis, Diagnosis, and Planning
Community Groups ● Results of forums and/or focus groups by market researchers
● Random selection or participants chosen to represent different groups of the population to discuss a topic and aid in determining the community interest in or significance of an issue
Geographical Information Systems (GIS) ● U.S. Geological Survey’s GIS showing: ○ Climate areas ○ Where people and disease cluster ○ Traffic ○ Buying patterns ○ Utility lines ○ Pollution spread
● GIS overlay of health variables and factors to enable analysis of health status
Health Information Systems Databases or data warehouses that contain pertinent population health information
● Using a SWOT analysis, the nurse categorizes the assessment findings for the population’s strengths, assets, and resources; notes weaknesses, challenges, limitations, restrictions, and overall threats to the group, and identifies both actual and potential diagnoses (see Table 1.6). The use of SWOT analysis promotes broader critical thinking about the population and environment (Community Tool Box, n.d.). Consideration of stakeholders and spiritual resources are included in this process. Table 1.6
SWOT Analysis Example
Strengths
● Housing in adequate condition ● Family shelter for those in need ● Immunization clinics rotate though
shopping areas that are within walking distance for most
● Multiple areas of housing for elderly with low incomes
● Discount food warehouses on outskirts of area
● Decreasing adolescent pregnancy rate ● City water fluoridation system
Weaknesses
● Lack of transportation (e.g., taxi or bus service)
● High rate of unemployment among young adult population
● Lack of low-income health clinics ● Multiple downtown retailers have closed
or gone out of business, leaving buildings empty with “For Rent” or “For Sale” signage and boarded windows
Opportunities
● Faith-based initiative forming free lunch program and gathering with those with health care needs
● New YMCA slated for spring construction with room for community events
● Interdisciplinary collaboration in place through the local health department—currently planning
Threats
● Flooding from river every spring and fall ● Increasing incidence of rabies ● Power outages during summer heat
waves leave elderly without air conditioning
● Increasing incidence of opioid overdose ● Increasing incidence of adolescent
suicide rate
Steps in the assessment of a population are similar to the logic model commonly used by health professionals known as the PRECEDE-PROCEED model (Van Gelderen, Krumwiede, Krumwiede, & Fesnke, 2018). The PRECEDE-PROCEED model is a comprehensive method of assessing community needs for social and ecological areas for health promotion, then identifying desired outcomes and the process for health promotion program implementation. The nurse can use this model to organize the assessment of a population, including epidemiological data, environmental diagnosis, and organizational and policy data as a basis for program planning. The nurse formulates nursing diagnoses for the community based on the findings and problems determined from the community assessment. The diagnoses can incorporate all aspects of health. Prioritization of the diagnoses can narrow the focus and guide care when a broad range of health care needs exist. Prioritization Example
If the water supply is found to have unsafe levels of lead and elevated serum lead levels are found in some children and adults, then the contaminated water supply would be a higher priority than the development of a program for scoliosis screening. An appropriate nursing diagnosis based on the relevant assessment data could be:
Contamination related to chemical contamination of water AEB venous blood lead levels of above 10mg/dL in 25% of the adult and pediatric population and lead contamination of drinking water of 100 parts per billion in 90% of samples (CDC, 2015; CDC, 2017a).
Selection of nursing diagnoses leads to determining outcome identification. Prioritization may be in terms of what outcome will reach the largest segment of the population and have the highest impact. Alternatively, perhaps a smaller segment has highly critical or life-threatening need and will become the target of care. In either event, the nursing diagnoses are rank ordered. Outcomes fashioned specifically for the targeted population are measureable, relevant, and achievable (within the capacity of resources) and hold an explicit time requirement for completion. Plans, derived from the identified outcomes, often include primary, secondary, and tertiary prevention components. Primary prevention components aim to strengthen the population’s resistance to stressors and illness. Secondary prevention targets areas that have stressed the population or causes illness or weaknesses. Secondary prevention provides support to lessen or overcome the stressors. Tertiary prevention intends to halt further system imbalances of the system or population (Eshlemann & Davidhizar, 2000). Planning should contemplate what the population would be like if the area of concern is resolved, then consider what interventions would grow toward making that outcome a reality. Use of available community resources provides support of the plan. Predetermining measurement of the
adolescent suicide intervention program for local schools and media campaign regarding opioid overdoses
outcomes will help determine if success is evident through population behavior changes and numerical and/or percentage statistical information.
Sample Nursing Community Diagnoses
● Contamination ● Deficient community health ● Ineffective community coping ● Readiness for enhanced health maintenance ● Risk for complicated immigration transition ● Risk for injection ● Risk for injury ● Social isolation (Herdman & Kamtisuru, 2018).
Intervention and Evaluation
● The nurse has direction toward the population’s primary needs for nursing care by analyzing data, prioritizing nursing diagnoses, and determining outcomes. Then, evidence-based and best practice research regarding successful approaches by others occurs, including how to sustain success effectively. Again, the PHN may use a logic model for organization. The PROCEED portion of the PRECEDE-PROCEED model is congruent with the intervention and evaluation process. The nurse chooses achievable strategies to fit the target population, determinates resources, and seeks assistance and/or funding as needed. Perhaps, the priority is outreach to local groups regarding the importance of influenza vaccination or preparation for weather disasters. Another priority may be outreach regarding diabetic education classes at a local public health setting. Whatever the priority, by setting outcomes and determining a plan of action, the nursing process is applied to the broader population. Evaluation of results occurs upon completion of the preplanned interventions. Input into statistical programs is encouraged to provide systemic support and the discovery of trends. Statistical results support evidence of change or areas that are lagging. Future programming or improvements have more strength
toward funding and persuasion of others when backed with data reflecting improvement in health and financial implications.
Impediments to Effective Practice
● Apathy Apathy is a barrier that can impede change in population health when the population and/or
health professionals believe that change is not possible or probable. “Knowing is not enough; we must apply. Willing is not enough; we must do.”—Goethe (Institute of Medicine, 2003, iii)Resignation to poverty, illiteracy, and other health disparities creates a vacuum for motivation to change. Beliefs that the world must have the underserved, underinsured, uninsured, and lack of funds or resources can be difficult to sway. Stigma can impede health of populations. Sexual orientation disparities, migrant status, cultural and language barriers, poverty, and illiteracy bear stigmas. Embarrassment, refusal to accept charity, fear of deportation, pride, fear of separation/removal of family members become brick walls at times, hindering access into health services.
Costs Barriers such as cost, transportation, age, and geographic location impede community access to health care programs and services. Among the ongoing barriers associated with cost for communities include lack of funds to develop physical infrastructure, hire human resources (employees) to provide services, and lobby efforts toward public policies. The insufficient number of BSN-prepared nurses creates gaps in services. In this century, policy support has grown for the preparation of those with BSN and advanced nursing practice. Fortunately, awareness is growing that the cost of illness is greater than the cost of primary and secondary preventative services, including a competent workforce. The Institute of Medicine (IOM) report, The Future of Public Health (IOM, 1988), revealed disarray in the public health infrastructure. Since the report’s publication, efforts have transpired to strengthen public health agencies, develop the workforce, and envision Healthy People 2010, then Healthy People 2020 initiatives
(IOM, 2003; IOM, 2011). In addition, the ACA promoted health system reform with provisions that pursued improved quality and effect, stronger workforce and health care infrastructure, and greater focus on public health and prevention (APHA, 2012). The ACA’s emphasis on wellness care supports access to and quality of care, including public health services (Berg & Dickow, 2014).
Resistance to Change Resistance to change impedes healthy behaviors. Individuals show resistance to behaviors necessary for health. Change has the connotation of losing control or choice, sacrificing pleasures, such as favorite foods, increased cost, loss of personal time, or increased work, in the form of dedicated physical exercise. Socially constructed norms, such as cultural beliefs, some spiritual practices, medical mistrust, or mistrust of government services delay progress for positive health behavior changes. Family or social support systems that do not discuss health-related information or ridicule change reduce perceptions that change is needed. A perception of lack of risk reduces the public’s preventative behaviors (You, Chen, & Liao, 2018). The health care structure and personnel affect motivation to change. Difficulty in accessing support services, such as nutritional information, diagnostic monitoring of progress, exercise facilities, or drug therapies, slows progress. The health care professional’s demeanor can impact motivation to change. Lack of health care professionals’ emphasis on the need for lifestyle change, the impression that such change does not have a high value for that professional, or the impression that the health care professional did not have confidence the person could make lifestyle changes affect the person’s motivation (Hardcastle, Maxwell-Smith, Hagger, O'Connor, & Platell, 2018). Those not motivated to make healthy behavioral changes are often those who are at the most risk (Hardcastle et al., 2015). Conflicting information, a patient’s lack of desire to arrange support, and lack of simple messages and strategies to stay healthy contribute to delay or reinforcement of change (Hardcastle et al., 2018). Research is ongoing in methods to impact these barriers to change. The nurse should conduct a self-examination of how healthy behaviors are valued and role modeled, accurate information is provided, nonjudgmental demeanors are conveyed, barriers to health care are reduced or removed, and methods of simple messages and support are within that nurse’s practice.
Reflective Summary Public/community health nursing has historical roots. The nursing role has evolved with expected competencies for public health nursing and information technology. Nursing practice targets groups of people in addition to individuals and families. An understanding of the interplay of systems is foundational to nursing care of populations. The community becomes the nurse’s client—not a singular patient, but a group of people who interact and participate in the health and wellness of the community at large. Social justice is a concept to guide ethical care within society. Disruption of health inequities and disparities are within the realm of nursing population health practice. Nurses can conduct an assessment of the community by using the nursing process, and thereby identifying and analyzing the problem areas, health disparities, and
resources for a population. This provides insight into the conditions in which the population lives, works, and plays. By working with community stakeholders, which includes spiritual groups, the nurse can make a difference in the health of larger groups.
Key Terms Aggregate: Grouping of persons because of common characteristics or location.
Commitment: Dedication or sense of duty toward someone or something.
Community: A group of people within an open social system who share similar goals and live within a similar area.
Community-Based Collaborative Action Research (CBCAR): A research approach to understanding patterns of health problems and inequities from a social justice/ecological perspective facilitated by key community stakeholders to promote human rights and health.
Community Health Nursing: Nursing care for acute and chronic conditions outside the traditional hospital setting with a focus of restorative care.
Demographics: Statistical information regarding groups of persons.
Distributive Justice: Fair allocation of resources and services.
Empowerment: Promotion of power and authority to make decisions and changes.
Epidemiology: The study of disease appearance, course, spread, and eradication.
Equilibrium: A state of balance between stressors and energies for resistance to stressors. The state of stability.
General Systems Theory: A structure with a network of interrelated, interacting, and exchanging features that form a complex, balanced whole that can withstand external influences and disruptions. Mathematical study of change by Dr. Ludwig von Bertalanffy.
Geographic Information Systems (GIS): Digital mapping system showing grouping of multiple variables, such as climate areas, clusters of people and disease, traffic, buying patterns, utility lines, and pollution spread. Capable of overlaying health variables and factors to enable analysis of health status.
Group: Persons placed together.
Health Disparities: Variables that contribute to inequities or an unequal distribution of resources for various populations; preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by disadvantaged populations; specifically relatable to social, economic, and/or environmental disadvantages.
Incidence: Numerical rate of newly diagnosed occurrences of a disease in a population; numerical value used as part of rate or frequency determination.
Mobilizing for Action Through Planning and Partnerships (MAPP): Method of community-wide strategic planning, facilitated by public health leaders using the essential services of public health to help communities make health and quality of life improvements.
Partner in Care: An individual or group within the population or community who becomes a partner and collaborator in the public health arena, with a voice in determining the approach to care.
Population: Inhabitants of an area.
Population-Focused: Attention particular to a given population.
Population Health: Defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group.
Prevalence: Numerical fraction or ratio of disease diagnosis (incidence) in comparison with the total population group; term used as part of rate or frequency determination.
Public Health: The practice of protecting and promoting quality of life of persons and communities through the use of science, research, and direct care to prevent disease outbreaks, environmental hazards, injuries, and poor health.
Public Health Nursing: “The practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences” (APHA, 2013, p. 2).
PRECEDE-PROCEED Model: Logic model, developed by Lawrence Green, used as a tool by health professionals to design, implement, and evaluate programs for health promotion and health behavior changes.
Social Justice: Treating all fairly no matter what socioeconomic background, ethnicity, age, citizenship, disability, or sexual orientation.
Stakeholder: Person or persons both involved and directly affected by plans, actions, and outcomes. Person with a vested interest or personal stake in the outcome.
SWOT Analysis: An assessment and analysis technique used to determine internal strengths, internal weaknesses, broader opportunities or external resources, and external threats for a population or an organization. Method to develop a more in-depth perspective of an issue.
Suprasystem: Large structure or system with smaller components or subsystems.
Vision: An aspiration or a plan for the future.
References American Nurses Association. (n.d.). Public health nursing. Retrieved from
http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PublicHealt hNursing
American Public Health Association. (n.d.). What is public health? Retrieved from https://www.apha.org/what-is-public-health
American Public Health Association. (2012). Affordable Care Act overview. Retrieved from https://apha.org/~/media/files/pdf/topics/aca/aca_overview_aug2012.ashx
American Public Health Association. (2013). The definition and practice of public health nursing. Retrieved from https://www.apha.org/~/media/files/pdf/membergroups/phn/nursingdefinition.ashx
Anderson, E. T., & McFarlane, J. M. (2015). Community as partner: Theory and practice in nursing. (7th ed.). Philadelphia, PA: Wolters Kluwer Health—Lippincott, Williams, & Wilkins.
Andrews, A. (2010). The butterfly effect: How your life matters. Naperville, IL: Simple Truths, LLC.
Association of Public Health Nurses. (n.d.). What is a PHN? Retrieved from http://phnurse.org/What-is-Public-Health
Barrett, D. H., Ortmann, L. W., Dawson, A., Saenz, C., Reis, A., & Bolan, G. (Eds.). (2016). Public health ethics: Cases spanning the globe. Springer Open. Retrieved from https://link.springer.com/content/pdf/10.1007%2F978-3-319-23847-0.pdf
Berg, J. G., & Dickow, M. (2014). Nurse role exploration project: The Affordable Care Act and new nursing roles. Nurse Leader, 12(5), 40-44. doi: 10.1016/j.mnl.2014.07.001
Buhler-Wilkerson K. (1985). Public health nursing: In sickness or in health? American Journal of Public Health, 75, 1155-1161. doi: 10.2105/AJPH.75.10.1155
Bush, G. W. (2004). Incentives for the use of health information technology and establishing the position of the national health information technology coordinator. Federal Register, 69(84), 24059-24061. Retrieved from https://www.federalregister.gov/documents/2004/04/30/04-10024/incentives-for-the-use-of-h ealth-information-technology-and-establishing-the-position-of-the
Canales, M., & Drevdahl, D. (2014). Community/public health nursing: Is there a future for the specialty? Nursing Outlook, 62, 448-458. doi: 10.1016/j.outlook.2014.06.007
Centers for Disease Control and Prevention Foundation. (2017). What is public health? Retrieved from https://www.cdcfoundation.org/what-public-health
Centers for Disease Control and Prevention. (n.d.). Ten essential public health services and how they include addressing social determinants of health inequities. Retrieved from https://www.cdc.gov/socialdeterminants/tools/index.htm
Centers for Disease Control and Prevention. (2010). Community health assessment and group evaluation (CHANGE) action guide: Building a foundation of knowledge to prioritize community needs. Atlanta, GA: U.S. Department of Health and Human Services.
Centers for Disease Control and Prevention. (2014). The 10 essential public health services: An overview. Retrieved from https://www.cdc.gov/stltpublichealth/publichealthservices/pdf/essential-phs.ppt
Centers for Disease Control and Prevention. (2015). Lead in drinking water. Retrieved from https://www.cdc.gov/nceh/lead/leadinwater
Centers for Disease Control and Prevention. (2017a). Lead. Retrieved from https://www.cdc.gov/nceh/lead
Centers for Disease Control and Prevention. (2017b). The public health system & the 10 essential public health services. Retrieved from https://www.cdc.gov/stltpublichealth/publichealthservices/essentialhealthservices.html
Community Tool Box. (n.d.). Chapter 3, Section 14. SWOT analysis: Strengths, weaknesses, opportunities, and threats. Retrieved from http://ctb.ku.edu/en/table-of-contents/assessment/assessing-community-needs-and-resourc es/swot-analysis/main
DeSalvo, K. B., Dinkler, A. N., & Stevens, L. (2015). The US Office of the National Coordinator for Health Information Technology: Progress and promise for the future at the 10-year mark. Annals of Emergency Medicine, 66(5), 507-510.
Devia, C., Baker, E. A., Sanchez-Youngman, S., Barnidge, E., Golub, M., Motton, F., . . . Wallerstein, N. (2017). Advancing system and policy changes for social and racial justice: Comparing a rural and urban community-based participatory research partnership in the U.S. International Journal for Equity in Health, 16, 1-14. doi: 10.1186/s12939-016-0509-3
Drack, M. (2009). Ludwig von Bertalanffy's early system approach. Systems Research & Behavioral Science, 26, 563-572. doi: 10.1002/sres.992
Eshlemann, J., & Davidhizar, R. (2000). Community assessment: An RN-BSN partnership with community. ABNF Journal, 11(2), 28-31.
Fee, E. & Bu, L. (2010). The origins of public health nursing: the Henry Street Visiting Nurse Service. American Journal of Public Health, 100, 1206-1207. doi: 10.2105/AJPH.2009.186049
Frontier Nursing Service. (2015). Introduction to Frontier Nursing University. Frontier Nursing Service Quarterly Bulletin, 90(2), 1.
Frontier Nursing University. (n.d.). History of FNU. Retrieved from https://frontier.edu/about-frontier/history-of-fnu
Hardcastle, S. J., Hancox, J., Hattar, A., Maxwell-Smith, C., Thøgersen-Ntoumani, C., & Hagger, M. S. (2015). Motivating the unmotivated: How can health behavior be changed in those unwilling to change? Frontiers in Psychology, 6, 835, 1-4. doi: 10.3389/fpsyg.2015.00835
Hardcastle, S. J., Maxwell-Smith, C., Hagger, M. S., O'Connor, M., & Platell, C. (2018). Exploration of information and support needs in relation to health concerns, diet and physical activity in colorectal cancer survivors. European Journal of Cancer Care, 27(1), 1-9. doi: 10.1111/ecc.12679
Harkness, G. A., & DeMarco, R. F. (2015). Community and public health nursing. (2nd ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Herdman, T. H., & Kamtisuru, S. (Eds.). (2018). NANDA International nursing: Diagnoses and classification 2018-2020. (11th ed.). New York: Thieme.
Institute of Medicine. (1988). The future of public health. Washington, DC: The National Academies Press.
Institute of Medicine. (2003). The future of the public's health in the 21st century. Washington, DC: The National Academies Press.
Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.
Joyce, B. L., O’Brien, K., Belew-LaDue, B., Dorjee, T. K., Smith, C. M. (2014). Revealing the voices of public health nurses by exploring their lived experience. Public Health Nursing, 32, 151-160. doi: 10.1111/phn.12113
Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health, 9, 380–383. doi: 10.2105/ajph.93.3.380
Kulbok, P. A., Thatcher, E., Park, E., & Meszaros, P. S. (2012). Evolving public health nursing roles: focus on community participatory health promotion and prevention. Online Journal of Issues in Nursing, 17(2), 1. doi: 10.3912/OJIN.Vol17No02Man01
Mengistu, D., & Misganaw, E. (2006). Community health nursing. Ethiopia: The Carter Center. Retrieved from https://www.cartercenter.org/resources/pdfs/health/ephti/library/lecture_notes/nursing_stude nts/comm_hlth_nsg_final.pdf
National Association of County and City Health Officials. (n.d.). Public health ethics. Retrieved from https://www.naccho.org/programs/public-health-infrastructure/ethics
National CPR Association. (n.d.). 20 nursing quotes selected to give you strength and inspiration. Retrieved from https://www.nationalcprassociation.com/20-nursing-quotes-selected-to-give-you-strength-an d-inspiration
Public Health Foundation. (n.d.). Quad Council public health nursing competencies. Retrieved from http://www.phf.org/resourcestools/Pages/Public_Health_Nursing_Competencies.aspx
Quad Council Coalition of Public Health Nursing Organizations. (n.d.). Quad Council competencies for public health nurses. Retrieved from http://www.quadcouncilphn.org/documents-3
Reifsnider, E., & Gracia, A. A. (2015). What’s in a name? Does population health have the same meaning for all stakeholders? Public Health Nursing, 32(3), 189-190. doi: 10.1111/phn.12202
Rotary International. (n.d.) Community assessment tools: A resource for Rotary projects. Retrieved from https://my.rotary.org/en/document/community-assessment-tools
Swider, S. M., Krothe, J., Reyes, D., & Cravetz, M. (2013). The Quad Council practice competencies for public health nursing. Public Health Nursing, 30(6), 519-536. doi: 10.1111/phn.12202
Swider, S. M., & Kulbok, P. A. (2015). Creating the future of public health nursing: A call to action. Public Health Nursing, 32(2), 91-93. doi: 10.1111/phn.12193
Van Gelderen, S. A., Krumwiede, K. A., Krumwiede, N. K., & Fenske, C. (2018). Trialing the community-based Collaborative Action Research Framework: Supporting rural health through a community health needs assessment. Health Promotion Practice, 19. doi: 10.1177/1524839917754043
Von Bertalanffy, L. (1972). The history and status of general systems theory. Academy of Management Journal, 15, 407-426. doi: 10.2307/255139
World Health Organization. (n.d.). Public health surveillance. Retrieved from http://www.who.int/topics/public_health_surveillance/en
World Health Organization. (2017). Human rights and health. Retrieved from http://www.who.int/mediacentre/factsheets/fs323/en
YMCA. (2012). Community audit tools: Three examples of assessments used to address community health and equity. Retrieved from https://activelivingresearch.org/sites/default/files/2012_CommunityAssessments_Hohman-P arker-Rufo-Morales.pdf
You, S. H., Chen, S. C., & Liao, C. M. (2018). Health-seeking behavior and transmission dynamics in the control of influenza infection among different age groups. Infection and Drug Resistance, 11, 331-343. doi: 10.2147/IDR.S153797
CHAPTER 2 Epidemiology and Global Health By Sue Z. Green
“In a world facing considerable uncertainty, international health development is a unifying – and uplifting – force for the good of humanity” —Dr. Margaret Chan, Director-General, World Health Organization (2017f).
Essential Questions ● How do epidemiology and communicable disease affect local, community, state,
national, and global health care? ● How do global health issues shape the provision of health care? ● What socioeconomic variables could be modified to impede or halt disease
development? ● Which Sustainable Developmental Goals apply to direct improvement of global health? ● How does societal unrest disrupt global health goals?
Introduction National and global threats to health are monitored by local, state, national, and international agencies and organizations. Researchers seek to identify and control these threats or eliminate them entirely. The principles used to examine and achieve prevention or control of disease are
foundational to public health care. Nurses gain knowledge and skill by learning research approaches that use statistical data to predict the potential for disease and identify the probabilities associated with disease prevention. In this chapter, initiatives to reduce threats to population health are discussed on both the national and global scale. The process used to investigate diseases that threaten a community or a larger population is also explored, in addition to methods nurses can employ to avert or reduce disease impact.
Global Perspective of Health Centers for Disease Control and Prevention
● The Centers for Disease Control and Prevention (CDC), an agency of the U.S. federal government, has multiple responsibilities to protect national and global health. T CDC is the foremost public health agency of the U.S. government. The CDC’s mission is to protect the nation’s health, safety, and security from threats within and from outside the United States (CDC, 2014). This agency operates 24 hours a day 7 days a week to uncover and react to local, national, and global health threats while using evidence-based methods and technology to prevent, contain, or eliminate disease, disability, and death in the United States (CDC, 2017). This includes the development of a public health workforce that promotes health and safety for individuals, communities, and the environment (CDC, 2014). The United States participates directly or indirectly in global programs that affect the nation’s health, such as activities lead by the World Health Organization (WHO).
The World Health Organization (WHO) The WHO, an agency of the United Nations, is considered the “global guardian of public health” (World Health Organization [WHO], 2016, p. 1) and has the overall role of global health security. Global health security is defined as proactive and reactive activities that reduce vulnerability of populations to health threats regionally and internationally. The health care system spans all countries of the globe and, while each country organizes the delivery of care differently, there are health concerns that all countries face. The health threats include disease outbreaks, malnutrition, bioterrorism, harmful environment or climate, and any emerging disease, epidemic, endemic, or pandemic. The frequency of world travel increases the likelihood of a health issue being transported from one country to another. The guardians of global and national health security implement policy and preventative measures to control and
eradicate the national, regional, and international threats. According to the WHO’s Director-General, Dr. Margret Chen, “countries with strong health systems are better prepared to cope with the added demands on health services and staff that outbreaks and other health emergencies inevitably bring” (WHO, 2017f, p. 27). Thus, monitoring global health threats and assisting other countries with health issues is pertinent to the CDC and national health security.
Epidemiology and Epidemiological Research Concepts
● Epidemiology is the study of disease appearance, course, spread, and eradication. The science, research, and technology associated with epidemiology aids the development of strong health systems. Applied epidemiology is the application of epidemiologic studies for control and prevention of diseases and other health problems. Epidemiological principles, including public health assessment, policy development, and public assurance, are applied throughout the essential functions and services of public health delivery. With various subspecialties, this science involves the interplay of human, animal, and insect populations and the environment. Epidemiologists aim to discover the factors affecting disease occurrence, determine who has the greatest risk from these factors, and evaluate the effectiveness of health services to reduce risks and improve population health. Disease detectives is a name that applies to the scientists, physicians, nurses, veterinarians, and other health professionals who work as Epidemic Intelligence Service (EIS) officers (CDC, 2018). These detectives conduct field investigations to identify causes of outbreaks or sudden eruptions related to diseases and health problems. Table 2.1 provides a list of public health problems and events that EIS officers investigate. Table 2.1
Public Health Problems and Events
Environmental Exposures Lead and heavy metals
Air pollutants and other asthma triggers
Note. Adapted from “Teacher Roadmap: What is Epidemiology?” by the Centers for Disease Control and Prevention, 2016. Copyright 2016 by the Centers for Disease Control and Prevention.
Epidemiological Approach Specific functions of public health departments, including the CDC and the WHO include public health surveillance; field investigation; analytic study; evaluation of public health services’ effectiveness, accessibility, and quality; and policy development (CDC, 2012). Public health surveillance is the uninterrupted systematic collection, analysis, and interpretation of health data to guide decision making, planning, implementation, and evaluation of public health practices (CDC, 2012; WHO, n.d.b). The surveillance provides information for action and becomes an early warning system for public health emergencies. The process utilized in public health surveillance also fosters documentation of the impact of health interventions, including tracking progress toward goals and monitors health problems to determine priorities. This information is used to inform the development of public health policies and strategies (WHO, n.d.b). The process of surveillance is not limited to communicable disease, but may include chronic disease, genetic and birth defects, maternal health, nutrition, health behaviors, and potentially health problems related to environment or occupation (CDC, 2012). Field investigators study
Infectious Diseases Foodborne illness
Influenza and pneumonia
Injuries Increased homicides in a community
National surge in domestic violence
Noninfectious Diseases Localized or widespread rise in a particular type of cancer
Increase in a major birth defect
Natural Disasters Hurricanes Katrina and Rita (2005)
Haiti earthquake (2010)
Terrorism World Trade Center (2001)
Anthrax release (2001)
outbreaks of infectious and noninfectious diseases and health problems to identify cases and causes. A case is what meets the standardized criteria of person, place, time, and clinical features specific to the outbreak or incident under investigation. The investigators also recommend and implement strategies for prevention and control of disease, disabilities, injuries, and death (CDC, 2018).
Descriptive and Analytic Epidemiology Epidemiologic researchers study the distribution of health events and health conditions to determine the potential causes of disease and identify approaches to control the spread of disease. In conjunction with surveillance and field investigations, descriptive epidemiology and analytic epidemiology research methods are employed when precision is required. Descriptive studies characterize outbreaks according to person, place, and time (CDC, 2012, 2014). Descriptive studies can generate hypotheses related to the people, time, and place associated with the outbreak. Analytic epidemiology examines the cause and effect relationship between variables through a comparison of groups. Hypothesis testing is conducted to explain the “how” and “why” of a health problem. The studies seek quantifiable data to determine the root causes of disease and to provide evidence for prevention and control measures.
Seminal Case
In 1854, approximately 600 people died within three weeks from an outbreak of cholera
in London (HavardX, 2017; Shiode, Shiode, Rod-Thatcher, Rana, & Vinten-Johansen,
2015). John Snow, a physician, suspected that cholera was spread by way of
contaminated water. Snow canvassed the neighborhood to determine who became ill
and where they obtained their water. At that time, human waste was commonly tossed
into the streets, and bodily fluids drained into the ground, contaminating the water
below. By conducting a field investigation and plotting the data on a map, Snow
determined that the concentration of people, place, and time coincided with incidence of
disease. He concluded that the individuals who were drinking water from a central water
pump became ill as a result of contaminated water. (HarvardX, 2017; Papini &
Santosuosso, 2017; Shiode et al., 2015). Snow’s hypothesis was supported when he
determined that workers at the local brewery and workhouse did not drink from the
Broad Street pump and did not contract cholera (HarvardX, 2017). Access to the pump
was removed, and cases of cholera began to decline shortly thereafter (Public
Broadcasting System, 2010).
Types of Analytic Epidemiological Studies Analytical epidemiological studies fall into one of two categories: experimental and observational. An experimental study involves a controlled process of exposure in which individuals or communities are exposed to specific environmental elements. Immediately following exposure, the researchers track the subjects for effects from the exposure. Comparisons may be drawn against a control group that is not exposed to the specific elements. (CDC, 2012, 2014). An observational study is more descriptive by nature. The researcher draws inferences from observations of study participants, such as their behaviors, exposure to elements, and related activities. Systematic collection of observable data forms the basis of the conclusions of the research. An observational study may be subcategorized as a cohort, case-control, or cross-sectional study (CDC, 2012, 2014). For a cohort study, each person within a subgroup of a larger population falls into categories according to his or her exposure to one or more risk factors for a disease or condition. In a case-control study, researchers compare one group of individuals with a disease or condition to a control group of individuals not affected by the disease or condition. In contrast, a cross-sectional study examines a target population at a particular point in time without regard to exposure or disease status. This approach provides information regarding the relative prevalence of disease at a particular point of time (CDC, 2012). Cross-sectional studies are the weakest of the analytic methods and are primarily intended to provide a snapshot or description of the population’s exposure and disease status rather than to determine causation.
Concepts of Disease Occurrence A fundamental approach to disease occurrence is represented in the epidemiologic triangle, also known as the epidemiologic triad or agent-host-environment model (see Figure 2.1). Originally used to study the infectious disease process, applications of the triangle are now used to aid in the explanation and study of other health conditions’ occurrences. The triangle’s agent component, also known as the “what,” of the triangle is the organism, genetic, chemical, or physical cause of disease. The host, or “who,” of the triangle is the person or animal who can acquire the disease or condition. Risk factors can influence the host’s susceptibility and response to the agent. Risk aspects include degree and duration of exposure to the agent, immunologic status, psychological wellness, anatomic structure—such as skin integrity—and overall health status, including nutrition, genetic makeup, presence of other diseases or conditions, medication use, and health practices. A carrier is a host that is infected or holding a genetic trait of the disease or condition. A host usually displays no symptoms, but the agent lives within the person, animal, or plant. The epidemiologic triangle’s environment component, or “where,” represents the factors within the host’s environment that contribute to the chance of exposure.
Figure 2.1
Agent-Host-Environment Model
Socioeconomic environmental factors contributing to disease occurrence include crowding, sanitization, availability of uncontaminated foods and water, and access to health care. Florence Nightingale focused on the environment in order to reduce the chances of exposure and increase the survival rate of soldiers in her care during the Crimean War. The aspects of clean living conditions, rest and sleep, healthy food and water, and clean air in the environment have been hallmarks of Nightingale’s legacy. Biologic environmental factors contributing to the risk of exposure are the living organisms that can transmit diseases, such as insects, rodents, or dogs. When an agent is transferred to a person through contact or bite, the animal becomes known as a vector. Mosquitoes and ticks are common vectors in the United States that transmit disease to and from humans and animals through their bite. Vector-borne diseases are commonly under CDC and WHO surveillance. Physical environmental factors encompass climate and geology including dust particles that can carry viruses.
While the epidemiologic triangle depicts the components required for a disease occurrence, the chain of infection depicts the process for disease transmission (see Figure 2.2). The infection will not happen if a break in the chain or barrier interrupts any point of the process. The agent lives in a reservoir or setting compatible for continued live existence. The reservoir may be human, animal, or the general environmental constituents, such as water, soil, plants, or a building’s composition and equipment features. The agent moves out of the reservoir though a portal of exit. The portal of exit is the agent’s pathway of escape from the reservoir, which happens through blood, feces, or mucus leaving a skin opening from splatters of body fluids, or from aerosol into the air via coughing or sneezing. The mode of transmission is the means of the agent’s travel from the portal of exit to the host. This vehicle for travel to the host is through direct or indirect contact, ingestion, or inhalation. On arrival to the host, the agent requires an entry into the host called the portal of entry. Skin openings, mucous membranes, or body orifices, such as the nose, mouth, or urethra, provide access into the host. A vector can create a portal of entry though its bite. The last link of the chain is the host. For the infection to occur, the host must be susceptible to the agent’s pathogenicity. If the host’s immune system is strong enough, it may halt the agent’s progress. Susceptible hosts often feature those who are very young or very old, inadequately nourished, chronically ill, currently ill, or otherwise immunocompromised. In addition to open wounds, the presence of invasive medical devices, lines, or airways strain the immune system.
Figure 2.2
Chain of Infection
Emerging diseases, endemics, epidemics, and pandemics can occur. An emerging transmissible disease occurs when a previously undetected or unknown organism becomes an infectious causative agent. Alternatively, emergence results from the evolution of an existing organism, the spread of infections to new populations, or the reemergence of old infections as a result of antibiotic resistance or the breakdown of public health measures. More recently, noncommunicable diseases (NCDs) have raised concerns as emerging health conditions have grown in endemic and epidemic proportions. NCDs are noninfectious, nontransmissible disease or chronic disease, such as type 2 diabetes, arising from a combination of factors including genetic disposition, as well as environmental, physiological, and behavioral factors. A disease or health condition becomes endemic when it begins affecting a particular region or population and is present at all times. For example, African sleeping sickness is endemically present in sub-Saharan Africa, but is not endemic in the United States (WHO, 2017g). Malaria is
endemic in Africa, Southeast Asia, the Eastern Mediterranean, and the Western Pacific, but not the United States (WHO, 2017c). In contrast, an epidemic is a disease outbreak affecting a community or many communities at the same time, but is not present all the time. Examples of epidemics occurring in this century are severe acute respiratory syndrome (SARS) and the Ebola virus. Pandemics occur on a global scale. The death toll in a pandemic is generally higher than in an epidemic. The prevalence of HIV/AIDS across continents is pandemic in scale.
Use of Statistical Data with Disease Occurrence The WHO has task forces and programs aimed to eradicate endemic communicable diseases. The Malaria Threats Map is an interactive map that shows data reported to the WHO in an effort to notify epidemiologists and other health professionals for the purposes of prevention, diagnosis, and treatment (WHO, 2017d). Ending Cholera—A Global Roadmap to 2030 is a new strategy for cholera control in 20 countries where the disease is endemic (Global Task Force on Cholera Control, 2017). Outbreaks are of concern because the sudden occurrence of new cases may indicate formation of an epidemic, endangering that region, country, and the world. Yellow fever is of current concern as an endemic disease that has a resurgence of epidemic outbreaks. In response to this emergency, the WHO supports a global strategy to eliminate yellow fever epidemics by 2026 through vaccination programs (WHO, 2018). Both the CDC and WHO monitor reports of disease and condition outbreaks and emergences for epidemic emergencies. Both organizations post information on a weekly basis regarding surveillance efforts and outbreaks. Epidemiologic research and reports from health professionals are crucial to anticipating communicable disease emergencies and aiding in the development of a response. Data warehouses, which are interactive tools such as the Malaria Threats Map, direct observations and work to converge data as well as warn of issues to prevent epidemic and pandemics. In recent years, surveillance, prevention, and control measures were set in place in response to the epidemic effects of Ebola and the Zika viruses, and the H1N1 virus pandemic of 2009. Other national and global health concerns include influenza, bacterial meningitis, and antimicrobial resistance.
Statistical data is of great importance when evaluating aspects of incidence, prevalence, morbidity, and mortality. These rates, ratios, and proportion calculations can indicate the degree of risk a population experiences and the frequency of occurrence. The incidence rates denote the emergence of a new illness. Prevalence rates reflect the amount of disease in a population, compared to the overall health of the population. Ultimately, the objective data predicts the further course and spread of the disease. Multiple sources of data collection serve to form the basis of epidemiological data. The retrieval sources include questionnaires; surveys; environmental samples from the air, water, and soil prior notifications to health departments; financial records; human samples from biological testing; and government records. Access to this information is aided by electronic storage systems.
Health information systems (HIS) provide electronic data for vital statistics and health indicators. Vital statistics are measureable data regarding population groups, including births and deaths. Health indicators, developed from the compilation of data and their statistical analysis, depict the current state of health for a population, including morbidity and mortality rates. Increases in a mortality rate can trigger surveillance of a population for signs, symptoms,
and causes of illness outbreaks. Data warehouses electronically maintain important epidemiologic information, contributing to the real-time availability of data for use by epidemiologists, nurses, and other health professionals. Data warehouses are of increasing importance to public health care. The Institute of Medicine’s (2001) report, Crossing the Quality Chasm: A New Health System for the 21st Century, emphasizes the importance of data collection, the movement toward electronic storage, and the sharing of vital information.
Public Health Surveillance and Cluster/Outbreak Investigation Continuous population surveillance aids in detection of emerging health problems in order to intervene before a major outbreak occurs. The ongoing monitoring determines what problems are currently taking place and organizes the data by health problem, time, place, and population or cohort. Indicators of chronic disease are under surveillance. Data is retrievable regarding a metropolitan area or state for chronic risk factors and number of those affected by chronic disease (CDC, 2015). The CDC and WHO both periodically review diseases and conditions, and then form the determination of which illnesses become reportable to health authorities based on rate of occurrence, such as an emerging communicable disease. For example, a case of sexually transmitted disease (STD) is reportable to the local health department on diagnosis. Ebola and the Zika virus are also reportable communicable diseases. Once reported to the local health department, persons who have STDs, Ebola, or other reportable conditions are monitored, following the prescribed process of investigation.
The systematic process for outbreak investigation includes examining data as a cluster. Outbreak investigation proceeds in an orderly fashion to reduce the possibilities of overlooking important information (see Figure 2.3). Clusters occur when a small number of disease or health conditions occur. Local and state public health departments monitor, investigate, and intervene in these cases, as needed. Public health departments, the CDC, or WHO initiate an investigation when sudden or higher than normal cases of a disease or health condition occur. Field investigators for the state, CDC, and/or WHO begin by researching the outbreak, gathering equipment and supplies, and making arrangements for travel to the outbreak location. On site, the investigators speak with patients, review symptoms, and review the outcomes of diagnostic testing to verify the health problem. A case definition is developed by the investigators based on qualitative and quantitative data to categorize the results by the problem’s clinical information, characteristics of those who have the illness, location information, and illness onset and duration features. In other words, descriptive epidemiologic research ensues to define the what, who, where, when, why, and how of the disease (CDC, 2012, 2014). Once a definition is established, local health professionals are able to provide any matching cases of the illness. Investigators study the additional dates, times, places, and persons from the match to determine patterns. Research proceeds with analytic study, hypothesis developments, and testing. Lastly, investigators work to control the disease through the best evidence-based methods available for the specific illness to prevent further occurrence or spread. The investigators then communicate the successful findings of prevention to local health
professionals, the public, and other leaders so that they are informed and can participate in prevention and control measures.
Figure 2.3
Outbreak Investigation
Note. Adapted from “Introduction to Epidemiology: Slide Presentation” by the Centers for Disease Control and Prevention, 2014.
Check for Understanding
1. Which aspects of global travel increase the risk of epidemics? 2. What steps would the local health department nurse take if a local hospital reported cases of microcephaly
associated with the Zika virus? 3. How does a local health nurse use epidemiological data to promote population health?
Social Determinants of Health Social determinants of health (SDOH) are conditions contributing or hindering a person’s well-being (see Figure 2.4). These conditions include where people are born, grow, live, play,
learn, worship, work, and age (HealthyPeople.gov, 2018a; WHO, n.d.a). “Health is a human right that requires “access to timely, acceptable, and affordable health care of appropriate quality as well as to providing for the underlying
determinants of health, such as safe and potable water, sanitation, food, housing, health-related information and education, and gender equality” (WHO, 2017b, para. 1).These intertwined elements are some of the biologic, environmental, social, and economic variables that affect a person’s ability to have and maintain good health. Health disparities are the impairments specifically related to social, economic, and/or environmental disadvantages. Poverty, poor housing, social exclusion, bad sanitation, contaminated water, insufficient healthy food sources, poor health care access, and inadequate health systems are among the numerous conditions or social determinants that contribute to risks of illness.
Health equity is the attainment of high-level health care for all individuals regardless of race, ethnicity, social inequalities, location, or historical and contemporary injustices (U.S. Department of Health and Human Services [HHS], 2008). The concept of equitable health relates to social justice. More than a decade has passed since the WHO spearheaded a focus on social justice and the SDOH (WHO, 2007). The WHO’s social justice focus underscores the idea that health is a human right that requires “access to timely, acceptable, and affordable health care of appropriate quality as well as to providing for the underlying determinants of health, such as safe and potable water, sanitation, food, housing, health-related information and education, and gender equality” (WHO, 2017b, para. 1). The core components to health require quality and quantity health care information, services, programs, and facilities for every person despite age, sex, location, and socioeconomic status (WHO, 2017b). Safe, effective, people-centered, timely, equitable, integrated, and efficient services are hallmarks of quality health services (WHO, 2017b). Policies and programs to achieve health equity reduce health disparities (HHS, 2008).
Figure 2.4
Social Determinants of Health
Note. Adapted from “Social Determinants of Health,” by the Office of Disease Prevention and Health Promotion, 2018. Copyright 2018 by the Office of Disease Prevention and Health Promotion.
One of the overall goals of Healthy People 2020 is to achieve health equity, seek elimination of disparities, and promote health improvements (HealthyPeople.gov, n.d.). Healthy People 2020 initiatives address the key SDOH areas of economic stability, education, social and community conditions, health and health care, and the physical environment, known as the neighborhood environment (see Figure 2.4) (HealthyPeople.gov, 2018a). Healthy People 2020 goals consist of more than 42 topics for improving health in the United States (HealthyPeople.gov, 2018b). Leading Health Indicators represent the 12 topics with high-priority issues and correspond with advancing SDOH to promote health equity and reduction of health disparities. The 10 Essential Public Health Services have been a means for the CDC to address the SDOH (CDC, n.d.). Addressing individual health issues does not increase overall health equity and reduce disparities (Davis & Chapa, 2015). Recently, the CDC launched an initiative, Health
Impact in 5 Years (HI-5), for innovative clinical and community-wide prevention approaches that have proven, positive results, including key SDOH issues (CDC, 2016a). Community partners work with public health sectors to improve early childhood education for improved cognitive development and reduction of obesity, child abuse and neglect, youth violence, and emergency department visits (CDC, 2016b). Among others, water fluoridation, use of clean diesel public transportation, home improvement funds, and earned income tax credits are advocated. These improvements reduce tooth decay, air pollution, cardiovascular and respiratory conditions, traffic injuries, infant mortality, and maternal mental health (CDC, 2016b). These community-wide efforts are anticipated to improve health equity and reduce health disparities within a 5-year period.
Global Health Initiatives Health equity is possible—not only here in the United States, but worldwide. Polio was once a
public health emergency, but the disease is nearly eradicated as a “When we try to pick out anything by itself, we find it hitched to everything else in the universe.” —John Muir (Discover John Muir, n.d.)result of global prevention efforts (Aylward, 2014). Common public health measures to improve a community’s health include sanitation, adequate housing, clean air, and safe drinking water. Two leading population health indicators are the reduction of health disparities and increased health equity. The 1978 Declaration of Alma-Ata (WHO, 1978), from an international conference on primary care, marks a turning point in global health and cooperation among governments for the right of complete physical, mental, and social well-being for all humans. Subsequently, the United Nations declared eight Millennium Development Goals (MDGs) for completion by 2015 to reduce poverty, hunger, disease, illiteracy, environmental degradations, and discrimination against women (WHO, 2015). Monitoring corresponding health indicators reveals progress in various areas, such as reduction of extreme poverty and hunger, the child mortality rate, and the maternal mortality ratio (Shrivastava, Shrivastava, & Ramasamy, 2016; WHO, 2015). The MDGs promoted global improvements by 2015, but did not end the need for global collaboration to promote human health rights. In 2016, new WHO goals launched with a target for completion by 2030. Known as the Sustainable Development Goals (SDGs) or Global Goals, they were designed not only to continue the previous progress, but also to expand the mission of human health rights and health promotion.
Challenges to the SDGs are factors that weaken global health security, such as war or emerging disease. Challenges that weaken health security can differ from country to country, but the localized issue can become a global concern. Epidemics, such as SARS, H1N1, Ebola, and the Zika virus result in the WHO declaring emergencies to global health and shifting from infrastructure building to shoring up against a new vulnerability (Rao, 2017). Intra- and intercountry conflicts increase poverty and malnutrition while displacing millions of people (d’Harcourt, Ratnayake, & Kim, 2017). Health facilities are shut down or may no longer be structurally sound in war-torn regions or sites of natural disasters, such as earthquakes,
hurricanes, or wildfires. Supplies are interrupted or inadequate because of the strains of infectious disease, epidemic, or war as aid workers are evacuated. Mental health suffers with the stress of weakened health security, further contributing to the risk factors for illness. Other countries attempt to mitigate the damage by sending supplies, rebuilding the infrastructure, caring for migrants, and setting up quarantines. The assistance of the other countries helps reduce the vulnerability of the population to illness and works to halt spread of health risks across international borders. The CDC partners with other U.S. agencies and international organizations to prevent, detect, and respond to any threats regarding global health security (CDC, 2016b). Ongoing threats include HIV, tuberculosis, malaria, antimicrobial resistance, and the threat of pandemic influenza (National Academies of Sciences, Engineering, and Medicine, 2017).
Check for Understanding
1. How do health initiatives by the WHO, CDC, and Healthy People 2020 reduce the incidence of illness? 2. How can nurses use advocacy skills to reduce health disparities?
Leading Causes of Death Many of the top 10 causes of deaths occurring in the United States coincide with the top 10 causes of death that occur globally (see Figures 2.5 and 2.6). Heart disease is the leading cause of mortality for both the U.S. and the world. While holding differing ranks, other shared causes include chronic lower respiratory disorders, cerebrovascular diseases, Alzheimer’s disease, pneumonia, and diabetes (National Center for Health Statistics, 2017; WHO, 2017g). These illnesses are among those that are modifiable or preventable, increasing the burden of disease. The burden of disease reflects the morbidity, mortality, financial costs, and health disparities resulting from disease, affecting human longevity and the well-being of countries’ social and economic bottom lines. The nurse’s role in health promotion and disease prevention is key in both national and global goals to reduce the current leading causes of death. One means of reduction is through educating patients and the public, targeting modifiable risk factors.
Figure 2.5
Top 10 Causes of Death Globally, 2015
Note. Adapted from “The Top 10 Causes of Death,” by the World Health Organization, 2017. Copyright 2017 by the World Health Organization.
Figure 2.6
Leading Causes of Death in the U.S., 2015
Note. Adapted from Health, United States, 2016: With Chartbook on Long-Term Trends in Health, by the National Center for Health Statistics, 2017. Copyright 2017 by the National Center for Health Statistics.
“NCDs disproportionally affect people in low- and middle-income countries where more than three quarters of NCD deaths-31 million-occur” (WHO, 2017e, para. 3). Modifiable risk factors of unhealthy diet, physical inactivity, excess weight and obesity, diabetes, high blood pressure, high cholesterol, and cigarette smoking all contribute to heart disease and strokes. Fardet and Boirie’s (2013) analysis of more than 60 years of quantitative nutritional research revealed that diabetes and obesity are key diseases that lead to other diet-related chronic diseases, including cardiovascular disease. Excessive body weight and physical inactivity are risk factors for development of type 2 diabetes, which is rapidly rising in low- and middle-income countries (WHO, 2017a). National and global health initiatives now target obesity and physical inactivity in attempts to reduce NCDs (HealthyPeople.gov, 2018c; WHO, n.d.a; WHO, 2017e). As researchers learn more about genomic processes, human mobility, nutrition, and the environment, more methods become known to halt or intervene in NCDs. For example, malnutrition is certainly detrimental to health and well-being. Malnutrition develops from the
quality as well as the quantity of a diet. Diets associated with deaths have findings for high intake of sodium, processed meats, and sugar-sweetened beverages (SSB), along with findings for low intake of nuts, seeds, omega-3 fats from seafood, fruits, vegetables, and whole grains (Micha et al., 2017). A diet leading to malnutrition is known as a suboptimal diet. More recently, it has been found that a sizable portion of deaths because of heart disease, stroke, or type 2 diabetes in the United States correlate with suboptimal diets (Micha et al., 2017). Suboptimal diets are the target of studies for potential benefits of policy changes regarding fruit, vegetable, and SSB consumption in order to reduce the burden of disease (Pearson-Stuttard et al., 2017).
Nursing Roles in Prevention Nurses are involved in all levels of prevention (Institute for Work and Health, 2015). The public benefits from guidance and education from nurses at each level. Interventions targeting nutrition prevent and reduce the effects of multiple health conditions.
Primary Prevention Primary prevention measures include personal hygiene, diet, physical activity, safe food and drinking water, sanitation, and immunizations (Fardet & Rock, 2016). Nurses work at this level to educate the public in health promotion measures to prevent the occurrence of disease. For example, nurses promote immunizations against disease, sanitization measures, and good handwashing regimes for primary prevention of communicable disease. Nurses promote health education regarding nutrition and exercise, knowing the interrelatedness of these health measures to avoiding the development of NCDs. Nutrition education centers on diets of reasonably sized portions high in whole grain, nuts, seeds, omega-3 fatty acids from seafood, fruits, and vegetables that are low in SSBs, processed meats, and sodium. This includes advocacy for healthy school lunch programs and education for all ages regarding portion sizes. Health promotion and education measures for exercise can use reliable sources, such as the American Heart Association (AHA), for details regarding the amount of physical activity needed to maintain health. For example, the AHA recommends 150 minutes per week of moderate exercise, 75 minutes per week of vigorous exercise, or a combination of both (American Heart Association [AHA], 2014). Children and adolescents should have 60 minutes of moderate exercise, preferably daily (AHA, 2018).
Secondary Prevention Nurses conduct screenings for early detection and treatment of health problems. Nurses again use education to promote health, but the education is directed at measures deterring the further complications of current health problems and reducing the duration of the disease. Reduction of barriers to adequate care are part of the nursing roles in secondary prevention. Promoting measures to increase the number of people seeking and maintaining treatment regimens reduces barriers, which facilitates reduction in costs, comorbidities, and mortalities (National Academies of Sciences, Engineering, and Medicine, 2017). Nursing advocacy for funding of specific NCDs screening and care promotes strengthening of systems. Screening for detection of health conditions, such as hypertension, diabetes, and high cholesterol, serves to halt or slow disease processes through subsequent treatment. Health education can prevent further injuries
or reoccurrence. For example, nutrition and physical activity programs benefit overweight adults, teens, and children. Population health puts nurses on the frontlines for returning people to health and well-being, preferably without long-term health conditions.
Tertiary Prevention Nurses continue health education and undertake measures to avoid chronic disability and to delay further deterioration from health issues. Tertiary preventions use rehabilitation measures, support groups, and health education to target complex and/or management of long-term health problems. Nursing care fosters quality of life. Advocacy for disability services is within the possibilities. The nurse seeks to return the person to healthy, everyday life, living with the condition and still preventing further harm or death.
Examples of Nutrition and the Levels of Prevention
● Primary preventive nutrition—Measures for the public to reach an optimal level of healthy nutrition from birth through aging, using nutrition programs such as Women, Infants, and Children (WIC); school lunch programs; and nutrition educational resources, such as food pyramids and pictures of portions for a healthy diet.
● Secondary preventive nutrition—Measures to maintain optimal healthy nutrition levels as long as possible for people at risk because of health conditions, such as Meals on Wheels and dietitian consultations.
● Tertiary preventive nutrition—Measures to influence rehabilitation or delay further deterioration, such as condition-specific restrictions as in end-stage renal disease or food supplements to increase intake of healthy nutrients (Fardet & Rock, 2016).
Reflective Summary The CDC, WHO, and other epidemiological researchers seek to prevent, reduce, or eliminate health conditions threatening the public’s health. Understanding epidemiological research approaches involves applying the concepts of disease occurrence, methods of research, and the importance of statistical data collection, storage, and analysis. Public health surveillance is an ongoing process with teams ready to investigate and intervene for clusters of disease occurrence along with the larger endemic, epidemic, and pandemic disease outbreaks. National and international cooperation creates progress to reaching substantive goals for the reduction of health disparities and disease, enhancing health for all. Nurses maintain an active role in all aspects of health promotion and advocacy. One way nurses accomplish this is through application of the levels of prevention to educate populations and to avert or impede the acute and chronic impact of communicable and noncommunicable diseases.
Key Terms Agent: The organism, chemical, or physical cause that is to blame for a disease or health condition.
Analytic Epidemiology: The method of epidemiological studies or research that searches for cause and effect; comparison of groups to provide a baseline and test hypotheses for quantifiable association of exposures and outcomes; seeks information on the quality and influences that determinants have on a disease occurrence.
Applied Epidemiology: The application of epidemiologic studies for control and prevention of diseases and other health problems.
Burden of Disease: Estimates of the health problems’ impact on the world in terms of indicators such as financial cost, mortality, and morbidity; estimates include statistical analyses of disability-adjusted life year (DALYs), years of life lost (YLL), and years lost due to disability (YLD).
Carrier: Person, animal, or plant infected or holding a genetic trait of the disease or condition, but displays no symptoms of the agent within.
Case: A disease, injury, event, or situation that meets standardized criteria of person, place, time, and clinical features specific to the outbreak or incident under investigation.
Case-Control Study: Researchers compare one group that has a disease or condition to a control group that does not have the disease or condition.
Chain of Infection: The components and process required for transmission of disease.
Cohort Study: Researchers study a selected population in which each person falls into categories of exposure to one or more risk factors for a disease or condition.
Communicable Disease: Disease that is transmissible via the chain of infection; also known as infectious or contagious disease.
Cross-Sectional Study: Researchers observe a target population at a particular point in time without regard to exposure to disease or disease status.
Cluster: A group of disease occurrences for time and place that is more than expected.
Data Warehouses: Large amounts of electronically stored data accumulated from a wide variety of sources that is useful for statistical analysis.
Descriptive Epidemiology: The method of epidemiologic studies or research that characterizes outbreaks according to person, place, and time to identify the problem and form hypotheses.
Emerging Disease: An infection or health condition that is recently occurring in a population whose incidence in humans is rapidly increasing over the past two decades or threatens to increase in the near future.
Endemic: A disease or health condition present at all times that affects a particular region or population.
Epidemic: A disease outbreak affecting many people or communities at the same time; excessive disease occurrence for a particular time and place, but is not present all the time.
Epidemic Intelligence Service: Training program for disease detectives who practice applied epidemiology and serve public health frontlines as ready responders to investigate public health threats in the United States and the world.
Epidemiologic Triangle: The epidemiologic triad of agent, host, and environment as a model of disease causation; another name for the Agent-Host-Environment Model.
Epidemiology: The study of disease appearance, course, spread, and eradication.
Experimental Study: A controlled process of exposure of an individual (clinical trial) or a community (community trial).
Field Investigation: Scientific investigation of outbreaks of infectious and noninfectious diseases and health problems, such as illness related to injuries, nutrition, environmental and occupational health.
Health Disparities: Variables that contribute to inequities or an unequal distribution of resources for various populations; preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by disadvantaged populations; specifically relatable to social, economic, and/or environmental disadvantages.
Health Equity: Provision of resources necessary to live well to all individuals regardless of varying social determinants of health (SDOH).
Health Indicators: Compilation of data that portrays the current state of health for a population from a variety of sources, including morbidity and mortality rates.
Health Information System: A confidential computerized system that records, stores, and conveys health-related data.
Health Security: Proactive and reactive activities that reduce vulnerability of populations to health threats regionally and internationally.
Host: Person or animal who can acquire an infectious disease or health condition.
Hypothesis: A testable statement of a relationship; an epidemiologic hypothesis is the relationship is between the exposure (person, time, and/or place) and the occurrence of a disease or condition.
Incidence: Numerical rate of newly diagnosed occurrences of a disease in a population; numerical value used as part of rate or frequency determination.
Levels of Prevention: Primary, secondary, and tertiary; these levels have a collective goal of preventing or improving health by promoting positive health promotion behavioral changes.
Millennium Development Goals (MDGs): Eight global goals for improving lives of the world’s poorest populations agreed upon by 189 countries and with a deadline of 2015.
Mode of Transmission: The agent’s travel from the portal of exit to the host through direct or indirect contact, ingestion, or inhalation.
Morbidity: Illness or the incidence of ill health; the state of being unhealthy or diseased.
Mortality: Death; the number of those who died within a population.
Noncommunicable Disease (NCD): Noninfectious, nontransmissible, or chronic disease arising from a combination of factors, including genetics, environmental, physiological, and behavioral aspects.
Observational Study: Study in which the researcher, without control of the determinants of a disease, draws inferences from observations of and systematic data collection from a group; an observational study may be subcategorized as a cohort, case-control, or cross-sectional study.
Outbreak: Sudden breaking out, eruption, or occurrence of a disease or condition.
Pathogenicity: The ability of an agent to cause a disease or health condition.
Pandemic: Widespread or worldwide epidemic.
Portal of Entry: Point where the agent enters the host.
Portal of Exit: The pathway for an agent’s means of escape from the reservoir through blood, feces, or mucus leaving an orifice or skin openings.
Prevalence: Numerical fraction or ratio of disease diagnosis (incidence) in comparison with the total population group; term used as part of rate or frequency determination.
Public Health Surveillance: The uninterrupted systematic collection, analysis, and interpretation of health data to guide decision making, planning, implementation, and evaluation of public health practices.
Rate: Number of cases, diseases, or health conditions occurring at a particular time, depending on the size of the population during that time.
Reservoir: The environment housing an agent that is compatible for continued live existence.
Social Determinants of Health (SDOH): Conditions of living, such as housing, socioeconomics, transportation needs, quality of education, that directly impact health and access to health care needs.
Social Justice: Treating all fairly no matter what socioeconomic background, ethnicity, age, citizenship, disability, or sexual orientation.
Suboptimal Diet: A diet leading to malnutrition.
Sustainable Development Goals (SDGs): Seventeen global goals of the United Nation to end poverty, protect the environment, and promote peace and prosperity by 2030; also known as Global Goals.
Vector: Mode or agent of disease transmission.
Vital Statistics: Measurable data regarding population groups including births and deaths.
References
American Public Health Association. (2012). Affordable Care Act overview. Retrieved from https://apha.org/~/media/files/pdf/topics/aca/aca_overview_aug2012.ashx
American Heart Association. (2014). American Heart Association recommendations for physical activity in adults. Retrieved from http://www.heart.org/HEARTORG/HealthyLiving/PhysicalActivity/FitnessBasics/American-H eart-Association-Recommendations-for-Physical-Activity-in-Adults_UCM_307976_Article.js p#.Wnj_cq6nFpg
American Heart Association. (2018). Preventing childhood obesity: Tips for parents and caretakers. Retrieved from http://www.heart.org/HEARTORG/HealthyLiving/HealthyKids/ChildhoodObesity/Preventing- Childhood-Obesity-Tips-for-Parents-and-Caretakers_UCM_456118_Article.jsp#.WnkAw66n Fpg
Aylward, R. B. (2014). Making history: From a public health emergency to a polio-free world. Bulletin of the World Health Organization, 92(7), 466. doi: 10.2471/BLT.14.142273
Centers for Disease Control and Prevention. (n.d.). Ten essential public health services and how they can include addressing social determinants of health inequities. Retrieved from https://www.cdc.gov/stltpublichealth/publichealthservices/pdf/ten_essential_services_and_s doh.pdf
Centers for Disease Control and Prevention. (2012). Principles of epidemiology in public health practice: An introduction to applied epidemiology and biostatistics. (3rd ed.). Atlanta, GA: Author. Retrieved from https://www.cdc.gov/ophss/csels/dsepd/ss1978/SS1978.pdf
Centers for Disease Control and Prevention. (2014). About CDC 24-7: Mission, role and pledge. Retrieved from https://www.cdc.gov/about/organization/mission.htm
Centers for Disease Control and Prevention. (2015). Chronic disease indicators. Retrieved from https://www.cdc.gov/cdi/index.html
Centers for Disease Control and Prevention. (2016a). Office of the associate director for policy: Health impact in 5 years. Retrieved from https://www.cdc.gov/policy/hst/hi5/index.html
Centers for Disease Control and Prevention. (2016b). Global health – CDC and the Global health security agenda: The global health security agenda. Retrieved from https://www.cdc.gov/globalhealth/security/ghsagenda.htm
Centers for Disease Control and Prevention. (2017). 2017 CDC: Saving Lives. Protecting People. [Brochure]. Retrieved from https://www.cdc.gov/about/report/docs/2017healthsecurityreport.pdf
Centers for Disease Control and Prevention. (2018). Epidemic Intelligence Service: What EIS officers do. Retrieved from https://www.cdc.gov/eis/what-eis-officers-do/index.html
Davis, S. L., & Chapa, D. W. (2015). Social determinants of health: Knowledge to effective action for change. The Journal for Nurse Practitioners, 11(4), 424-429. doi: 10.1016/j.nurpra.2015.01.029
Discover John Muir. (n.d.). Main page. Retrieved from https://discoverjohnmuir.com d'Harcourt, E., Ratnayake, R., & Kim, A. (2017). How can the sustainable development goals
improve the lives of people affected by conflict? Bulletin of the World Health Organization, 95(2), 157-158. doi: 10.2471/BLT.16.179622
Fardet, A., & Boirie, Y. (2013). Associations between diet-related diseases and impaired physiological mechanisms: A holistic approach based on meta-analyses to identify targets for preventive nutrition. Nutrition Reviews, 71(10), 643-656. doi: 10.1111/nure.12052
Fardet, A., & Rock, E. (2016). The healthy core metabolism: A new paradigm for primary preventive nutrition. Journal of Nutrition, Health & Aging, 20(3), 239-247. doi: 10.1007/s12603-015-0560-6
Global Task Force on Cholera Control. (2017). Ending cholera—A global roadmap to 2030. Retrieved from http://www.who.int/cholera/publications/global-roadmap/en
HarvardX. (2017, April 19). John Snow and the 1854 Broad Street cholera outbreak [Video file]. Retrieved from https://www.youtube.com/watch?v=lNjrAXGRda4
HealthyPeople.gov. (n.d.). About healthy people. Retrieved from https://www.healthypeople.gov/node/5840
HealthyPeople.gov. (2018a). Social determinants of health. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
HealthyPeople.gov. (2018b). Leading health indicators. Retrieved from https://www.healthypeople.gov/2020/Leading-Health-Indicators
HealthyPeople.gov. (2018c). Heart disease and stroke. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke
Institute for Work and Health. (2015, Spring). What researchers mean by…primary, secondary and tertiary prevention. At Work, 80, 2. Retrieved from https://www.iwh.on.ca/at-work/80
Institute of Medicine. (2001). Crossing the quality chasm: A new health for system for the 21st century. Washington, DC: National Academy Press.
Micha, R., Peñalvo, J. L., Cudhea, F., Imamura, F., Rehm, C. D., & Mozaffarian, D. (2017). Association between dietary factors and mortality from heart disease, stroke, and type 2 diabetes in the United States. JAMA, 317(9), 912-924. doi: 10.1001/jama.2017.0947
National Academies of Sciences, Engineering, and Medicine. (2017). Global health and the future role of the United States. Washington, DC: The National Academies Press.
National Center for Health Statistics. (2017). Health, United States, 2016. Hyattsville, MD. Retrieved from https://www.cdc.gov/nchs/data/hus/hus16.pdf
Papini, A., & Santosuosso, U. (2017). Snow's case revisited: New tool in geographic profiling of epidemiology. The Brazilian Journal of Infectious Diseases, 21(1), 112-115. doi: 10.1016/j.bjid.2016.09.010
Pearson-Stuttard, J., Bandosz, P., Rehm, C. D., Penalvo, J., Whitsel, L., Gaziano, T., …& Capewell, S. (2017). Reducing U.S. cardiovascular disease burden and disparities through national and targeted dietary policies: A modelling study. PLoS Med 14(6). doi: 10.1371/journal.pmed.1002311
Public Broadcasting System. (2010). John Snow: Pioneer of epidemiology. Retrieved from https://az.pbslearningmedia.org/resource/envh10.sci.life.nathis.johnsnow/john-snow-pionee r-of-epidemiology/#.WnERdq6nFpg
Rao, K. S. (2017). Challenging times for public health towards attaining Sustainable Development Goals. Indian Journal of Community Medicine, 42(2), 65-68. doi:10.4103/0970-0218.205210
Shiode, N., Shiode, S., Rod-Thatcher, E., Rana, S., & Vinten-Johansen, P. (2015). The mortality rates and the space-time patterns of John Snow's cholera epidemic map. International Journal of Health Geographics, 14(1), 1-15. doi: 10.1186/s12942-015-0011-y
Shrivastava, S. R., Shrivastava, P. S., & Ramasamy, J. (2016). Assessing the status of United Nations Millennium Development Goals. Annals of Tropical Medicine and Public Health, 9(2), 87-89. doi:10.4103/1755-6783.177373
U.S. Department of Health and Human Services. (2008). The secretary’s advisory committee on national health promotion and disease prevention objectives for 2020. Phase I report: Recommendations for the framework and format of Healthy People 2020. Section IV. Advisory committee findings and recommendations. Retrieved from https://www.healthypeople.gov/sites/default/files/PhaseI_0.pdf
World Health Organization. (n.d.a). Social determinants of health: About the social determinants of health. Retrieved from http://www.who.int/social_determinants/sdh_definition/en
World Health Organization. (n.d.b). Health topics: Public health surveillance. Retrieved from http://www.who.int/topics/public_health_surveillance/en
World Health Organization. (1978). Declaration of Alma-Ata: International conference on primary health care, Alma-Ata, USSR, 6–12 September 1978. Retrieved from http://www.who.int/publications/almaata_declaration_en.pdf?ua=1&ua=1
World Health Organization. (2007). Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: Switzerland: Author. Retrieved from http://apps.who.int/iris/bitstream/10665/43943/1/9789241563703_eng.pdf
World Health Organization. (2015). Millennium development goals (MDGs). Retrieved http://www.who.int/mediacentre/factsheets/fs290/en
World Health Organization. (2016). The global guardian of public health. Retrieved from http://www.who.int/about/what-we-do/global-guardian-of-public-health.pdf?ua=1
World Health Organization. (2017a). Diabetes. Retrieved from http://www.who.int/mediacentre/factsheets/fs312/en
World Health Organization. (2017b). Human rights and health. Retrieved from http://www.who.int/mediacentre/factsheets/fs323/en
World Health Organization. (2017c). Malaria. Retrieved from http://www.who.int/mediacentre/factsheets/fs094/en
World Health Organization. (2017d). Malaria: New interactive mapping tool. Retrieved from http://www.who.int/malaria/news/2017/malaria-threats-map/en
World Health Organization. (2017e). Noncommunicable disease. Retrieved from http://www.who.int/mediacentre/factsheets/fs355/en
World Health Organization. (2017f). Ten years in public health 2007-2017. Retrieved from http://www.who.int/publications/10-year-review/en
World Health Organization. (2017g). Trypanosomiasis, human African (sleeping sickness). Retrieved from http://www.who.int/mediacentre/factsheets/fs259/en
World Health Organization. (2018). Emergencies preparedness, response: Eliminating yellow fever epidemics (EYE) strategy: Meeting demand for yellow fever vaccines. Retrieved from http://www.who.int/csr/disease/yellowfev/meeting-demand-for-vaccines/en
CHAPTER 3 Community as Client By Angel Falkner Essential Questions
● Why is cultural competence so important in providing care for patients within the community?
● What role does the public health nurse play in providing education to individuals and communities?
● How does the nurse use evidence-based practice to identify disparities of health in varying populations?
● How does the public health nurse address the varying learning needs of different patient groups?
● What models are appropriate for community or population health improvement?
Introduction Health promotion is a key element of public health. Public health nurses (PHNs) utilize tools and nursing models that help them to promote health. PHNs also need to understand the importance of cultural competence when working with emerging and vulnerable population groups. In addition, the PHN’s role as patient advocate and educator is crucial to providing optimal care for patients in diverse communities. The PHN also utilizes the nursing process to help improve community health and move toward the goal of achieving health equity.
Culture, Race, and Ethnicity Public health requires an understanding of the concepts of culture and cultural values as well as the importance of cultural competence in caring for diverse populations. Cultural pluralism can be described simply as the coexistence of multiple cultures within a population, which is a common occurrence in many places throughout the world. The United States has long been called a melting pot where varying cultures existing together. With each culture comes different values that guide the daily behaviors and thought processes of individuals. Values heavily influence an individual’s outlook on health care, illness, wellness, and treatment. Phrases such as “He has very conservative values,” or “She has Christian values,” are examples of common statements used to describe an individual’s belief system. The PHN must become familiar with how these ascribed values directly impact health.
Cultural competence is the ability to interact effectively with people of different cultures, belief systems, and preferences. In so doing, PHNs demonstrate respect and responsiveness to health beliefs and practices. Other terms associated with cultural competence include cultural preservation, cultural repatterning, cultural brokering, and cultural dissonance (Bronheim, 2011; Huber, 2009)
Example of Cultural Dissonance
The family of a female patient requests a female nurse to replace the male nurse originally assigned to care for the patient. The male nurse may be upset or think that he did something wrong, but really, the request was based on the family’s cultural beliefs. The male nurse’s feelings are based on a misunderstanding of the patient’s cultural values. This is something that all nurses may face in their career and needs to be met head on in order to provide care to all patients regardless of differences.
Culture and Subculture Culture is defined in many different ways. The general consensus explains culture as a group of people who share similar beliefs related to values, communications, dietary preferences, and socialization patterns. Because culture impacts most aspects of life, it has a significant role in health care choices, treatment, and compliance. A subculture is a group that falls under the larger culture group umbrella, but constitutes its own set of values and beliefs (Campinha-Bacote, 2011). An example of this would be the larger Hispanic culture having a subculture of persons from Cuba. Though Cubans might be part of the larger Hispanic culture, they have their own set of values, beliefs, and customs that are different from other groups within the Hispanic culture, which makes them distinct. Nurses will undoubtedly work with individuals from multiple cultures and subcultures, providing them with culturally appropriate resources and education. It is essential for the nurse to be aware of and sensitive to the differences between a culture and its subcultures in order to provide truly culturally competent, holistic nursing care.
Stereotypes and Biases The PHN will need to be aware of issues that may arise when working with diverse populations within different communities. There are a number of stereotypes and biases associated with different people depending on gender, race, and age. A stereotype is a preconceived assumption regarding a certain group of people. A bias is personal feeling or attitude toward a person or group based upon the stereotype associated with the individual or group of people. Bias is widely described as “the negative evaluation of one group and its members relative to another,” (FitzGerald & Hurst, 2017, p. 2). Implicit bias, a term used within the health care community, is the unconscious attitude displayed based on stereotypes that directly affect understanding, decisions, and actions that may impact patient care. This type of bias has been found in a large number of health care workers (The Joint Commission, 2016; FitzGerald & Hurst, 2017). The nurse should be well informed regarding stereotypes and biases in order to be sensitive to these issues and provide the most unbiased care possible. Discrimination based
on these stereotypes and biases is an unfortunate yet common occurrence in health care. The nurse should be aware of these issues and be a strong advocate for those who have experienced this kind of discrimination. Once again, this highlights the importance of cultural competence as an imperative nursing skill, as ensuring that all people receive adequate health care regardless of gender, race, age, or other socioeconomic disadvantage is the goal of health equity (FitzGerald & Hurst, 2017).
Cultural Frameworks and Assessment Tools To complete a thorough assessment, it is crucial to address the individual’s cultural needs when formulating a plan of care. The PHN receives information through a thorough question and answer session with the patient. Incorporating cultural assessment is a requirement for all assessments in order to provide culturally competent care. To assess the patient’s cultural needs, the PHN may ask questions such as:
1. What are your or your family’s beliefs about health, life, nature and relationships? 2. What language and dialect is spoken within the home? How well do you speak and
understand English? 3. Do you and your family affiliate with a certain religion? Do you and your family attend
church regularly? 4. What health care providers do you or your family use? How do you and your family
perceive health care providers? 5. When do you or your family seek treatment for illness or injury? 6. Do you and your family practice any health promotion strategies in daily life? (Andrews &
Boyle, 2016)
The LEARN Model The LEARN communication model (see Figure 3.1) has been used as an effective way to move through feelings of apprehension triggered by cultural dissonance. The five steps of this model include:
1. Listen 2. Explain 3. Acknowledge 4. Recommend 5. Negotiate
The PHN can use this tool to communicate effectively and provide culturally competent care. Figure 3.1 LEARN Model
Example of Culturally Competent Care
The PHN may assess a patient who is of Mexican heritage and professes to be a
practicing Catholic. The patient ascribes to the values of Christianity and the teachings
of the Catholic faith in particular. She has five children and does not want to become
pregnant again, but she expresses concern about seeking birth control. She
understands that the use of birth control does not align with the social teachings of the
Catholic church. The PHN must take the patient’s concern into consideration when
forming a plan of care that respects her client’s values. The PHN elects to teach her
client to track her menstrual cycle and ovulation to avoid conception (American
Pregnancy Association, 2016).
Another way the PHN could provide culturally competent care for this patient would be
to apply the LEARN model to communicate with the patient.
● Listen: “Would you like to discuss options for pregnancy prevention that are natural and not permanent?”
● Explain: “You are concerned because you do not wish to have more children at this time, but you do not want to use typical birth control methods. Let me discuss some options with you.”
● Acknowledge: “Though there are many safe and effective medical options for pregnancy prevention, there are also ways to prevent pregnancy that are natural and effective. Let’s talk about those.”
● Recommend: “I will review the natural family planning method with you now.” ● Negotiate: The PHN answers questions and addresses any concerns the patient
may have about the natural family planning method, and the patient decides whether it is the correct plan of action for her.
Campinha Bacote Cultural Framework Model The Campinha Bacote cultural framework model (see Figure 3.2) outlines five elements that may occur in the process of becoming culturally competent. This model is regarded as a prominent guide for cultural competence in nursing. The five elements of the Camphina Bacote Model include:
● Cultural Awareness—the process of self-reflection that must occur in order for the health care provider (in this case, the RN) to take care of multicultural populations
● Cultural Knowledge—the RN seeking information and education regarding different cultures
● Cultural Skill—the process of utilizing assessment techniques, such as open-ended questioning in order to obtain valuable cultural data
● Cultural Encounters—the interactions between the RN and culturally diverse patients that occur daily when providing care at the bedside or within the community
● Cultural Desire—the RN’s inner motivation to become culturally competent (Transcultural C.A.R.E Associates, n.d.)
Motivation to become culturally competent is not something that can be taught, but is an element of self-discovery, much like cultural awareness. Campinha-Bacote (Transcultural C.A.R.E Associates,” n.d.) stated, “Cultural competence is a process of becoming culturally competent, not being culturally competent,” (para. 2). Figure 3.2
Campinha-Bacote Culture Model
Note. Adapted from “Delivering patient-centered care in the midst of a cultural conflict: The role of cultural competence,” by J. Campinha-Bacote, 2011, OJIN: The Online Journal of Issues in Nursing, 16. Copyright 2011 by OJIN: The Online Journal of Issues in Nursing.
Cultural Care Theory Another prominent theorist is Madeleine Leininger. Leininger is often considered to be the founder of transcultural nursing care. Leininger developed the cultural care theory (CCT), which is based on the many interconnecting facets of an individual’s life that contribute to overall health. CCT incorporates culture as well as religion, education, and economic and social factors, all of which contribute to the individual’s well-being and influence the individual’s decisions to seek medical treatment, when to seek treatment, and from whom to seek care. The sunrise model for cultural competence is often utilized as a visual representation of the CCT when educating nurses and health care providers on cultural competence. The sunrise model (see Figure 3.3) illustrates how the elements involved in cultural care affect one another as well as the nurse’s actions and care, all of which contribute to the individual’s health. At the center of the model is the healthy, balanced patient. The patient’s health is directly influenced by a variety of factors, including social, religious, economic, and cultural; collectively these are referred to as the patient’s cultural care worldview. The nurse considers all elements within the patient’s worldview and understands that they each play an important role in affecting the patient’s health. Below the healthy, balanced patient, the model shows the different ways in which the patient may seek to restore health, including folk care, nursing care, and professional systems. Below this are the elements of cultural care that the nurse utilizes in order to provide culturally congruent nursing care to the patient.
Figure 3.3
Leininger’s Sunrise Model
Note. Adapted from “The Sunrise Model: A Contribution to the Teaching of Nursing Consultation in Collective Health,” by L. Pereira de Melo, 2013, in American Journal of Nursing Research, 1(1), 20-23. Copyright 2013 by the Science and Education Publishing.
Cultural and Linguistic Needs As communities grow and become more diverse, the PHN’s ability to deliver culturally competent care becomes more imperative. A major component within cultural care is addressing the linguistic needs of these populations. The PHN must evaluate individual’s ability to understand and comprehend English and provide resources in the appropriate language if
necessary, which may involve providing qualified interpretive services (Agency for Healthcare Research and Quality [AHRQ], 2013).
A widely utilized and effective tool for provision of cultural care is the culturally and linguistically appropriate services standards (CLAS). This tool (see Table 3.1) is used as a guide to provide appropriate cultural care within various health care settings. The tool addresses common concerns when providing culturally congruent care, such as respect of cultural or spiritual practices, providing care in the patient’s preferred language, and health literacy concerns.
Table 3.1
CLAS Standards
National Enhanced Culturally and Linguistically Appropriate Service Standards
Principal Standard
Standard 1: Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.
Governance, Leadership and Workforce
Standard 2: Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources.
Standard 3: Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area.
Standard 4: Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.
Communication and Language Assistance
Standard 5: Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.
Standard 6: Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.
Standard 7: Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.
Standard 8: Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.
Engagement, Continuous Improvement and Accountability
Standard 9: Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization's planning and operations.
Standard 10: Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into assessment measurement and continuous quality improvement activities.
Standard 11: Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.
Standard 12: Conduct regular assessments of community health assets and needs, and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.
Standard 13: Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.
Standard 14: Create conflict- and grievance-resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints.
Note. Adapted from “Enhanced Cultural and Linguistic Services Standards: Not Just Language Anymore,” by V. Sanders-Thompson, 2016, Washington University in St. Louis Institute for Public Health. Copyright 2016 by the Washington University in St. Louis.
Models of Health The PHN needs a basic understanding of models that will help them to assess their patients and formulate a tailored plan of care. There are a variety of conceptual models that outline patterns of behavior related to health. These models are utilized as the basis for many health promotion models seen in public health. Six major models will be overviewed followed by a chart for comparison.
Health Belief Model The health belief model (HBM) (see Figure 3.4), created in the 1950s by psychologists Hochbaum, Rosenstock, and Kegels, is a way to determine an individual’s motivation for seeking health care (LaMorte, 2016b). The six primary components within this model include:
1. Perceived susceptibility (“That will never happen to me, will it?”) 2. Perceived severity (“It is not that bad; I will be fine.”) 3. Perceived benefits (“Even if I go to the doctor, it won’t help.”) 4. Perceived barriers (“It will hurt. It costs too much. I don’t have time.”) 5. Cues to action (motivators to act and seek treatment, such as pain, disability, familial
pressure) 6. Self-efficacy (“Can I comply with treatment?”)
These elements are helpful to consider when evaluating whether an individual is ready to receive education. The nurse can utilize this model by having meaningful and honest discussion with clients to understand reasons for seeking or avoiding treatment and what motivates or deters them in successful compliance. Figure 3.4
Health Belief Model
Standard 15: Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.
Note. Adapted from “A Population-Based Study into Knowledge, Attitudes and Beliefs (KAB) about HIV/AIDS,” by M. Dadgarmoghaddam, M. Khajedaluee, & M. Khadem-Rezaiyan, in Razavi International Journal of Medicine, 2016, 4(1). Copyright 2016 by Razavi International Journal of Medicine.
Health Promotion Model Nola Pender and associates created the health promotion model (HPM) (see Figure 3.5), which focuses on behaviors to improve health and achieve wellness (Khodaveisi, Omidi, Farokhi, & Soltanian, 2017). The HPM states that health promotion behaviors are determined by:
● Personal experiences and characteristics, ● Perceived benefits and barriers, and ● Observed outcomes of intervention.
Figure 3.5
Health Promotion Model
Note. Adapted from Health Promotion in Nursing Practice (2nd ed.), by N. J. Pender, 1987. Copyright Pearson Education.
Health Promotion Model Example
Josie, a 35-year-old mother of three has gained a significant amount of weight since the birth of her first child 8 years ago. She attempted to take the weight off unsuccessfully a year ago. Discouraged by her lack of progress, she says, “Everyone in my family is overweight. I am just going to have to get used to it.” Her motivation to lose weight stems from her desire to keep up with the kids and not be so tired all the time. Her barriers, or behavior specific cognitions, include not having much free time, not having much energy, no access to a gym, and her sister always telling her to “get used to being fat.” Her husband and her mom are motivating and
supportive of her desire to make changes. Her plan of action is to begin a food diary, eliminate all fried foods, and start increasing her physical activity by hiking on weekends with the family and walking the kids to school in the mornings instead of driving. Once she begins the plan and sticks with it for a period of time, the hope is to see results, such as increased energy (behavioral outcome). The PHN supports and encourages her throughout this process and sets attainable goals that both Josie and the PHN agree upon together.
Primary Health Care Model Another model is the primary health care model (PHCM) developed by Shoultz and Hatcher. The primary health care model is closely tied to community health in that it embodies the idea of health care for all people within a community. The focus is on community participation and prevention measures based on six factors:
● Environment ● Economics ● Politics ● Education ● Health services ● Nutrition
The idea is that each of the six elements interact with one another and affect community health overall. This model is not specific to individual patients but focuses more on the community as a whole (Shoultz, Kooker, Sloat, & Hatcher, 2003). The PHN understands that these elements interact and affect one another, and instead of focusing solely on improvement of health services, they focus on helping to create change in all six of these areas in order to improve community outcomes. The PHN may do this by assessing and identifying issues within the community’s environment, such as a lack of walking paths available in the neighborhoods. The PHN understands that ease and accessibility to walking paths will most likely increase the probability that community members will increase their physical activity levels. The PHN takes this information and makes recommendations to the local government officials to increase the number of walking paths within neighborhoods.
Change Model Kurt Lewin developed the change model (see Table 3.2), which can be used in community health as well. This theory defines three phases of unfreezing, change, and refreezing. Unfreezing is the preparation stage, which many find to be the most difficult. Once the individual moves into the change stage, it becomes easier but requires support and motivation. During the refreeze stage, the individual might have met set goals, but they will still require support and reassurance and may set new goals at this point (Cummings, Bridgman, & Brown, 2015).
Table 3.2
Change Model
Note. Adapted from “Unfreezing Change as Three Steps: Rethinking Kurt Lewin’s Legacy for Change Management,” by S. Cummings, T. Bridgman, & K. G. Brown, 2015 in Human Relations, 69(1), 33-60. Copyright 2015 by Human Relations.
Change Model Example
Phil is a 41-year-old man who is overweight and has been diagnosed with high blood pressure. He used to work out when he was in his 20s but hasn’t in a very long time. In the unfreeze stage, Phil recognizes that he has to change his diet and increase his activity to improve his health, but he says, “I am afraid of change and I am comfortable with my lifestyle as it is.” His friends, family, and medical team all encourage him to come up with a plan that incorporates changes slowly and when he is ready. Phil enters the change stage when he decides to take evening walks with his kids three nights a week. After a month of doing this routinely, he is excited but anxious to see real changes. His medical team encourages him and praises him for his dedication and hard work. During the refreeze phase, Phil continues to make more changes and improvements in his lifestyle, but tries to set realistic goals with the help and support of the medical team, PHN, and his family and friends.
Transtheoretical Model The transtheoretical model (TTM) (see Table 3.3), developed by Prochaska and DiClemente, highlights motivational factors related to readiness for change (Pro-Change Behavior Systems, Inc., n.d.). The TTM has five distinctive phases that can be observed by the nurse. The nurse may be most actively involved in the preparation and action phases, when behavior change requires planning and initiation.
Unfreeze Change Refreeze
Preparation stage; explains why the change is needed
Action phase; requires time and communication; huge learning curve
Support during change process; evaluation of barriers; allow for feedback
Most stressful stage; people are most resistant and question reasons for suggested changes
Hands-on support by caregiver is necessary to engage audience (e.g., patient or community members)
Clearly defined expectations; constant communication
Time for motivating; get others to be excited for change
Make benefits of change as clear as possible
Consistent support, praise, reassurance
Table 3.3
Transtheoretical Model
Change Phase Behavior Example Comment Intervention
Precontemplati on
No desire to make changes
“I like eating whatever I want.”
Education regarding proper nutrition, healthy lifestyle, risks associated with poor diet choices
Contemplation Consideration of change
“I might be eating too much fried foods, I do feel very groggy and run down when I eat that way, I might cut back to 2 times per week”
Encourage patient to make better choices, acknowledge willingness to make small changes, ongoing support
Preparation Planning to make change
“I will eliminate fast food from my diet and eat vegetables 2 times per day to help me feel more energized and less run down”
Help patient set goals, reiterate importance of adherence to plan, help make environmental changes that will support meeting goal
Action Plan initiation “I stocked my house with healthy food and intend on taking a new route to work so I can avoid passing the fast food place all the time”
Support of plan, encourage self-evaluation, reward compliance to plan
Maintenance Initiation and maintenance for 6 months or more
“I eat vegetables with every meal and haven’t eaten at the fast food place since January, I
Set new goals, prepare for setbacks, ongoing support
Social Cognitive Theory Bandura’s social cognitive theory (SCT) focuses on the learning process and the relationship between person, environment, and behavior that is needed for learning to occur. This theory focuses heavily on the individual’s environment and suggests that changes in the environment changes will lead to behavior change (LaMorte, 2016a). Bandura also describes self-efficacy in the process of behavior change. Self-efficacy, which goes beyond the individual’s capability to manage his or her health care needs, involves the individual’s ability to believe he or she is fully capable of self-management and behavioral modifications. The nurse plays an integral role in nurturing feelings of self-efficacy in order to support the individual in making long-term changes that promote health. This is done mainly through positive reinforcement and consistent encouragement. The nurse should speak openly with patients, ensuring them that they are capable of creating and sustaining desired changes.
Social Ecological Model The social ecological model (SEM) can be seen in use for a number of preventative plans of care within community health, such as the encouragement and education regarding colonoscopies as a preventative measure for screening and detection of colon cancer. The model, founded by Urie Bronfenbrenner, considers the relationship between the person, community, relationships, and society in relation to promoting change behaviors or prevention (Sincero, 2012). Each piece has elements for the PHN to consider that influence the patient’s ability to make changes that promote health and prevent disease. The inner most ring of the model (see Figure 3.6) is the individual level, which involves the individual’s attitudes and perceptions of his or her health care needs, such as the need for colorectal cancer screening. The next level is the interpersonal level, which indicates the individual receiving gentle coaching or encouragement to participate in prevention activities, such as colonoscopies or biannual dental cleanings. The third level, organizational, is the health care clinic or institution that performs the screening or administers the preventative treatment. The fourth level, community, involves working within communities to institute education regarding the importance of prevention screenings. The last level, policy, involves work on a legislative level, such as working to mandate that insurance companies provide well-woman exams or colonoscopies at no cost to patients as part of health promotion and prevention measures (Centers for Disease Control and Prevention [CDC], 2015a).
Figure 3.6
Social Ecological Model
feel much better and less groggy all the time”
Note. Adapted from “Colorectal Cancer Control Program (CRCCP): Social Ecological Model,” by the Centers for Disease Control and Prevention.
Ecological Systems Theory Urie Brofenbrenner also describes different environments that are influential throughout an individual’s lifespan. They include the microsystem, mesosystem, exosystem, macrosystem, and chronosystem (Sincero, 2012) (see Figure 3.7 and Table 3.4). Originally, the ecological systems theory was developed for application in children, and highlighted the relevance of the relationships within each system and their effect on the individual. The nurse understands and values the importance of the impact and effect of each system, and works to support and advocate for the needs of the patients depending upon their specific situation.
Figure 3.7
Ecological Systems Theory
Note. Adapted from “What is Bronfenbrenner’s Ecological Systems Theory?” by Psychology Notes HQ, 2013. Copyright 2013 by Psychology Notes HQ
Table 3.4
Ecological Systems Theory
System Explanation
Microsystem Direct environment
Example: friends, teachers, or neighbors
Mesosystem Interaction between microsystem relationships
Example: parental involvement may lead to excelling in school
Exosystem How the elements in each individual's life directly impact one another
Example: mom’s work schedule impacting the child’s ability to play sports
Macrosystem Cultural facets of the individuals environment, including socioeconomics
Note. Adapted from “Ecological Systems Theory,” by S. M. Sincero, 2012.
Ecological Systems Theory Example
Mark, a 22-year-old paraplegic, relies on his mother and full-time caregiver to meet his basic daily needs. His mother and his home environment are his microsystem. Mark travels to his doctor’s office two times a month and also goes to church on a weekly basis; his physician’s office and church are part of his mesosystem. Mark’s father works full time and is not at home much; however he just had a change in his medical benefits that will directly impact which physician Mark can go see now; this is an example of Mark’s exosystem. Mark and his family are very excited because he will soon receive his associate’s degree in generalist studies from the local community college; this is an example of Mark’s chronosystem. The nurse understands that each of these systems and their elements are a crucial balance in Mark’s overall health and wellness. If one of these systems is disrupted in some way, it can negatively or positively impact Mark’s health. When the nurse conducts an assessment, he or she can discover more details about each of these systems and, if needed, help to restore balance or recommend resources to help restore balance for Mark. In this example, the nurse could help find a list of physician’s within the area that accept Mark’s new medical insurance and are familiar with treating patients who are paraplegics.
Population Considerations Vulnerability Versus At Risk When discussing the terms vulnerability and at risk, it is important to recognize their similarities and differences. A population or individual who is at risk may have predisposing factors that cause an increased susceptibility to acquiring a disease or disorder, but might not necessarily be part of a vulnerable population group. Vulnerable populations require special attention and advocacy based on factors such as age, mental or physical disability, poverty, or ethnicity (Stanhope & Lancaster, 2014).
At Risk vs. Vulnerable Example
Example: religious influences, poverty levels
Chronosystem Transition periods in life
Example: marriage, divorce, births, transitioning from high school to college
Jane is a 45-year-old Caucasian female with a familial history of breast cancer and heart disease, putting her at risk for development of getting either of these diseases. She does not fall into a vulnerable population group because she has stable employment, has medical insurance benefits, and lives in a middle-class neighborhood.
Gene is a 51-year-old African American male with a family history of heart disease. Gene lives in a neighborhood that falls well below the poverty line and works two jobs but still cannot afford to pay for medical insurance. His social determinants of health (SDOH), along with his ethnicity, make him part of a vulnerable population group; his ethnicity and family history also place him in the at risk category.
Vulnerable Populations Vulnerable populations are groups of people who require special attention related to well-being and safety, including persons who cannot advocate for their own needs such as children, prisoners, and the cognitively, emotionally, and physically impaired. Persons who fall into the vulnerable category often have SDOH that contribute to such vulnerability such as poverty, ethnic minorities, sexual preference, and insurance status (Waisel, 2013). The PHN will work with a wide range of populations, including those who fall under this description. PHNs must exhibit excellent cultural competency skills in working within these population groups as well as take into consideration the various barriers to health promotion these persons will face. There are many populations that continue to grow due to global factors. It is essential that the PHN become familiar with such populations in order to provide individualized care.
Refugee and Immigrant Population In recent years, there has been an increase in the refugee and immigrant population seen in America and other countries worldwide (World Health Organization, n.d.). Refugees and immigrants can be defined as vulnerable populations because they are often in an unknown environment with little understanding of the new culture, resources, or language and will likely require a host of support in order to acclimate to their new environments. PHNs must address their needs with compassion and patience and advocate for their needs to the best of their ability. This includes accounting for language barriers, lack of insurance, and provision of resources such as clothing, food and water, and possibly housing needs.
Impoverished Population A portion of the population within the United States continues to live below the poverty line. Statistics indicate that 12.7% of the population, or approximately 40.6 million people, live in poverty (Semega, Fontenot, & Kollar, 2017). The impoverished are those who cannot financially provide the basic necessities of life such as food, clothing, and shelter; as such, they are considered a vulnerable population (CDC, 2018c). The PHN must assist these individuals in accessing health care and treatment, as well as resources to provide basics such as food, water, and clothing. The PHN does so by collaborating with case management and social work within all health care settings. Once these immediate needs are met, the nurse can focus attention on health promotion education, but must also consider barriers to learning, such as health literacy, reading level, motivation, and inability to participate in follow-up care.
Lesbian/Gay/Bisexual/Transgender/Questioning Population The lesbian/gay/bisexual/transgender/questioning (LGBTQ) population requires the support and attention of the health care community. Their vulnerability stems from the adversity and discrimination they may face when seeking necessary medical services, as well as certain disease processes that may be more prominent in the LGBTQ population group. The LGBTQ may have a higher rate of diseases such as human immunodeficiency virus (HIV) and autoimmune immunodeficiency syndrome (AIDS) which require special medical attention and lifelong treatment (HIV.gov, 2017). Screenings, education regarding safe sex practices, access to safe-sex methods, and prompt treatment in the event of a diagnosis should be key in caring for members of this population. The PHN has a duty to support and fully advocate for the needs of persons within this community and provide resources whenever necessary.
Uninsured and Underinsured With the changes in the economy and the fluctuating unemployment rate, the number of Americans without health insurance remains a huge concern. After the Affordable Care Act (ACA) was enacted, many Americans were able to obtain health insurance. In fact, rates of uninsured persons in the United States fell from 44 million in 2013 to 28 million by the end of 2016 (Henry J. Kaiser Family Foundation, 2017).
Individuals who do not have insurance are vulnerable because they often do not advocate for their health care needs because of fear of cost or no access to resources. The PHN can help provide information regarding low cost or free health clinics as well as free health screenings. The PHN can also work with the health care team to help find resources to for the individual to obtain health insurance or additional insurance coverage if possible.
Free care clinics are available in most cities and towns across the country. Some are run by local or county governments and others are nonprofit organizations that offer low cost or free services to the underserved, underinsured, or uninsured populations of their communities. These facilities offer free medical, dental, and mental health care to patients free of charge. The PHN can help locate clinics and coordinate care for patients who are in need of care from these facilities. In addition, many PHNs may work at such facilities, either in a leadership or clinical role providing nursing care and education to patients and mentoring and supporting colleagues (Kamimura, Christensen, Tabler, Ashby, & Olson, 2013).
Barriers to Health Promotion Intervention Programs Strategies must be developed to help reduce and eliminate the various barriers to health promotion amongst vulnerable populations to ensure patients from these groups achieve optimal health. As patient advocates, the primary goal for the PHN is to help discover the patients’ or communities’ needs and work to meet those needs and provide necessary resources with the interdisciplinary team. A number of programs exist to aid in reducing risks associated with vulnerable population groups. These include Medicaid, affordable housing,
welfare, and food stamps, now known as Supplemental Nutrition Assistance Program (SNAP). Often, providing the basic living necessities is required before incorporation of health promotion education or information can be provided.
The primary objective for the PHN is to help develop and incorporate health promotion programs that foster healthy living choices. These programs are largely based upon clinical practice guidelines (CPGs), which are statements based on evidence-based practice (EBP) to help guide health care providers in making educated patient care decisions (Politi, Wolin & Légaré, 2013). With regard to health promotion, many CPGs are being incorporated with the use of shared decision making (SDM) in which the patient is included in the discussion and is able to make an informed and educated decision about his or her own health. Following this discussion, the provider is able to recommend choices based on the latest CPGs to optimize the patient’s health care outcomes.
SDM Example
The PHN is assessing the needs of a new client who was recently diagnosed with high cholesterol. The client expresses concerns about the complications of high cholesterol and wants to know the best course of action to take but is nervous about medication therapy. The PHN takes these concerns into consideration when discussing the client’s options with him and allows the client to determine the best course of action that fits his needs and his life.
Health Promotion and Health Protection Education Programs Community Programs There are many programs throughout varying communities aimed at health promotion. The PHN is involved in development and implementation of such programs after assessment occurs. The following overview illustrates several types of programs that might be seen within communities.
Family Programs Family programs involve providing health promotion information and guidance regarding daily life. Subjects of importance may include infant care, breastfeeding support, weight management tips, healthy eating classes, and support groups, including coping with a new diagnoses or grief support. Often, these types of classes are offered by local hospitals (Banner Health, n.d.). There are also many programs that emphasize the importance of increasing physical activity and offer low-cost sports and recreational activities. Community centers offer a wide variety of fitness classes for all ages and levels, including group sports teams and family sports events (City of Phoenix, n.d.).
School Programs School-based programs are perhaps the most widely known of and acknowledged community health programs. They have a dramatic effect on promoting healthy lifestyle choices from an early age and target hot-button topics such as drugs and alcohol, bullying, nutrition and exercise, and sex education. The role of school nurses in providing such education is invaluable, and the PHN can be instrumental in providing education to school workers about how to promote health in children (National Association of School Nurses, 2018). Since the 1980s, the Centers for Disease Control and Prevention (CDC) has helped coordinate improved school programs using the Whole School, Whole Community, Whole Child (WSCC) model. This model focuses on four important elements for school safety: social and emotional climate, physical environment, community involvement, and family engagement (CDC, 2015c). One program called “Bam! Body and Mind” is a collection of virtual information accessed on the CDC website that offers advice on food and nutrition, physical activity, and safety. The website also offers educational games and information that helps teachers to incorporate the program into their curriculum (CDC, 2018a).
Workplace Programs Workplace health promotion programs have gained more momentum in recent years. This has occurred as a result of the shift in the focus of health care from treating disease to health promotion. Both the employer and employee have many benefits associated with participation in such programs. Benefits noted have been fewer missed days from work, decreased use of medical insurance and disability benefits, increased productivity, and a decrease in turnover rates (Black, 2017).
Workplace Health Promotion Example
L.L. Bean, Inc. developed a wellness program for their employees, called The Healthy Bean, that integrates wellness benefits, such as free onsite fitness centers and discounts to offsite fitness centers, instituting tobacco-free workplaces, and offering incentives for employee participation in health risk appraisals (L.L. Bean, n.d.). Many employers have followed suit with this growing trend, offering similar wellness programs that promote healthy lifestyles and habits.
Faith-Based Programs Faith-based community programs are essential to promoting the spiritual aspect of health, which is an important component to many populations who value spirituality and religion. In addition to focusing attention on the physiological, faith-based nursing drives attention to the spiritual needs of the individual, which is an important aspect in providing holistic nursing care to the individual and community. Perhaps the most widely recognized faith-based programs may be hospital facilities that were founded by denominations of the Christian faith such as Catholic, Lutheran, Baptist, and Methodist. Medical care provided at a secular versus faith-based facility is largely the same. Both offer spiritual care and chaplain services to patients and provide holistic medical and nursing care. Faith-based institutions are based on the concepts of religious leaders, such
as Jesus Christ and his teachings of service to others and compassion and caring for all people (Levin, 2016). Also of note is the White House Office of Faith Based Community Initiatives (OFBCI), which developed an initiative during the Obama administration to assist with the President’s Emergency Plan for AIDS Relief (PEPFAR) (Levin, 2014).
Hospital Programs Hospitals are partners with various establishments within the community. They work together with businesses, schools, senior centers, and organizations to provide health promotion programs and resources to individuals within the community. Nonprofit hospitals are required to provide community benefits, such as free or low-cost classes and seminars on common issues including household safety, first-aid training, infant care, breastfeeding support, and car seat safety. Many hospitals also provide online resources and education through their websites. Nonprofit hospitals also perform a community health needs assessment every few years in order to maintain their nonprofit status (CDC, 2015b).
Military Programs Members of the military and their families require special attention and care as they often face multiple stressors related to frequent life changes. The United Service Organizations (USO) partnered with the White House under the Obama administration to form Joining Forces, which aims to provide support for members of the military and their families (The White House: President Barack Obama, n.d.). Joining Forces offered programs that provide education for expectant mothers regarding healthy pregnancy and infant care, couples seminars, children’s comfort group, employment resources, and access to health and wellness services (The White House: President Barack Obama, n.d.). The USO is a nonprofit organization that has supported members or the military for nearly 80 years (United Service Organization [USO], n.d.). The USO offers a number of support programs including those for families of loved ones who are currently serving, those who have lost loved ones in the military, and couples (USO, n.d.). These programs require careful evaluation for their effectiveness once they have been instituted. It is essential for the PHN to understand that these types of resources are available to patients who may require such services.
Community/Public Health Assessment Just as the community as a whole requires assessments and needs planning, so to do the families and individuals within the communities that PHNs work. Social, environmental, and cultural needs must be addressed within this process as well. The process in community health demands a focus on health risks. There are many assessment tools utilized to assist in this process, such as the health risk appraisal, lifestyle assessment, and stress risk assessment.
Health Risk Appraisal The PHN utilizes the health risk appraisal (HRA) to determine an individual’s health threats based on demographic, behavioral, and personal characteristics. The HRA is a questionnaire that gathers data on basics such as age, gender, ethnic background, history of disease, and current lifestyle practices. Physical measurements such as height, weight, blood pressure, and heart rate are taken. An individual’s personal results are then compared against national averages of persons with similar characteristics in order to determine the level of risk for certain diseases. The goal is to provide this information to the individual and assist the person in developing a plan of action to help decrease these risks through lifestyle modification (Goetzel, et al., 2011).
Lifestyle Assessment Lifestyle assessment (LA) focuses on controllable lifestyle behaviors that are contributing to overall health status. This may include diet, exercise level, smoking, illicit drug use, drinking alcohol, or any other risk-taking behavior. During the assessment process, which involves asking lifestyle questions, the PHN provides information regarding recommended lifestyle changes and choices, immunization schedules, screening tests for common diseases, proper nutrition, and increasing physical activity.
Stress Risk Assessment The stress risk assessment (SRA) is utilized to evaluate the effect of major life stressors on an individual’s overall health. The Social Readjustment Rating Scale (SRRS) is used to help determine these effects with a series of questions related to stressful events such as a death in the family, marriage or divorce, or changes in career. Each item receives an associated point value and they are then tallied. The higher the number, the higher the risk for developing an illness (see Table 3.5). The PHN assists in developing a plan and provides resources for the individual to cope with these stressors and address physiologic symptoms associated with stress.
Table 3.5
Social Readjustment Rating Scale
Life Event Change Units
Death of a Spouse 100
Divorce 73
Marital Separation 65
Note. A total of more than 150 points indicates an increased probability of an illness. Adapted from “Social Readjustment Rating Scale (SRRS),” by S. McLeod, 2010, Simply Psychology. Copyright 2010 by Simply Psychology.
Health Teaching in Community Health Baccalaureate-prepared nurses are inundated with critical-thinking skills that broaden their capabilities to care for their patients in more in-depth ways. Learning details of patient education is one element that is crucial to this process. Patients’ education needs will vary based on multiple factors, and education level, language barriers, socioeconomic status,
Death of a Close Family Member 63
Personal Injury or Illness 53
Marriage 50
Fired at Work 47
Marital Reconciliation 45
Retirement 45
Pregnancy 40
Death of a Close Friend 37
Change in Line of Work 36
Foreclosure 30
Change in Responsibilities at Work 29
disability, and interest all affect the patient’s capability to receive information provided. This chapter focuses on health teaching and its role in health promotion and disease prevention in the community setting rather than the details of patient education in the acute care setting. The assessment process and tools discussed for these purposes are applicable to the individual patient as well as the community when dealing with groups of learners as an audience.
Patient education often occurs during an acute hospital stay or upon discharge. For instance, the RN may educate the newly diagnosed diabetic patient on how to properly monitor his or her blood sugars at home when the patient is discharged; however, health teaching begins long before the acute event occurs. For example, the nurse provides health teaching regarding the importance and preventative benefits that regular cardiovascular exercise has on heart health on a long-term basis. The purpose of health teaching is health promotion and disease prevention. The intent is to help individuals make healthy choices in their everyday lives to prevent an acute hospitalization related to disease.
The Adult Learner In order to maximize the learner’s comprehension of delivered content, it is essential that the PHN become familiar with the concept of adult learning styles or andragogy. In 1980, Malcolm Knowles, a prominent educator, developed the theory of andragogy, which encompasses the idea that adults have their own individualized needs as learners (Pappas, 2013). There are four prominent principles that embody the generalized needs of adult learners:
1. Adults desire involvement in their education plan. 2. Adults base their current learning process on past learning experiences. 3. Adults relate given teaching concepts to things that are relevant to their lives. 4. Adults base their learning on finding a solution to a current problem.
Collaboration with the educator and the need to be respected are critical to the learning process for adults. Adults desire validation of knowledge they have already gained from past experiences in order to be open to accepting new information. In addition to the individual’s learning needs, the nurse instructor must also be aware of the collective community’s learning needs.
Learner Assessment The learner must have a certain degree of emotional readiness in order to be open to any kind of instruction. This means the learner must have a motivation or willingness to learn new concepts or skills. Experiential readiness is based on the learners’ background, skill, and ability to learn (Ohio State University, 2007). This also includes cultural needs and barriers the learner may possess. Assessment of each of these involves the nurse instructor asking a series of open-ended questions to evaluate the learner’s attitudes and readiness toward the education process (see Table 3.6).
Table 3.6
Learner Assessment
Note. Adapted from Nurse as Educator: Principles of Teaching and Learning for Nursing Practice, 3rd edition, by S. Bastable, 2014. Copyright 2014 by Jones and Bartlett Publishers.
Health Literacy Health literacy is the level at which an individual can accept, process, and comprehend basic health information. As nurses identify needs and create health promotion programs or plans of care, they must take into consideration the identified audience’s capability to understand the information being provided to them (Johnson, 2015). Programs and plans of care must be catered to the specific health literacy needs of the given population. The nurse must not assume the audience or individual will understand the concepts presented and must provide time for the audience to ask questions and have all inquiries thoroughly addressed.
Every learner has barriers they must overcome in order to comprehend information being taught. The nurse instructor must also learn to assess for such barriers. Obvious physical
Readiness Level Example Questions Rationale
Emotional Readiness ● What do you do in your everyday life to keep healthy?
● What makes being healthy difficult for you?
● What would you like to learn more about?
● Assess attitudes about health promotion
● Assess barriers or stressors
● Assess for promotion priorities
Experiential Readiness
● Background ● Skills ● Ability
Background
● Tell me about yourself, your family, your culture.
Skills
● How would you describe your ability to learn a new skill?
Ability
● How does outside influence, such as sound or people, affect your ability to concentrate?
Background
● Obtain information regarding familial and cultural influence on health
Skill
● Assess learners self-perception of capability to learn
Ability
● Assess for educational environment needs
barriers such as poor vision may require the use of a larger font on learning materials or audio or video media. Emotional barriers may be more difficult to address and may require a great amount of patience to allow the learner to feel comfortable with the instructor. Cultural or language barriers may require the nurse instructor to utilize official interpretive services or, in some instances, only speak to the patriarch or matriarch of the learner’s family.
Nurse instructors must be aware of health literacy barriers and modify the way in which they educate their patients to accommodate their needs (AHRQ, 2016). The “teach back” method is a widely used and trusted way to ensure comprehension. In addition to health literacy, low literacy is also a barrier that must be assessed and addressed. Several assessment tools are available to gather information regarding patients’ literacy levels, which helps determine appropriate learning materials for patients. Tests such as the Rapid Estimate of Adult Literacy in Medicine Short Form (REALM-SF) and the SMOG readability test are commonly utilized for evaluation of literacy levels (AHRQ, 2016). The SMOG readability test is a way to assess the learning materials for grade-level reading and comprehension (see Table 3.7). The prospective reading materials are reviewed by counting off 10 sentences in the beginning, middle, and end of the text. The words are then given a number value depending on the number of syllables in each word. The numbers are then added together to determine the approximate grade level of the written material. The higher the number, the higher the reading level of the material (see Table 3.7). Once the readability of the material is determined, nurse educators can evaluate whether to use it or find alternatives that are more appropriate to the patient’s needs (Readability Formulas, n.d.). If the patient is unable to read, there are other options to provide education, such as pictures and video. As always, the nurse instructor must remain sensitive when addressing these needs, as they may spark feelings of embarrassment and shame for the patient. Once assessment is complete and the barriers are identified, the teaching process can begin.
Table 3.7
SMOG Readability
Score Reading Level by Grade
≤ 6 Sixth Grade
7 Seventh Grade
8 Eighth Grade
9 High School Freshman
Note. Adapted from “Readability Tests,” by G. Gústafsdóttir, 2018. Copyright 2018 by Siteimprove.
Principles of Teaching Teaching Techniques Before teaching and learning can take place, aspects of physical environment, which includes temperature of the room, ease of accessibility for the intended audience, lighting, and appropriate seating, should be considered. The nurse instructor should also be aware of the educational environment, which includes body language, eye contact, and participation of the learner, to help learning occur. In order to teach effectively, it is important to become familiar with different teaching methods. The nurse may have some notion of teaching basic topics, but addressing large groups may require new ideas and recommendations (see Table 3.8). The methods for which education can be provided are truly limitless and can be elaborated upon by the instructor’s individual creativity. The key is to retain the learners’ attention and incorporate their input and address questions when they arise.
Table 3.8
Teaching Methods
10 High School Sophomore
11 High School Junior
12 High School Senior
13 College Freshman
14 + College Sophomore
Method Advantages Disadvantages Examples
Audiovisual Visually stimulating; highlights key concepts
May require equipment that is inaccessible
Flip charts, DVDs, PowerPoint presentations, projectors
Note. Adapted from “Is the effectiveness of lecture related to teaching approach or content type?” by J. Danielson, V. Preast, H. Bender, & L. Hassall, 2014, Computers and Education, 72, 121-131; “What Is Your Teaching Style? 5 Effective Teaching Methods for Your Classroom,” by E. Gill, 2013; “Teaching Strategies,” by George Mason University, n.d.
Objectives and Content Selection Also crucial to the education process is the creation of applicable learning objectives that guide the learner in understanding the take-away message. These objectives should guide the nurse instructor as well, reminding the instructor of what the content’s focus should be. Objectives should be direct and state what the learner should gain as a result of the education. An example would be “The learner will describe the importance of practicing safe sex methods.” Objectives also include the domains of learning: cognitive, affective, and psychomotor. This means the objectives should encompass learning the new skill, acquiring the tools to apply the skill in daily life, and finally incorporation of attitudes and feelings surrounding the new knowledge and skill application. Evaluation and revision are essential to ensuring that optimum benefits are achieved from instituted health teaching programs (Clark, 2015).
Evaluation When evaluating the effectiveness of a new health education program, the program’s objectives should be reviewed to see if the learners met them. When evaluating short-term outcomes, the cognitive domain is assessed to determine whether learners understood the presented material. Long-term evaluation is a bit more difficult because the nurse instructor often does not have long-term access to the learner. Only the learner truly knows if, over time, he or she has benefited from a health teaching program. The nurse instructor can observe for changes in the community after a community outreach education program by gathering statistical data related to the topic. For example, a lower rate of teenage pregnancy one year after presenting a safe-sex practices program to the community.
In order for nurse instructors to improve their teaching style and related outcomes, it is imperative that he or she is evaluated as well. The evaluation should be of the instructor, the content being taught, and ways in which the content was provided. Feedback from the learners as well as peers are good ways for nurse instructors to gain valuable insight into their effectiveness on the intended audience.
Lecture Inexpensive; instructor can customize; appeals to all learners
Passivity of learners; lack of attention
Traditional lecture, recorded lecture, blogs
Group Discussion Learner/Instructor interaction; learner feedback
Not effective in very large groups; some learners may not participate
Question and answer sessions, discussion following lecture
Community Planning and Intervention A community can have many definitions; generally it is considered a group of people within an open social system who share similar goals and live within a similar area. There are several models used in community health that are used for community assessment. The process for planning and intervening for communities varies from the process for individuals. PHNs are instrumental in the process of planning for and intervening in communities in a number of ways. Becoming familiarized with the steps of the process and various tools utilized in the process is essential for the baccalaureate student.
Community Health Organizational Structure Models PRECEDE/PROCEED Model The PRECEDE/PROCEED model (see Figure 3.8), is used for community health assessments and needs planning. The PRECEDE part of this model stands for:
● Predisposing, ● Reinforcing, and ● Enabling ● Causes in ● Educational ● Diagnosis and ● Evaluation.
The PRECEDE portion of this model is divided into phases. During the first phase, the community health assessment is performed to determine the specific needs of the community. During the second phase, the priority need is identified and achievable goals are developed that aim to resolve or improve the identified problem. Factors are then examined that may be contributing to the source of the problem, such as insufficient knowledge (predisposing factor) or insufficient resources (enabling factor). The final phase of the PRECEDE portion of this model involves determining best practice methods to help improve the problem and working with local organizations to help determine any roadblocks to integrating the suggested changes (Community Tool Box, n.d.b). Once the need has been identified, the PROCEED part of this model helps to define the implementation process. PROCEED stands for:
● Policy ● Regulatory and ● Organizational ● Constructs in ● Educational and ● Environmental
● Development.
During this part of the process, the plan is implemented and then evaluated. Widely used within public health, this model has been heavily relied upon as the best method for assessing, identifying, and creating applicable plans of action that create change within the given community (Tapley & Patel, 2016). Figure 3.8
PRECEDE/PROCEED Model
Note. Adapted from Health Promotion Planning: An Education and Ecological Approach (4th ed.), by L. Green & M. Kreuter, 2005. Copyright 2005 by Mayfield Publishers.
Community Partnership Model Sometimes called the community as partner model, the community partnership model (CPM) was founded at the University of Texas School of Nursing. This model is loosely based on Neuman’s systems theory and focuses on the community as partner and the nursing process. The model describes the community and its relation to eight subsystems that all affect and relate to one another (see Figure 3.9). The PHN works within the community to help plan, implement, and evaluate ways to reduce stressors and restore balance (McNicoll, 2017). For example, if the patient has issues with safety and transportation, the nurse would work with the interdisciplinary team and the patient to attain reliable transportation resources, such as a bus pass. The nurse takes into consideration all elements that can affect the patient’s overall wellness.
Figure 3.9
Community Partnership Model
Note. Adapted from Community as Partner: Theory and Practice in Nursing (5th ed.), by E. T. Anderson & J. M. McFarlane, 2008. Copyright 2008 by Lippincott Williams & Wilkins.
Helvie Energy Framework Model The Helvie model was developed by Carl Helvie after his many years working in public health as an RN. Helvie defined the community itself as a constantly changing energy field that is continually influenced by other energies within the community environment such as education and economics (Sines, Fanning, & Potter, 2013). This framework is mainly used by advanced practice nurses in community health. The PHN working in the advanced practice role uses this model to develop and implement a plan to help bring a balance between all elements and restore harmony within the community.
Epidemiology Framework Models: GENESIS and MAPP There are two primary epidemiology framework models: general ethnographic and nursing evaluation studies (GENESIS) and mobilization for action through planning and partnerships (MAPP). GENESIS blends epidemiologic and ethnographic data in order to determine a community’s health needs. The model assesses areas in the community such as economy, education, employment, and environment.
MAPP is a tool used to develop plans to improve health and public health systems (National Association of County & City Health Officials, n.d.). MAPP is largely considered a cyclical process, as efforts to make improvements within communities will always continue (see Figure 3.10). MAPP begins much like other models with assessment of needs within a given community, progressing to identification of the priority problem, formulation of goals, creation of strategies to integrate change, implementation, and evaluation. The six steps of the MAPP model include:
● Development—A committee is formed, and the process is planned. ● Visioning—The community and committee work together to form a cohesive vision of
community health. ● Assessment—Four in-depth community assessments are collected.
○ Community themes and strengths ○ Local public health systems assessment ○ Community health status assessment ○ Forces of change assessment
● Strategic Issues—Data is examined and key issues are determined. ● Goals/Strategies—A plan of action to address key issue or issues is formed ● Action Cycle—Planning, implementation, and evaluation of action plan is planned,
implemented, and evaluated (Community Tool Box, n.d.d)
Figure 3.10
MAPP
Note. Adapted from “Section 13. MAPP: Mobilizing for action through planning and partnerships” by Community Tool Box. Copyright 2018 Community Tool Box.
Examples of Planning Initiatives Partnerships to Improve Community Health (PICH) Partnerships to Improve Community Health (PICH) is a 3-year initiative developed by the CDC that aims to implement best practice methods to reduce the prevalence of chronic illnesses within various communities across the United States (CDC, 2018b). In 2014, 39 communities, including large cities and Native American tribes, were awarded sums of money to be disbursed over a 3-year period to assist with the coordination of programs that targeted specific problems such as tobacco use, poor nutrition, physical inactivity, and health promotion. PHNs within these
communities assist with the development and incorporation of programs that target these topics in order to create improvements in the given population’s health overall (CDC, 2018b)
Community Health Improvement Plans (CHIP) Community health improvement plan (CHIP) was developed by the Institute of Medicine (IOM) as a framework for guiding the process of community improvements. This planning and implementation occurs after the community health assessment has been performed. Similar to other models described, a CHIP begins with identification of the problem, followed by the formulation of a feasible plan of action that will create change, implementation of the plan, and evaluation for efficacy; this process may start over again if necessary (see Figure 3.11). The CHIP model necessitates the involvement of all key stakeholders, including the community members who are directly affected by the identified problem. For instance, victims of domestic abuse should be involved in the planning process to develop a plan to advocate for and support abused women. As with many other models described, the priority issue is identified, community members are identified for collaboration, the team and community members analyze the issue, a plan of action is formulated and implemented, and the outcomes are monitored (Community Tool Box, n.d.c).
Figure 3.11
CHIP Model
Note. Adapted from Improving Health in the Community , by J. S. Durch, L. A. Bailey, and M. A. Stoto (Eds.), 1997. Copyright 1997 by the National Academy Press.
Racial and Ethnic Approaches to Community Health (REACH)
Racial and Ethnic Approaches to Community Health (REACH) is a national program administered by the CDC that specifically aims to reduce health disparities among racial and ethnic minorities. Much like PICH, communities are awarded funding to support health concerns of tobacco use, physical inactivity, poor nutrition, and health promotion; however, the REACH program awards funding to ethnic and racial minority populations. Funding is intended to create evidence-based programs that directly target these primary health concerns within these communities. PHNs participate in this process by helping to incorporate programs that target these specific health concerns once funding is allocated to these communities (CDC, 2017).
Community Health Toolbox (CHT) The Community Health Toolbox (CHT) is a free online resource developed by the University of Kansas. This resource, utilized both locally and globally by professionals as well as the public, offers hundreds of modules and various tools related to public health in three languages. The online resource offers tools on assessing, planning, and implementing community action plans and 46 chapters related to community building skills. PHNs, students, and other members of the interdisciplinary and public health team can use this resource to locate tools and learn details of how to apply assessment plans to communities (Community Tool Box, n.d.a).
Role of PHNs in Community Health Planning While each model for assessment planning will present itself with different steps, the process is similar to the nursing process because it requires careful assessment, diagnosis of the problem, planning, implementation of the plan, and evaluation. Typically, the community assessment process involves some more detailed steps such as collection and analyzation of data specific to the presenting issue. For instance, data related to teen drug use in a given community would be collected over a period of time. This process is often conducted by PHNs who are familiar with the community and its residents. Once data is collected and presented, the problem can be clearly identified and goals can be set that focus on improving the problem. Once again, PHNs assist with this process as they often have a clear picture of the community’s issues and work directly with the population. Effective strategies can be developed utilizing the PHNs advice and other key stakeholders input. Finally, once the plan is instituted, it must be monitored for progress and success or failure rates, which can be a task allocated to PHNs as well (Catholic Health Association of the United States, 2013).
Scope and Standards for Public Health Nurses The American Nurses Association (ANA) Scope and Standards for Public Health Nurses specifies the roles and obligations of the public health nurse (see Table 3.9). The American Public Health Association (APHA) defines public health nursing as, “the practice of promoting and protecting the health of populations using knowledge from nursing, social and public health sciences,” (American Public Health Association, 2013, p. 2). The process for public health nurses contains similar steps to the standard nursing process with some particular differences such as diagnosis. Typically, nurses do not diagnose; however, in public health nursing, this is a crucial step in creating necessary change within communities (American Nurses Association [ANA], 2013). In addition, the Quad Council Coalition of Public Health Nursing Organizations
(QCC) also developed a series of competencies that are specific to the PHN and the varying roles. The QCC competencies are divided into three tiers, with the first being for the majority of public health nurses who work hands on with members of the community (see Table 3.10).
Table 3.9
ANA Standards of Practice for Public Health Nursing
Note. Adapted from Public Health Nursing: Scope and Standards of Practice (2nd ed.), by the American Nurses Association, 2013. Copyright 2013 by the American Nurses Association.
Table 3.10
PHN Tiered Competencies
Standard 1 Assessment The public health nurse collects data related to the health of the given population.
Standard 2 Population Diagnosis
The public health nurse analyzes collected data to determine health priorities
Standard 3 Outcome Identification
The public health nurse determines expected outcomes based on priorities
Standard 4 Planning The public health nurse assists with development of plan of action that will achieve expected outcomes
Standard 5 Implementation 1. Coordination: coordinating the implementation of the plan.
2. Health Education and Promotion: involvement in the education process
3. Consultation: community groups consulted to facilitate the incorporation of the plan.
4. Regulatory Activities: assists in making public health regulation changes as needed.
Standard 6 Evaluation The public health nurse evaluates the population for effectiveness of implemented plan
Tier Competencies
Note. Adapted from “Quad Council Competencies for Public Health Nurses,” by Association of Community Health Nursing Educators, 2011. Copyright 2011 by the Association of Community Health Nursing Educators.
Reflective Summary The public health nurse’s role continues to be of great importance in addressing the varying needs of communities as well as individuals across the United States. Cultural competence and obtaining the skills and tools necessary to provide such care is essential to all nurses no matter their area of expertise. Health promotion will continue to be the primary focus in providing optimal care for patients, with nurses being the primary proponent in developing and providing programs and individual education on varying topics. As emerging populations change and grow, it is vital to remain aware of their ever changing needs and advocate for individualized care whenever possible. Education and community base programs will continue to improve when they are based on EBP and the latest research.
Key Terms Affective Domain: Feelings and emotions associated with the learning process.
Andragogy: Theory encompassing the idea that adults have their own individualized needs as learners.
Bias: External and internal influences within a study that can affect the validity and reliability of the outcomes.
Cognitive Domain: The acquisition and dissemination of knowledge.
Community Health: Health care focused on improving the health of individuals within a given community.
Tier 1 Competencies apply to the day to day functioning of the generalist nurse in the public health setting.
Tier 2 Competencies apply to the PHN that is in a management or supervisory role, assists in implementation of public health programs.
Tier 3 Competencies apply to the PHN in executive or senior management roles. These PHNs are responsible for administration, organization and operation of public health programs.
Community: A group of people within an open social system who share similar goals and live within a similar area.
Cultural Awareness: Being knowledgeable about one’s own thoughts, feelings, and sensations, as well as the ability to reflect on how these can affect interactions with others.
Cultural Brokering: Using cultural and health science knowledge to help formulate a culturally sensitive plan of care.
Cultural Competence: To be respectful and responsive to the health beliefs and practices as well as cultural and linguistic needs of diverse population groups.
Cultural Desire: Inner motivation to become culturally competent.
Cultural Dissonance: Sense of discomfort caregivers may experience when an individual or population has cultural differences that may be considered difficult to accept.
Cultural Encounters: Interactions between RN and culturally diverse patients.
Cultural Knowledge: Seeking out information and education regarding different cultures.
Cultural Pluralism: The coexistence of multiple cultures within a population.
Cultural Preservation: The ability of the nurse to uphold and respect cultural values and practices.
Cultural Repatterning: The sensitive education regarding a practice that may cause harm.
Cultural Skill: The process of utilizing assessment techniques to obtain valuable cultural data.
Culture: Traditional beliefs and values shared among a common group of people.
Emotional Readiness: Motivation or willingness to learn new concepts or skills.
Experiential Readiness: The learners’ background, skill, and ability to learn.
Health Literacy: The level at which an individual can accept, process, and comprehend basic health information.
Health Promotion: Educating people about healthy lifestyles, reduction of risk, developmental needs, activities of daily living and preventive self-care that enables them to improve their health by making positive decisions.
Health Teaching: Begins before the onset of disease; the purpose of which is health promotion and disease prevention.
Implicit Bias: The unconscious attitude displayed based on stereotypes that directly affect understanding, decisions, and actions that may impact patient care.
Learning Objectives: Goals explaining what the learner is expected to understand and take away from the learning experience.
Learning Styles: Individualized way of learning based on different personality characteristics.
Patient Education: Individualized and structured process to provide pertinent information to patients regarding their specific plan of care.
Psychomotor Domain: Application of the learned skill.
Public Health: The practice of protecting and promoting quality of life of persons and communities through the use of science, research, and direct care to prevent disease outbreaks, environmental hazards, injuries, and poor health.
Stereotype: A preconceived notion of who a person is based on factors such as race, gender, weight, and socioeconomic status.
Subculture: Group that falls under the umbrella of a larger culture group, but has its own set of values and beliefs.
Teaching Methods: Ways of providing educational information to the intended audience (visual, audio visual, lecture).
Values: The beliefs that serve as standards that ultimately influence behavior and thought processes within the cultural group.
Vulnerable Populations: People who require special attention related to well-being and safety, including persons who cannot advocate for their own needs such as children, prisoners, and cognitively impaired.
References Agency for Healthcare Research and Quality. (2013). Planning culturally and linguistically
appropriate services. Retrieved from https://www.ahrq.gov/professionals/systems/primary-care/cultural-competence-mco/plancla s.html
Agency for Healthcare Research and Quality. (2016). Health literacy measurement tools (revised). Retrieved from http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy/inde x.html
American Nurses Association. (2013). Public health nursing: Scope and standards of practice (2nd ed.). Retrieved from https://www.nursingworld.org/~4adc06/globalassets/catalog/book-toc/public-health-nursing- scp--stds-2e_toc.pdf
American Pregnancy Association. (2016). Fertility awareness: Natural family planning (NFP). Retrieved from http://americanpregnancy.org/preventing-pregnancy/natural-family-planning/
American Public Health Association. (2013). The definition and practice of public health nursing: A statement of the public health nursing section. Washington, DC: American Public Health Association. Retrieved from https://www.apha.org/~/media/files/pdf/membergroups/phn/nursingdefinition.ashx
Andrews, M. M., & Boyle, J. S. (2016). Transcultural concepts in nursing care (pp. B1-B3). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Banner Health. (n.d.) Classes, support groups and events. Retrieved from https://www.bannerhealth.com/calendar
Black, A. (2017). Five reasons employee wellness is worth the investment. Retrieved from https://health.gov/news/blog-bayw/2017/05/five-reasons-employee-wellness-is-worth-the-in vestment/
Bronheim, S. (2011). Promising practices: Cultural brokers help families and providers bridge the cultural gap. Retrieved from https://nccc.georgetown.edu/documents/NCCC_PP_Cultural%20Brokers.pdf
Campinha-Bacote, J. (2011). Delivering patient-centered care in the midst of a cultural conflict: the role of cultural competence. OJIN: The Online Journal of Issues in Nursing, 16(2). doi: 10.3912/OJIN.Vol16No02Man05
Catholic Health Association of the United States. (2013). Assessing and addressing community health needs. Retrieved from https://www.chausa.org/docs/default-source/general-files/cb_assessingaddressing-pdf.pdf? sfvrsn=4
Centers for Disease Control and Prevention. (2015a). Colorectal cancer control program (CRCCP): Social ecological model. Retrieved from https://www.cdc.gov/cancer/crccp/sem.htm
Centers for Disease Control and Prevention. (2015b). Community health assessments and health improvement plans. Retrieved from https://www.cdc.gov/stltpublichealth/cha/plan.html
Centers for Disease Control and Prevention. (2015c). Expanding the coordinated school health approach. Retrieved from https://www.cdc.gov/healthyschools/wscc/approach.htm
Centers for Disease Control and Prevention. (2017). Racial and ethnic approaches to community health. Retrieved from https://www.cdc.gov/nccdphp/dnpao/state-local-programs/reach/index.htm
Centers for Disease Control and Prevention. (2018a) Bam! Body and mind. Retrieved from https://www.cdc.gov/bam/index.html
Centers for Disease Control and Prevention. (2018b). Partnerships to improve community health. Retrieved from https://www.cdc.gov/nccdphp/dch/programs/partnershipstoimprovecommunityhealth/index.h tml
Centers for Disease Control and Prevention. (2018c). Social determinants of health: Know what affects health. Retrieved from https://www.cdc.gov/socialdeterminants/
City of Phoenix. (n.d.). Classes and programs. Retrieved from https://www.phoenix.gov/parks/classes-and-programs
Clark, D. R. (2015).Bloom’s taxonomy of learning domains. Retrieved from http://www.nwlink.com/~donclark/hrd/bloom.html
Community Tool Box. (n.d.a). Home. Retrieved from https://ctb.ku.edu/en Community Tool Box. (n.d.b) Section 2: PRECEDE/PROCEED. Retrieved from
http://ctb.ku.edu/en/table-contents/overview/other-models-promoting-community-health-and -development/preceder-proceder/main
Community Tool Box. (n.d.c). Section 6. The Institute of Medicine’s community health improvement process (CHIP). Retrieved from
https://ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-develop ment/chip/main
Community Tool Box. (n.d.d). Section 13. MAPP: Mobilizing for action through planning and partnerships. Retrieved from https://ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-develop ment/mapp/examples
Cummings, S., Bridgman, T., & Brown, K. G. (2015). Unfreezing change as three steps: Rethinking Kurt Lewin’s legacy for change management. Human Relations, 69(1), 33-60. doi:10.1177/0018726715577707
FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: a systematic review. BMC Medical Ethics, 18(19). doi: 10.1186/s12910-017-0179-8.
Goetzel, R. Z.; Staley, P.; Ogden, L.; Stange, P.; Fox, J.; Spangler, J.; Tabrizi, M.; Beckowski, M. …Taylor, M. V. (2011). A framework for patient-centered health risk assessments-providing health promotion and disease prevention services to Medicare beneficiaries. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/policy/hst/HRA/FrameworkForHRA.pdf
Henry J. Kaiser Family Foundation. (2017). Key facts about the uninsured population. Retrieved from https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/
HIV.gov. (2017). What are HIV and AIDS? Retrieved from https://www.hiv.gov/hiv-basics/overview/about-hiv-and-aids/what-are-hiv-and-aids
Huber, L. M. (2009). Making community health care culturally correct. American Nurse Today 4(5). Retrieved from https://www.americannursetoday.com/making-community-health-care-culturally-correct/
Johnson, A. (2015). Health literacy: how nurses can make a difference. Australian Journal of Advanced Nursing, 33(2), 20-27.
Kamimura, A., Christensen, N., Tabler, J., Ashby, J., & Olson, L. (2013). Patients utilizing a free clinic: physical and mental health, health literacy, and social support. Journal of Community Health, 38(4), 716-723. doi:10.1007/s10900-013-9669-x.
Khodaveisi, M., Omidi, A., Farokhi, S., & Soltanian, A. R. (2017). The effect of Pender’s health promotion model in improving the nutritional behavior of overweight and obese women. International Journal of Community Based Nursing and Midwifery, 5(2), 165–174.
L.L. Bean. (n.d.). Winning programs: L.L. Bean, Inc. (2012). Retrieved from http://thehealthproject.com/winner/l-l-bean-inc-healthy-bean/
LaMorte, W. W. (2016a). The social cognitive theory. Retrieved from http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralCh angeTheories5.html
LaMorte, W. W. (2016b). The health belief model. Retrieved from http://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralCh angeTheories2.html
Levin, J. (2014). Faith-based partnerships for population health: Challenges, initiatives, and prospects. Public Health Reports, 129(2), 127–131.
Levin, J. (2016). Partnerships between the faith-based and medical sectors: Implications for preventive medicine and public health. Preventive Medicine Reports, 4, 344–350. doi: 10.1016/j.pmedr.2016.07.009
McNicoll, L. (2017). Geriatric co-management as a service line: Spreading co-management within an institution. Innovation in Aging, 1(1), 612. doi: 10.1093/geroni/igx004.2147
National Association of County & City Health Officials. (n.d.). Mobilizing for action through planning and partnerships (MAPP). Retrieved from https://www.naccho.org/programs/public-health-infrastructure/performance-improvement/co mmunity-health-assessment/mapp
National Association of School Nurses. (2018). Healthy communities – The role of the school nurse. Retrieved from https://www.nasn.org/advocacy/professional-practice-documents/position-statements/ps-he althy-communities
Ohio State University. (2007). Getting your message across: Clear and effective health communication. Retrieved from https://medicine.osu.edu/sitetool/sites/pdfs/ahecpublic/HL_Get_the_Message.pdf
Pappas, C. (2013). The adult learning theory-andragogy of Malcolm Knowles. Retrieved from https://elearningindustry.com/the-adult-learning-theory-andragogy-of-malcolm-knowles
Politi, M., Wolin, K., & Légaré, F. (2013). Implementing clinical practice guidelines about health promotion and disease prevention through shared decision making. Journal of General Internal Medicine, 28(6), 838-844.
Pro-Change Behavior Systems, Inc. (n.d.). The transtheoretical model. Retrieved from https://www.prochange.com/transtheoretical-model-of-behavior-change
Readability Formulas. (n.d.). The SMOG readability formula, a simple measure of gobbledygook. Retrieved from http://www.readabilityformulas.com/smog-readability-formula.php
Semega, J. L., Fontenot, K. R., & Kollar, M. A. (2017). Income and poverty in the United States: 2016. Washington, DC: U.S. Census Bureau. Retrieved from https://www.census.gov/library/publications/2017/demo/p60-259.html.
Shoultz, J., Kooker, B. M., Sloat, A. R., & Hatcher, P. A. (2003). Four ways to teach phc in a changing world. International Nursing Review, 45(6), 187–191. doi:10.1046/j.1466-7657.45.no.6issue342.8.x
Sincero, S. M. (2012). Ecological systems theory. Retrieved from https://explorable.com/ecological-systems-theory
Sines, D., Fanning, A., & Potter, K. (Eds.). (2013). Community and public health nursing (5th ed.). Sussex, UK: John Wiley & Sons, Ltd.
Stanhope, M., & Lancaster, J. (2014). Foundations of nursing in the community: Community-oriented practice (4th ed.). St. Louis, MO: Elsevier.
Tapley, H., & Patel, R. (2016). Using the PRECEDE-PROCEED model and service-learning to teach health promotion and wellness: An innovative approach for physical therapist professional education. Journal of Physical Therapy Education, 30(1), 47-59.
The Joint Commission. (2016). Implicit bias in health care. Quick Safety, (23). Retrieved from https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_23_Apr_2016.pdf
The White House: President Barack Obama. (n.d.). Joining forces. (n.d.). Retrieved from https://obamawhitehouse.archives.gov/joiningforces.
Transcultural C.A.R.E Associates. (n.d.). Our model of service. Retrieved from http://transculturalcare.net
United Service Organizations. (n.d.). The organization: Our mission. Retrieved from https://www.uso.org/about
Waisel, D. (2013). Vulnerable populations in healthcare. Current Opinion in Anesthesiology, 26(2), 186-192. doi: 10.1097/ACO.0b013e32835e8c17
World Health Organization. (n.d.). Refugee and migrant health. Retrieved from http://www.who.int/migrants/en/
CHAPTER 4 The Environment, Policy, and Health Effectiveness By Sue Z. Green
‘Saving our planet, lifting people out of poverty, advancing economic growth … these are one and the same fight. We must connect the dots between climate change, water scarcity, energy shortages, global health, food security, and women’s empowerment. Solutions to one problem must be solutions for
all.” —Ban Ki-moon, former United Nations Secretary-General (2011, paras. 23-24).
Essential Questions ● What are the environmental influences on populations? ● How do environmental influences affect nursing practice? ● What oversight organizations guide regulations and policies? ● What are the interrelationships among health policy, social justice, and nursing practice?
Introduction Health care’s rapid transformation during this century centers on the environment, health care policies, and effectiveness of the health care system. When entering nursing, the focus is often on bedside skills, an individual’s immediate needs, and the closest health care setting. Advancement in nursing practice now demands that nurses look beyond the proximate and seek to understand the larger world that encompasses health care. Health disparities, inequities of care, and the need to advocate for social justice become integral to new nursing roles for this century. An understanding of environmental health and the components of the U.S. health care system provide a foundation for care of populations.
Environmental Health
● Environmental health is the broad science focused on how the environment influences human health, injury, and disease. According to the World Health Organization (WHO) (2018a), environmental health is “all the physical, chemical, and biological factors external to a person and all the related behaviors.” The science includes the assessment and control of these factors affecting health with the goal of disease prevention and healthy environments (World Health Organization [WHO], 2018a). Environmental health science does not include human behaviors resulting from genetics or from the psychosocial/cultural environment (WHO, 2018a). The American Public Health Association (APHA) denotes environmental health as a critical component of public health systems (American Public Health Association [APHA], 2018). The public health focus is on relationships between people and their environment for health
promotion and safe, healthy communities (APHA, 2018). In 2012 alone, unhealthy environments resulted in a global mortality rate of 1 in 4, accounting for approximately 12.6 million deaths (WHO, 2016a).
Environmental Threats to Health
● Risk factors for more than 100 injuries and diseases are environmental, including air, water and soil pollution, chemical exposures, climate change, and ultraviolet radiation (WHO, 2016a). The largest share of environment-related deaths results from noncommunicable diseases (NCDs), such as cardiovascular disease, stroke, cancers, and chronic respiratory disease (WHO, 2017b). Healthy People 2020’s overview of environmental health includes natural and technological disasters as part of the concerns (HealthyPeople.gov, n.d.a), such as injuries sustained from a tornado, a disease outbreak due to flooding, or a nuclear leak resulting from a breakdown in technological surveillance. Environmental health is connected to the social determinants of health (SDOH). SDOH are conditions of living, such as housing, socioeconomics, transportation needs, and quality of education that directly impact health and access to health care needs. Environmental health concerns related to the SDOH center on working conditions, housing, water, sanitation, and healthy lifestyles (Prüss-Üstün, Corvalán, Bos, & Neira, 2016). In other words, a healthy environment contains healthy living conditions or SDOH. Environmental barriers to healthy living conditions become detrimental to health. For example, lack of adequate shelter to protect an individual from temperature extremes can cause harm, as can a lack of access to healthy and ample nutrition. The poor physical conditions of housing and high household energy costs negatively affect the health of low-income families’ economic, physical, and behavioral health and security (Hernández, 2016). Because some form of energy is required for basic cooking, lighting, and heating, those with low incomes may face hardships if household energy expenditures exceed 10% of their income (Hernández, 2016). Expenditures on heating or cooling may increase due to poor housing physical conditions, such as air leaks, broken windows, or lack of insulation. The economic situation may cause families to consider whether they can afford to both heat and eat (Hernández, 2016). The prioritization of resources and trade-off decisions affect physical and behavioral health through stress and deprivation. Higher risks of cardiovascular diseases, stroke, and diabetes result from an unhealthy diet (Micha et al., 2017; WHO, 2017b). Recent studies find that exposure to violent crimes, household-noise levels, proximity to traffic noise, and air pollution affect the development of cardiovascular diseases (Chum & O’Campo, 2015). These neighborhood factors are thought to
reduce physical activity, sleep, and rest and increase stress, depression, and anxiety, all of which negatively impact cardiovascular health (Chum & O’Campo, 2015). Reduced access to grocery stores, parks, and recreation and easy access to fast food in neighborhoods also increases cardiovascular health risks (Chum & O’Campo, 2015). Poor air quality at home or work correlates with development of lung disorders, such as chronic bronchi or alveolar disorders. Cancer, asthma, and chronic obstructive pulmonary diseases result from exposure to radon, smoke, lead, toxic gases and particulates, coal dust, or asbestos, with smoking being the highest risk of death (WHO, 2017b). Thus, a poor environment increases the burden of disease regarding NCDs. The burden of disease reflects the morbidity, mortality, financial costs, and health disparities resulting from disease, affecting human longevity and the well-being of countries socially and economically.
Exposure to poor environments results in poor health. Poor health results in vulnerability to communicable disease. Proximity and specific types of behavior can lead to spread of disease. Poor sanitation and water pollution can lead to an outbreak of cholera or other gastrointestinal-related infectious diseases. Growth of molds, bacteria, mycotoxins in damp housing increases respiratory infectious disease occurrence (Prüss-Üstün et al., 2016). Uncontrolled populations of mosquitoes, ticks, fleas, lice, and sandflies increase the risk of vector-borne diseases, such as malaria, Chagas, dengue fever, yellow fever, Zika virus, West Nile virus, Lyme disease, typhus, and plague (WHO, 2017d). Tuberculosis, hepatitis B and C, parasitic diseases, and sexually transmitted diseases (STDs) increase in unsafe, unhealthy environments (Prüss-Üstün et al., 2016). A growing concern is the world’s reliance on antibiotics to control infections and the increased development of antimicrobial-resistant pathogens. Poor hand hygiene and contact precautions increases the transmission risk of antimicrobial-resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) (Seibert, Speroni, Oh, DeVoe, & Jacobsen, 2014). Antimicrobial resistance reduces the range of effective antibiotics available, lengthens illness and hospital stays, and increases the risk of death (Duckworth, 2017). Crowding, skin-to-skin contact, and shared equipment, supplies, or personal items spread MRSA in the community. Spread of MRSA within a community can occur to the point of forcing the shutdown of public areas to decontaminate equipment and surfaces, especially schools, day care centers, and athletic venues (Centers for Disease Control and Prevention [CDC], 2016b). According to the National Academy of Sciences, Engineering, and Medicine (NASEM) (2017a), the antimicrobial resistance has become an emerging and global health condition, resulting in a number of deaths. The WHO (2017a) considers antimicrobial resistance to be “one of the biggest threats to global health, food security, and development today” (para. 1). The commonly resistant organisms are Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus (MRSA), Mycobacterium tuberculosis, Streptococcus pneumoniae, Enterococci faecium (Vancomycin-resistant Enterococci or VRE) and Salmonella (National Academy of Sciences, Engineering, and Medicine [NASEM], 2017a; WHO, 2018c). In addition, Clostridium difficile (C. diff) is an urgent concern in U.S. health care environments (NASEM, 2017a).
Reducing the Health Impacts of Global Climate and Environmental Changes
● The current environment has modifiable health risks. For example, better environmental conditions reduce transmission of diseases from the animal world. Animals have diseases considered zoonotic, meaning they are transmissible to humans. Modern day communicable disease epidemics often originate from animal transmissions. Such is the case for Ebola, salmonellosis, severe acute respiratory syndrome (SARS), and influenzas. The WHO notes that 61% of human disease-causing microorganisms are from animal transmissions and represent 75% of emerging infectious diseases in the past decade (WHO, 2018d). The following topics are prominent means for health promotion and disease prevention when confronting climate and environmental changes.
One Health
● One approach to combating climate and environmental issues is collaboration among multiple professions and/or multiple nations. The Centers for Disease Control and Prevention (CDC), WHO, and professional organizations use this approach. The One Health initiative uses the
concept of global interdisciplinary collaboration among physicians, “A One Health approach is important because 6 out of every 10 infectious diseases in humans are spread from animals.” (CDC, 2018c, para. 2)veterinarians, and other health and environmental professionals to address all aspects of health care for humans,
animals, and the environment (One Health Initiative, n.d.b). Joint efforts among these professionals currently conduct public health surveillance of cross-species diseases, including treatment and preventative measures. The initiative seeks to advance health care by “accelerating biomedical research discoveries, enhancing public health efficacy, expeditiously expanding the scientific knowledge base, and improving medical education and clinical care” (One Health Initiative, n.d.a, para. 1). Efforts include multiple collaborations among professional and educational settings for medical, veterinary, public health, and the environment sciences. Goals include a better understanding of cross-species disease transmission and environmental research. The initiative’s objectives aim to provide and improve diagnostics, vaccines, prevention and control measures, and education for political leaders and the public. The National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) notes that people live “in an interconnected world where an outbreak of infectious disease is just a plane ride away” (CDC, 2018b, para. 1). The CDC has experts working on a One Health Zoonotic Disease Prioritization to focus and mitigate impact of endemic and emerging zoonotic disease threats to the public. The One Health approach is an ecosystem approach, keeping the links between humans, animals, and the environment (Gyles, 2016; Van Helden, Van Helden, & Hoal, 2013; Shrestha, Acharya, & Shrestha, 2018).
Sustainable Development Goals
● Risk factors for transmission of communicable disease directly link with poor environments. The Sustainable Development Goals (SDGs), which are holistic, people-centered global health initiatives for the year 2030, were developed by the United Nations (UN) and the WHO. These goals align with the concept of social justice as well as the idea that health is a right that is to be equitably available to all. The SDGs include:
1. No poverty 2. Zero hunger 3. Good health and well-being 4. Quality education 5. Gender equality 6. Clean water and sanitation 7. Affordable and clean energy 8. Decent work and economic growth 9. Industry, innovation, and infrastructure 10. Reduced inequalities 11. Sustainable cities and communities 12. Responsible consumption and production
13. Climate action 14. Life below water 15. Life on land 16. Peace, justice, and strong institutions 17. Partnerships for the goals (United Nations, n.d.)
The various initiatives and other SDGs interact to meet SDG 3—ensure healthy lives and promote well-being for all ages and address environmental factors (WHO, 2018f). For example, promoting sustainable agriculture (SDG 2) helps achieve food security and reduces malnutrition, which will promote health and well-being. Clean water and sanitation (SDG 6) targets water shortages, poor water quality, and sanitation issues, which will reduce transmission of disease. SDG 7’s aim for affordable clean energy addresses food production, climate change, and economic livelihoods, thereby improving the environment and health. SDG 13 tackles actions combating climate change. Recent estimates hold that 92% of the global population is living in areas where the air pollution levels exceed the WHO limits (WHO, 2016b). The BreatheLife campaign is a global collaborative effort to increase awareness of health risks of even short-lived climate pollutants. Poor air quality increases the global burden of disease and increases mortality. Air pollution is a leading risk factor for the development of NCDs. Air pollution-related deaths have been linked to the following NCDs: 36% of lung cancer, 35% of pulmonary disease, 34% of stroke, and 27% of heart disease deaths (BreatheLife, n.d.; WHO, 2018b). Counteractive measures include promoting green spaces and alternatives to burning waste and fuels for transportation, heating, and cooking (WHO 2016b). Such measures are expected to help reduce climate changes as well.
A joint effort between the WHO and the United Nations International Children’s Fund (UNICEF) (WHO & United Nations International Children’s Fund [UNICEF]) seeks global prevention measures for provision of safe water, sanitation, and hygiene (WASH). WASH can improve nutritional statuses, reduce diarrheal diseases, intestinal parasite infections, and environmental enteropathy, thereby reducing the global burden of disease and deaths (WHO & UNICEF, 2017). Billions lack safe water at home and/or have no toilets (see Figure 4.1 and Figure 4.2). SGD 6 incorporates measures to combat this issue and the lack of soap and water for handwashing (see Figure 4.3). These measures overlap with goals from One Health. In addition, the measures create overall improvements in maternal, newborn, and child health. Recently, the UN Secretary-General called for global action for WASH in all health-care facilities noting that a survey of 100,000 facilities revealed that “more than half lacked the simple necessities, such as running water and soap” (WHO, 2018e, para 10).
Figure 4.1
Access to Safe Water for All by 2030
Note. Adapted from “Progress on drinking-water, sanitation and hygiene, 2017: Infographics,” by the World Health Organization.
Figure 4.2
Access to Safe Sanitation for All by 2030
Note. Adapted from “Progress on drinking-water, sanitation and hygiene, 2017: Infographics,” by the World Health Organization.
Figure 4.3
Access to Soap and Water for Handwashing
Note. Adapted from “Progress on drinking-water, sanitation and hygiene, 2017: Infographics,” by the World Health Organization.
Healthy People 2020 and Environmental Quality
● Healthy People 2020 objectives focus on objectives in six categories that direct actions toward environmental health issues involving outdoor air quality, surface and ground water, toxic
substances and hazardous waste, homes and communities, infrastructure and surveillance (such as public health departments), and global environmental health (HealthyPeople.gov, n.d.a). These objectives are congruent with the mission, goals, and objectives of the Environmental Protection Agency (EPA), another U.S. government agency. The EPA’s mission “is to protect human health and the environment” (Environmental Protection Agency [EPA], n.d.b, para. 1). Goals and objectives of the EPA’s strategic plan include clean air, land, and water by enforcing federal laws to protect human health and the environment and requiring the safe use of chemicals (EPA, n.d.a). The significant emerging environmental issues involve climate change, disaster preparedness, and nanotechnology. Nanotechnology at the EPA involves researching how to measure the nanomaterial concentrations and seek to determine how minute chemicals and materials in products pose risks to human health and the environment (EPA, n.d.c). Air quality improvement measures from the EPA and Healthy People are aimed toward the use of alternative modes of transportation, such as bicycling, walking, mass transit, or telecommuting. Measures are in place to reduce adverse health effects resulting from toxic emissions from manufacturing and other sources. The water quality objectives address methods for meeting federal regulations for safe drinking water, such as the Safe Drinking Water Act of 2008; reducing waterborne disease outbreaks; conserving water; and sustaining coastal waters safe for swimming (HealthyPeople.gov, n.d.a). Evidence of progress in the area of toxic substances and hazardous wastes is verified through the increase in recycling efforts as well as the reduction in hazardous waste sites, pesticide exposure, and serum lead levels in toddlers and preschoolers (HealthyPeople.gov, n.d.a). Residents of healthy homes seek to reduce indoor household allergen levels from cockroaches, mice, and dust; radon exposure risk; and lead-based paint as well as dust- and soil-lead hazards (HealthyPeople.gov, n.d.a). In addition, the initiatives monitor the health of community educational systems to provide healthy school environments with indoor air quality management; a reduced amount of molds; proper use, storage, and disposal of hazardous materials; safe drinking water; and prudent use of pesticides. Healthy People 2020 initiatives measure the body burden of toxins or the amount of a radioactive element or toxic material in a body, especially lead. Routes of entry include oral, integumentary, and respiratory. Storage sometimes occurs in human or animal fat tissue.
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Since Florence Nightingale, nurses are accountable for managing the environment to promote health (Jackman-Murphy, 2015). In 2007, the American Nurses Association (ANA) published ANA’s Principles of Environmental Health for Nursing Practice with Implementation Strategies. These principles incorporated nursing’s heritage of disease prevention and social justice, ongoing global climate changes, and increasing burdens of individual exposures (American Nurses Association [ANA], 2007). The ANA’s Scope and Standards of Practice guides all
nurses to practice in a safe and environmentally healthy manner (ANA, 2010). Nurses work to counteract the direct and indirect health implications of climate changes that result in temperature extremes, air pollution, toxic exposures, food shortages, and water scarcity. Climate changes have health repercussions, especially in the very young, older adults, those with preexisting chronic health conditions, immigrants, and the poor (Allen, 2015). Extreme weather events pose risks of drowning, physical injuries, heat exhaustion, postdisaster infections, mental health consequences, and risks of fires. In a study of weather-related mortality among U.S. residents from 2006 to 2010, “about 31% of these deaths were attributed to exposure to excessive natural heat, heat stroke, sun stroke, or all” (Berko, Ingram, Saha, & Parker, 2014, p. 1). Because of extreme heat, there are about 618 preventable human deaths each year in the United States (CDC, 2017b). The world experienced 15 of its warmest years on record since 2000 (CDC, 2016a). The rise in the annual temperature correlates with climate changes. The EPA (2016) monitors key indicators related to causes and effects of climate changes as noted in the report Climate Change Indicators in the United States. The report discusses the multiple indicators and the effects of climate on health. Nurses are in the position of sharing this evidence-based research and increasing awareness within the nursing practice. Nurses can subscribe to professional publications and attend workshops to foster their own development. For example, NASEM, formerly the Institute of Medicine (IOM), sponsored a workshop in 2017 called “Protecting Health and Well-Being of Communities in a Changing Climate” and published on its website a brief summary of the workshop proceedings with results from four regions of the United States (NASEM, 2017b). The Alliance of Nurses for Healthy Environments (ANHE, pronounced Annie) recognizes nursing’s pivotal role in health promotion and environmental health through nursing education and professional leadership, research, evidence-based practice, and policy advocacy (Alliance of Nurses for Healthy Environments [ANHE], 2017). All nurses have the responsibility to practice in an environmentally safe manner and to provide evidence-based information about environmental health to the nursing field, the patients, the public, and policy makers.
Healthy Work Environments
● Healthy work environments are the primary focus of two U.S. federal agencies: National Institute for Occupational Safety and Health (NIOSH) and the Occupational Safety and Health Administration (OHSA). NIOSH is a research agency, under the auspices of the CDC, established by the Occupational Safety and Health Act of 1970 (CDC, 2018a). NIOSH researches workplace environments and makes recommendations for prevention of work-related injury and illness. NIOSH maintains a list of antineoplastic and other hazardous drugs in health care settings. OHSA is structured under the U.S. Department of Labor with the
mission of assuring safe and healthy work conditions through writing and enforcing regulatory standards (Occupational Safety and Health Administration [OSHA], n.d.a). OSHA has links for filing safety and health complaints, reports of death or severe injury, and whistleblower information regarding employee protections from retaliation when reporting injuries, safety concerns, and similar activities. OSHA maintains eTools with information on hazards present in health care, such as blood-borne pathogens, mercury, and workplace violence (OSHA, n.d.c). Both NIOSH and OSHA link the public and health care professionals to topical resources for workplace safety and health. For example, both sites have links to information regarding ergonomics, and the agencies jointly published a hospital respiratory protection program toolkit (CDC, 2015a). Both agencies target prevention of harm to the human body, particularly the musculoskeletal system through the ergonomic design and arrangement of the workplace environment, including equipment and the persons. Nurses, for example, study body mechanics to determine the best use of workplace equipment to make beds, move persons, and transport equipment. Lifting, carrying, pushing, and pulling all use musculoskeletal functions. Poorly designed equipment can be harmful. Today’s technology may have a person performing one function or movement over long periods each day, and this repetition can be injurious to the body. The stressors to the body often result in musculoskeletal disorders (MSD), which trigger one-third of lost work days or workday cases. The U.S. Bureau of Labor Statistics (2017) uses the days away from work as a measure of severity of injuries and illnesses. Specifically, health care workers have a high rate on nonfatal occupational illness and injury (U.S. Bureau of Labor Statistics, 2017). The ANA surveyed nurses regarding work-related injuries, and of the respondents, 62% of the nurses reported concerns of suffering a disabling musculoskeletal injury as one of the top three workplace safety concerns; 80% reported working despite frequent musculoskeletal pain (ANA, 2011). Therefore, nurses need to keep informed of the dangers of MSD risks in the workplace. In 2014, the ANA published Safe Patient Handling and Mobility: Interprofessional National Standards and Implementation Guide to Safe Patient Handling and Mobility: Interprofessional National Standards. OHSA recommends minimization of manual lifting of patients and the elimination of lifting when possible (OHSA, n.d.b). The nurse should monitor coworkers for risks and educate others about ways to counteract the risks.
Hazardous waste is another area of concern in workplace safety and the environment. Hazardous waste includes, but is not limited to, regulated medical waste (RMW) and other hazardous substances such as chemicals, cleaning solutions, corrosives, heavy metals, and radioactive materials. RMW must be disposed of separately, usually incinerated, from other waste to avoid spreading communicable disease from blood, body secretions, or otherwise potentially infectious materials. Hazardous waste and RMW has to be tracked with manifests and signatures throughout the disposal chain of custody.
To identify hazardous waste consistently around the world, the United Nations Economic Commission for Europe (UNECE) created an international system of chemical classifications by types of hazard, called the Globally Harmonized System of Classification (United Nations Economic Commission for Europe [UNECE], 2013). The Globally Harmonized System (GHS) categorizes chemicals into classes according to either physical, health, or environmental hazards. This system standardized these chemical classifications, labeling requirements, and
information sheet requirements, known as Safety Data Sheets (SDS). In the United States, OSHA requires an SDS for each hazardous item in the workplace (OSHA, n.d.b). Product labels and the SDS communicate the hazardous nature of the chemical through the hazard statements, signal words of “Warning” and “Danger,” and pictograms. For example, a pictogram of skull and crossbones indicates danger of severe toxicity, and a flame indicates highly flammable chemicals (see Figure 4.4).
Figure 4.4 Severe Toxicity and Highly Flammable GHS Symbols
Every worker should have access to the SDS for reference. Nurses need to know the location of hazardous chemicals and the SDS. Organizations have policies and procedures in place to meet OSHA standards. In addition, the nurse must protect and educate coworkers of these risks, proper containment, and disposal methods according to OHSA and organizational standards.
Check for Understanding
1. Which global environmental threats are encountered in your nursing practice? 2. How can the nurse incorporate concepts of social justice to promote environmental health? 3. What additional environmental hazards could be removed from the workplace?
U.S. Health Care System
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According to a recent report, the U.S. health care system ranks last in overall performance among 11 countries examined (Schneider, Sarnak, Squires, Shah, & Doty, 2017). The United States pays the highest cost per person, yet has poor health care outcomes (Schneider et al., 2017, The Commonwealth Fund, 2017). The bottom line is that the U.S. system is not working as well as others (The Commonwealth Fund, 2017), which is due, in part, to the complexity of the U.S. health care system. To advocate for health care system improvements, the nurse needs an understanding of the current system.
Organizational Structure Health care in the U.S. is decentralized with a variety of public and private access points. The public health system includes government entities and collaborative efforts with community nonprofit organizations and faith-based organizations (see Figure 4.5). Government entities include health agencies at the federal, state, and local levels, public safety agencies, and environmental agencies. Government agencies include state and local health departments, providing care such as laboratory services, health screenings, treatment of disease, and epidemiology surveillance. Private health care is delivered in inpatient, outpatient, or ambulatory care; long-term or residential; mental health; home care; wellness center; and alternative medicine settings. Private institutions are either for-profit private facilities or nonprofit private facilities, with the latter being the largest component. According to the American Hospital Association (AHA), there are more than 5,500 private, short-term care hospitals in the United States (American Hospital Association [AHA], 2018). Both private and public health care is offered by professionals known as providers, who include physicians, nurse practitioners, nurses, and other ancillary professionals who deliver health care directly to their clients or patients (Kahn, 2011). A trained workforce assists providers in care provision and are considered resources. Other resources include technology, equipment, and supplies. The vulnerable aspect of the system is the consumer who is at risk of harm if the health care system does not function efficiently and safely when delivering care.
Figure 4.5
The Public Health System
Note. Adapted from “The Public Health System & the 10 Essential Public Health Services,” by the Centers for Disease Control and Prevention, 2017.
Agencies Associated With Health Care No matter the setting or organizational formation, the facilities have the overarching governmental regulatory mechanisms of the Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Food and Drug Administration (FDA), the CDC, and OSHA (Healthcare Triage, 2014). Other federal agencies involved in health care include the:
● Center for Global Health; ● Office of Noncommunicable Diseases Injury and Environmental; ● Office of Infectious Diseases; ● Office of Public Health Preparedness and Response; ● Office of Public Health and Science (OPHS); ● Office for State, Tribal, Local, and Territorial Support; and ● Office of Surveillance, Epidemiology, and Laboratory Services.
Other federal agencies with a relationship to health care entities include the ● Office of Veterans Affairs (VA), ● EPA, ● Department of Justice, ● Department of Labor, ● Department of Defense, ● Department of Agriculture, and ● National Science Foundation.
This large collection of agencies reveals the complexity and sometimes fragmentation of U.S. health care. Agencies at state and local levels center on state and local public health care agencies, such as state and local health boards and state, county, or city departments of health. Multiple volunteer organizations complete the final aspect of health care services. Not all areas have government fire, police, and emergency services. Volunteer emergency medical technicians and paramedics provide emergency care in some locales. Other volunteer agencies may have a national outreach. For example, Volunteers of America (VOA) (n.d.) offers assistance for senior living and care services. The National Association of Free and Charitable Clinics (NAFC) (n.d.), a network of volunteer agencies, provides medical services for the underinsured.
Financing Mechanism for U.S. Health Care Financing Costs for Individual Care Paying for health care is a major concern in the United States. Although individuals may have freely accessible health care at a variety of settings, the health providers and organizations expect payment for services rendered in order to remain operational; however, transportation, restrictions on eligibility for certain services, and ability to pay are barriers for some. The cost
of services and has risen to new heights in this century. One means of paying for health care is through out-of-pocket payment or self-payment of services. Most Americans have neither the income nor savings to cover the full cost of health services when faced with more than a minor illness or condition. Ability to pay for services often comes in the form of health insurance coverage. Health insurance is an arrangement with the government or a private company to guarantee payment for health care services, generally for illnesses, injuries, and health conditions.
Federal and state governmental resources for health care are available for some (see Figure 4.6). Active duty military service members, veterans, their families as well as members of the National Guard and military reserves have eligibility for federally government-funded health insurance coverage through a health care program called Tricare (Tricare, n.d.). People who are 65 or older, those younger than 65 with certain disabilities, and those of any age with end-stage renal disease are commonly eligible for Medicare, a federal health insurance program (Centers for Medicare & Medicaid Services [CMS], 2014). Currently, more than 18% of the U.S. population, or 57 million people, depend on Medicare (Dean, Noel-Miller, & Lind, 2017). Medicare consists of multiple parts and eligibility stipulations, which confuses some about whether they are eligible for these benefits. The individual must apply for Medicare enrollment during specified times of the year, usually during the fall. The Medicare health and medications plans change yearly, requiring the person to review and choose coverage annually. Medicare Part A is hospitalization insurance for stays in acute care hospitals, short-term skilled nursing facilities, and some hospice and home care (CMS, 2014). Typically, the person pays a deductible before Medicare begins to provide compensation. Deductibles are out-of-pocket expenses. Medicare Part B provides coverage for practitioner services, outpatient care, and durable medical equipment, such as oxygen and wheelchairs. Medicare Part B coverage requires user enrollment and the payment of a monthly government premium. Medicare Part B generally provides 80% compensation for the cost of services, and the person must pay the remaining 20% as a copayment, plus any deductible. Medicare Part C, better known as Medicare Advantage, is not a separate Medicare benefit, but allows for Medicare coverage for those who wish to enroll in some private insurance plans (CMS, n.d.). Medicare Part D coverage requires user enrollment and the payment of a monthly government premium for lower cost prescription medications.
Figure 4.6
Financing Structure of the U.S. Health Care System
Note. Adapted from United States of America: Health System Review, by T. Rice, P. Rosenau, L. Y. Unruh, A. J. Barnes, & R. B. Saltman, 2013, Health Systems in Transition, 15, p. 27. Copyright 2013 by Health Systems in Transition .
Medicaid is a health insurance program for certain families with low incomes, which is jointly funded by the federal government and the state where the family resides. Note that Medicaid is for families, not low-income adults without children, but it does provide for eligible blind or disabled persons. Since 2014, in accordance with provisions of the Affordable Care Act (ACA), states have the authority to expand eligibility for Medicaid to persons under the age of 65 if the family income is below 133% of the federal poverty level (FPL) for that family’s size (Medicaid.gov, n.d.b). The states, the U.S. territories, and the District of Columbia vary in Medicaid coverage. Some persons receiving Medicaid are also eligible for Medicare, known as dual eligibility. Oversight of federal program policies and procedures for Medicaid, the Children’s Health Insurance Program (CHIP), and the Basic Health Program (BHP) is through the Center for Medicaid and CHIP services (CMCS) (Medicaid.gov, n.d.b). The CHIP program provides states with federal matching funds for provision of health coverage to children of eligible families (Medicaid.gov, n.d.b). To be eligible for CHIP coverage, the family income must be too high to qualify for Medicaid and yet still too low to afford private coverage (Medicaid.gov, n.d.b). Most states allow coverage for children of families at 200% or greater of FPL (Medicaid.gov, n.d.b). More than 74 million adults and children are covered by Medicaid or the CHIP program
(Medicaid.gov, n.d.a). The BHP is a health insurance coverage option, which is another provision of the ACA, allowing state health benefits for low-income adults, who have eligibility to purchase private insurance coverage through a health insurance exchange or marketplace (Medicaid.gov, n.d.b).
The majority of the U.S. population finances health care costs through private health insurance (Kahn, 2011). The individual pays a premium to the private insurance company. If employed, people can often enroll in their companies’ group health plan, for which the employer typically pays a significant portion of the premium, reducing the cost to employees. In the past century, especially the 1960s, individuals could chose whatever health care facility and provider they wished, and the private insurance company would compensate the services (Kahn, 2011). Because of the rising cost of health care, insurance companies placed restrictions on choice. Now, private health insurance companies negotiate contracts with providers and facilities for acceptance of prearranged cost of services. Health maintenance organizations (HMOs) provide tighter management of funds with enrollees paying a premium and predetermined fee for services from a preset list of providers and facilities (Kahn, 2011). Ordinarily, care delivered by those not on the preset list results in no compensation, and the individual is then responsible for the cost, unless a preapproved referral is in place. Preferred provider organizations (PPOs) provide a more flexible list of providers and facilities, but with higher fees (Kahn, 2011).
The ACA provided an expectation that every American have health care insurance. One of the concepts was to provide health insurance options for those who were unemployed or uninsured in the United States. The population had no centralized means of surveying options, leaving many unsure of how to find a health insurance plan that was best suited for themselves or their families. With the advent of the ACA, health insurance exchanges or marketplaces emerged. Some exchanges are ACA government-regulated, standardized health care plans. Others are private non-ACA exchanges, generally for small businesses. Both provide central sites for browsing health care plans competitively offered by the private insurance companies choosing to participate. The ACA concepts of transparency and accountability aid in the sharing of expenses across larger groups of people, more like a group plan. Moreover, marketplace and insurance companies share plan information through electronic data interchanges (EDIs) when an individual enrolls. Most states use the federal marketplace, Healthcare.gov.
Public Health Financing for Populations Population health programs cannot operate without facilities, personnel, equipment, and supplies, all of which require funding. The most common sources of monies come from federal grants, state and local funds, and city or county revenues (CDC, 2013). Funding also comes from private organizations. Funding varies according to the current government’s health budget and legislative policy making (CDC, 2013). Grants provide funds to accomplish specific public purposes, and contracts or purchase orders with vendors normally acquire the equipment, supplies, and other services (CDC, 2017a). The Prevention and Public Health Fund (PPHF or The Fund), established under the ACA, is the compulsory annual funding of federal monies directed to the improvement of the U.S. public health system for prevention, wellness, and public health initiatives (EveryCRSReport, 2017; CDC, 2017c). For example, public health
initiatives for smoking cessation used funds from PPHF to develop the mass media campaign, Tips from Former Smokers (American Lung Association, n.d.).
One Family
The following is an example of how one family structure can encounter multiple methods of financing their health care.
Mary, a retired, 65-year-old woman, now has a Medicare Part A card for health care. John, her 64-year-old husband, maintains insurance through his employer. Their daughter, Sarah, and granddaughter, Grace, are on Medicaid, but their son, Bob, has an income too high for Medicaid. Bob’s family is covered by CHIP.
Check for Understanding
1. How do One Health collaborations aid epidemiological surveillance? 2. How could access to health care be improved in the United States? 3. What aspects of the public health system have improved in the past decade? 4. How does an understanding of health care financing provide a foundation for advocacy related to population
health nursing practice?
Public Health Delivery and Institute of Medicine Reports Two major nonprofit organizations greatly influence the direction of public health care: the Robert Wood Johnson Foundation (RWJF) and NASEM. Sometimes, the influence comes through RWJF campaigns for action or sometimes through research reports. For example, in 2009, the RWJF requested that the IOM examine measurement, law, and funding within public health (Institute of Medicine [IOM], 2011a). This study followed the IOM’s report, The Future of Public Health (IOM, 1988), which scrutinized public health.
The Future of Public Health With the advent of sanitation, safe water, protection against epidemics, and lower infant mortality rate than in the 1900s, there has been difficulty maintaining an appreciation of the critical nature of providing public health (IOM, 1988). The Future of Public Health was a landmark report that revealed that the public health infrastructure was poorly focused and inadequate (IOM, 1988). Recommendations were to regain dedication to the mission of public health with the government playing a vital role in policy development toward its mission at federal, state, and local levels (IOM, 1988). Government support emphasized environmental health, mental health, social services, and medical care for impoverished people (IOM, 1988).
Shortly after The Future of Public Health was published, the IOM followed up with To Err is Human, (IOM, 2000), which resulted in national outcry over medical errors. The RWJF and the American Association of Retired Persons (AARP) began campaigns to correct these issues, now reflected in the initiatives described in Culture of Health and the Future of Nursing: Campaign for Action (American Association of Retired Persons [AARP], n.d.; Reinhard, 2018, Robert Wood Johnson Foundation [RWJF], n.d.a; RWJF, n.d.b).
Crossing the Quality Chasm: A New Health System for the 21st Century Subsequent to the publication of To Err is Human, the IOM scrutinized the overall U.S. health care system for ways to improve the quality of care in light of a new century. The report, Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001), triggered reactions still felt today. The publication documented that inadequate funding, insufficient accountability, and lack of partnerships with other health care service providers continued to plague the health care system (IOM, 2001). The IOM recommended six aims for improvement, shifting health care’s focus to safe, effective, timely, efficient, equitable, and patient-centered provision of care (IOM, 2001). Thus, the focus changed from errors and safety to a focus on quality as a means of error prevention and creation of safety. Strategies incorporate customization of care based on an individual’s needs, continuous healing care, patient control over health care decisions, evidence-based practice, free flow of clinical information, and transparency (IOM, 2001). In light of public health nursing, the emphasis on equitable care aligns with the concept of social justice and reduction of health care disparities.
The Future of the Public’s Health in the 21st Century The IOM conducted further analysis of the public health system in The Future of the Public’s Health in the 21st Century (IOM, 2003). This report showed that there was still inadequate funding, insufficient accountability, and lack of coordination to collaborate with other health care services (IOM, 2003). The report distinguished three core functions of public health, which continue in the present: assessment, policy development, and assurance of the public (IOM, 2003). Furthermore, 10 essential public health services were determined (IOM, 2003). These core functions and essential services are now national public health performance standards (see Figure 4.7).
Figure 4.7 The 10 Essential Public Health Services
Advocacy for Improvement of Population Health
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Universal Health Coverage (UHC) As of June 2017, the number of uninsured Americans dropped to 9% of the population, down from 16% in 2010 (Clarke, Schiller, & Norris, 2017). This means that 28.8 million Americans are still uninsured (Clarke et al., 2017). In addition, almost 4.6% of the U.S. population, or 15 million people, failed to seek medical care during the previous 12 months because of cost of care (Clarke et al., 2017). An American may have health insurance, yet fail to seek medical care because of the out-of-pocket cost of the deductible (Chin, 2017; Olen, 2017). Some insured Americans must make the difficult choice of whether to seek needed care and pay a medical bill or pay for food and housing (Chin, 2017; Olen, 2017). Americans are in poorer health than other high-income countries globally, which disputes beliefs that U.S. has the best health care (Schneider & Squires, 2017). Many believe that the ACA is the closest to universal health coverage (UHC) that the United States can achieve.
During the last century, the WHO declared health as a fundamental human right (WHO, 2018g). UHC is in alignment with the SDG 3 of promoting good health and well-being for all people and all ages (WHO, 2018d). One of the WHO’s global goals is that all people have access to needed health promotion and prevention, curative rehabilitation, and palliative health services with sufficient, effective quality and without financial hardship (WHO, 2018g). As of 2017, over half the global population still does not have access to necessary health services (WHO, 2017c). The WHO advocates equitable access to all health services, quality health services, and protection against financial hardship when needing health care (WHO, 2018g). Out-of-pocket expenses are minimal under UHC (Schneider & Squires, 2017). The challenge in the United States is the hodgepodge financing, high health care costs, and accessibility to health care (Robinson, 2016; Schneider & Squires, 2017).
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A crucial position of the nursing profession, nationally and globally, is the provision of equitable health care and the reduction of health disparities. As nurses know well, the perception that a nurse merely carries out physician orders is incorrect; nurses are change agents. Since Nightingale, nurses have acted as advocates for policy and system advancements that improve health for every human (Thurman & Pfitzinger-Lippe, 2017). Through lifelong learning and an understanding of change theory, nurses are engaged in transforming care for vulnerable and at-risk populations, reducing health disparities and social injustices, and improving the global perception of health care (Edmonson, McCarthy, Trent-Adams, McCain & Marshall, 2017; Paquin, 2011; Walter, 2017). Nurses demonstrate this engagement when they identify stakeholders who have a vested interest to support change or maintain the status quo, determine sources of power to enable the change process, and examine their own professional perspective of inequitable conditions (Walter, 2017). Evidence-based practice and mentoring by
those already involved in advocacy for social justice provide powerful knowledge and skills for social policy change (Paquin, 2011). Nurses recognize that social equity comprises all basic human needs, such as food, clothing, shelter, education, and employment, extending beyond access to health care (Walter, 2017).
Health in All Policies (HiAP)
● A framework for governmental collaboration and decision making resulted in the Health in All
Policies (HiAP) guidelines. HiAP is a collaborative approach that “You cannot get through a single day without having an impact on the world around you. What you do makes a difference, and you have to decide what kind of difference you want to make.” —Dr. Jane Goodall (The Jane Goodall Institute, n.d., para. 1) incorporates public health considerations into government decisions and policy making, ensuring a neutral or positive influence on the SDOH (SurgeonGeneral.gov, n.d.). The process uses collaboration with public and private stakeholders, creating a prevention-focused strategy that values health for the individuals, families, and public that explores the array of possible outcomes of a new decision or policy before it is made and the sequelae has unintended effects on health. HiAP originated as an approach through the WHO. The guidelines have a prominent focus for the U.S. National Prevention Strategy and Healthy People initiatives (CDC, 2016c). As prominent problem solvers, nurses make a difference and can advocate for approaches that reduce health inequities that a policy or decision could create. Nurses sometimes hesitate to become active in the political arena, but they are a needed voice (Webb, 2017). The CDC maintains a site for HiAP resources (CDC, 2015b).
Figure 4.8
HiAP Wheel
Note. Adapted from “Health in All Policies,” by the Centers for Disease Control and Prevention, 2016. Copyright 2016 by the Centers for Disease Control and Prevention.
Advanced Nursing Leadership, the IOM, and the ACA
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The reports by the IOM and the passage of the ACA expanded the role of nursing leadership for the 21st century. While nursing is already the largest workforce in U.S. health care, the IOM report, The Future of Nursing: Leading Change, Advancing Health, has created even more opportunities for advance practice nursing (IOM, 2011b). Now with the focus of health care moving from traditional illness to preventative care, nursing roles also are transforming (Berg & Dickow, 2014). The new roles create leaders who seek health equity and the advancement of the SDOH. The IOM report indicates that, with the passage of the ACA, nurses are in prime position to now practice as fully as possible, reducing barriers to advanced practice nursing. This has meant including nurse practitioners in Medicare compensation, just as physicians already were. The report urged states to revise their Nurse Practice Acts to remove barriers to advance practice (IOM, 2011b). Among the recommendations was the reduction of barriers to furthering nursing education such as expansion of scholarships, loans, and grants, as well as recommendations for an increase in baccalaureate-prepared nurses and development of nurse residency programs (IOM, 2011b). The advancement of nursing leadership includes meeting the recommendation of doubling the number of nurses with a doctorate, along with the expectation of all nurses to incorporate theory, research, clinical competency, and leadership development to meet the changing needs of health care (IOM, 2011b). An endorsement for placing nurses in policy and other decision-making capacities incorporated nurses on various public and private boards for health advancement (IOM, 2011b). The number of nurses encouraged to take the reins of change makes for an impressive influence (Berg & Dickow, 2014). The health promotion and preventative care aspects of the ACA are well within the leadership roles of nursing. The United States is capable of having the best health care in the world, and nursing is on the forefront for this change (Schneider & Squires, 2017).
Healthy People 2030
● Every 10 years, new national goals are set for Healthy People initiatives, and, as such, the Healthy People 2030 program is being developed. The proposed framework was open to public comment, which the HHS reviews before making final revisions. When the time occurs for formulation of the 2030 objectives, additional public comment is a possibility. Meanwhile, the proposed framework for Healthy People 2030 is available on the HealthyPeople.gov website (HealthyPeople.gov, n.d.b). Currently, the proposed framework equates health and wellness with attaining health literacy, eliminating health disparities, and achieving health equity. Nurses monitoring the site and health news are aware as the plans progress.
Check for Understanding
1. How does the WHO goal of universal health coverage align with U.S. goals for health care? 2. What aspects of HiAP improve quality of population health care? 3. Which aspects of public health quality monitoring have improved as a result of the IOM reports?
Reflective Summary Public health nursing began with a focus on disease prevention and wellness by providing safe water and sanitation. The health of the environment expanded from a focus on a neighborhood to one of the whole world. Nurses now advocate for ongoing legislative reform, safe and supportive communities, and environmental sustainability. The U.S. health care system’s fragmented financing system has led to millions of Americans who are uninsured or lack access to health care because of costs. The conditions of this century’s current health care demand that nurses become knowledgeable about policies affecting health and health care. Nurses, as advocates with leadership abilities, are in a position to turn health care in the United States from being 11th to Number 1 in the world.
Key Terms Affordable Care Act (ACA): Health care reform legislation with multiple provisions signed into law by U.S. President Barack Obama and became known as Obamacare; among the provisions include health insurance coverage to uninsured, measures to lower costs and improve health care system efficiency, preventative care, extension of care to dependents under the age of 26, and prohibited insurance claim denial or higher premiums for preexisting conditions.
Basic Health Program (BHP): Health insurance coverage option under the Affordable Care Act that allows eligible low-income adults to receive and purchase private insurance coverage through the health insurance marketplace.
Body Burden: The amount of a radioactive element or toxic material in a body.
Burden of Disease: Estimates of health problems’ impact on the world in terms of indicators such as financial cost, mortality, and morbidity; estimates include statistical analyses of disability-adjusted life year (DALYs), years of life lost (YLL), and years lost due to disability (YLD).
Children’s Health Insurance Program (CHIP): Health insurance coverage for children of parents whose income is too high to qualify for Medicaid but too low to pay for private health insurance coverage.
Climate Change: Any major change in the temperature, precipitation, wind, and other measurable weather patterns that occur for at least 10 years.
Copayment: A form of cost sharing for services; usually a fixed amount or percentage established by the insurance plan.
Deductible: The amount an individual must pay for services prior to an insurance plan providing compensation coverage.
Durable Medical Equipment: Equipment that serves a medical purpose in the treatment of a health conditions, such as canes, crutches, hospital beds, oxygen, traction equipment, ventilators, walkers, or wheelchairs.
Eligibility: Meeting criteria; allowed or permitted to take part in.
Environmental Health: The broad science focused on how the environment influences human health, injury, and disease with the goal of health promotion, disease prevention, and safe, healthy communities.
Environmental Protection Agency (EPA): Federal agency with the mission to protect human health and the environment through writing and enforcing U.S. regulatory standards for stewardship of natural resources, health, economics, energy agriculture, transportation, industry, international trade, and reduction of environmental risks.
Equitable Care: “Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status” (IOM, 2001, p. 6).
Ergonomics: The science of designing and arranging the workplace equipment and environment for safety and efficiency.
Extreme Heat: Higher temperature than average in a particular time and place, factoring in relative humidity.
Group Health Plan: Health insurance plans offered at a group rate through an employer or organization for the employee and employee’s family.
Health in All Policies (HiAP): A collaborative approach that incorporates public health considerations into government decisions and policy making, ensuring a neutral or positive influence on the social determinants of health (SDOH).
Health Insurance: An arrangement with the government or a private company to guarantee compensation for health care services, normally for illnesses, injuries, and health conditions.
Health Insurance Exchange: Entities that foster a competitive market for the purchase of private health insurance coverage; also known as a health insurance marketplace.
Health Maintenance Organization (HMO): A type of health insurance plan in which the individual enrolls for a predetermined fee for services from a preset list of providers and facilities; care delivered by providers not on the preset list will result in no compensation from the insurance company to the provider or facility. The individual requires a referral from the individual’s primary care provider for any other provider or services. For example, to have coverage for a visit to a dermatologist, the individual must have the primary provider’s approval via a referral.
Medicaid: Health insurance program for people with low incomes; jointly funded by the federal government and the state where the persons reside.
Medicare: Federal health insurance program for most people who are 65 or older; those under 65 with certain disabilities, and those of any age with end-stage renal disease.
Nanotechnology: Technology addressing extremely small-scale measurements or nanometers, such as maneuvering atoms, molecules, and supramolecules to achieve precise accuracy and ultra-fine dimensions.
National Institute for Occupational Safety and Health (NIOSH): U.S. federal agency, and part of the Centers for Disease Control and Prevention (CDC)/U.S. Department of Health and Human Services; conducts research and makes recommendations to prevent work-related injury and illness.
Noncommunicable Disease (NCD): Noninfectious, nontransmissible, or chronic disease arising from a combination of factors, including genetics, environmental, physiological, and behavioral aspects.
Occupational Safety and Health Administration (OHSA): Agency of the U.S. Department of Labor that helps to ensure safe and healthy work conditions by setting and enforcing standards.
Out-of-Pocket: Self-payment for cost of service.
Preferred Provider Organization (PPO): A type of health insurance plan in which the individual enrolls for a predetermined fee for services from a preset list of providers and facilities; care delivered by those not on the preset list may result in no or less compensation from the insurance company to the provider or facility.
Premium: Money paid for an insurance policy.
Prevention and Public Health Fund (PPHF): The permanent annual funding of federal dollars directed to the improvement of the U.S. public health system’s prevention, wellness, and public health initiatives; established under the Affordable Care Act; also known as The Fund.
Social Determinants of Health (SDOH): Conditions of living, such as housing, socioeconomics, transportation needs, quality of education, that directly impact health and access to health care needs.
Universal Health Coverage (UHC): To provide all people access to needed health promotion and prevention; curative, rehabilitative, and palliative health services with sufficient, effective quality and without financial hardship.
Whistleblower: Person who reports illegal, unethical, or unsafe activities of a person, employer, or organization.
Zoonotic: Diseases that are transmissible from animals to people, such as the Ebola virus or salmonellosis.
References
Allen, P. J. (2015). Climate change: It's our problem. Pediatric Nursing, 41, 42-46. Retrieved from https://lopes.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db= ccm&AN=103756359&site=ehost-live&scope=site
Alliance of Nurses for Healthy Environments. (2017). About. Retrieved from https://envirn.org/about
American Association of Retired Persons. (n.d.). Public policy institute. Retrieved from https://www.aarp.org/ppi/?intcmp=AE-SEARCH-AARPSUGG-ppi
American Hospital Association. (2018). Fast facts on U.S. hospitals. Retrieved from https://www.aha.org/statistics/2018-01-09-fast-facts-us-hospitals-2018
American Lung Association. (n.d.). ACA prevention and public health fund. Retrieved from http://www.lung.org/lung-health-and-diseases/protecting-your-lungs/aca-prevention-public-h ealth-fund.html?referrer=https://www.google.com
American Nurses Association. (2007). ANA’s principle of environmental health for nursing practice with implementation strategies. Retrieved from http://ojin.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/ANAsPrin ciplesofEnvironmentalHealthforNursingPractice.pd http://ojin.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Nurse/ANAsPrin ciplesofEnvironmentalHealthforNursingPractice.pd
American Nurses Association. (2010). Nursing: Scope and standards of practice. Silver Springs, MD: Author.
American Nurses Association. (2011). 2011 ANA health and safety study. Silver Springs, MD: Author.
American Public Health Association. (2018). Environmental health. Retrieved from https://www.apha.org/topics-and-issues/environmental-health
Berg, J. G., & Dickow, M. (2014). Nurse role exploration project: The Affordable Care Act and new nursing roles. Nurse Leader, 12(5), 40-44. doi: 10.1016/j.mnl.2014.07.001
Berko, J., Ingram, D. D., Saha, S., & Parker, J. D. (2014). Deaths attributed to heat, cold, and other weather events in the United States, 2006-2010. National Health Statistics Reports, no 76. Hyattsville, MD: National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/products/nhsr.htm
BreatheLife. (n.d.). Homepage. Retrieved from http://breathelife2030.org Centers for Disease Control and Prevention. (2013). Public health financing. Retrieved from
https://www.cdc.gov/stltpublichealth/docs/finance/public_health_financing-6-17-13.pdf Centers for Disease Control and Prevention. (2015a). Hospital respiratory program toolkit.
Retrieved from https://www.cdc.gov/niosh/docs/2015-117/default.html Centers for Disease Control and Prevention. (2015b). Office of the associate director for policy:
Health in All Policies. Retrieved from https://www.cdc.gov/policy/hiap/resources Centers for Disease Control and Prevention. (2016a). Climate change and extreme heat: What
you can do to prepare. Retrieved from https://www.cdc.gov/climateandhealth/pubs/extreme-heat-guidebook.pdf
Centers for Disease Control and Prevention. (2016b). General information about MRSA in the community. Retrieved from https://www.cdc.gov/mrsa/community/index.html
Centers for Disease Control and Prevention. (2016c). Health in All Policies. Retrieved from https://www.cdc.gov/policy/hiap/index.html
Centers for Disease Control and Prevention. (2017a). About CDC funding. Retrieved from https://www.cdc.gov/funding/AboutCDCFunding.html
Centers for Disease Control and Prevention. (2017b). Extreme heat. Retrieved from https://www.cdc.gov/disasters/extremeheat/index.html
Centers for Disease Control and Prevention. (2017c). Prevention and public health fund. Retrieved from https://www.cdc.gov/funding/pphf/index.html
Centers for Disease Control and Prevention. (2018a). About NIOSH. Retrieved from https://www.cdc.gov/niosh/about/default.html
Centers for Disease Control and Prevention. (2018b). National Center for Emerging and Zoonotic Infectious Diseases (NCEZID). Retrieved from https://www.cdc.gov/ncezid/index.html
Centers for Disease Control and Prevention. (2018c). One Health. Retrieved from https://www.cdc.gov/onehealth
Centers for Medicare & Medicaid Services. (n.d.). How do Medicare Advantage Plans work? Retrieved from https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantag e-plans/how-medicare-advantage-plans-work.html
Centers for Medicare & Medicaid Services. (2014). Medicare program—General information. Retrieved from https://www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo/index.html
Chin, M. (2017). 1 in 4 Americans refuse medical care because they can’t afford it. Retrieved from https://nypost.com/2017/06/07/1-in-4-americans-refuse-medical-care-because-they-cant-aff ord-it
Chum, A., & O'Campo, P. (2015). Cross-sectional associations between residential environmental exposures and cardiovascular diseases. BMC Public Health, 15(1), 1-12. doi: 10.1186/s12889-015-1788-0
Clarke, T. C., Schiller, J. S., & Norris, T. (2017). Early release of selected estimates based on data from the January–June 2017 national health interview survey. National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/nhis/releases/released201712.htm
Dean, O., Noel-Miller, C., & Lind, K. (2017, November). Who relies on Medicare? A profile of the Medicare population. Retrieved from https://www.aarp.org/content/dam/aarp/ppi/2017/11/who-relies-on-medicare-a-profile-of-the- medicare-population.pdf
Duckworth, L. (2017). Under the microscope. Community Practitioner, 90(5), 28-32. Retrieved from https://search-proquest-com.lopes.idm.oclc.org/docview/1894941550/fulltext/CC70921EE62 C433FPQ/27?accountid=7374
Edmonson, C., McCarthy, C., Trent-Adams, S., McCain, C., & Marshall, J. (2017). Emerging global health issues: A nurse's role. Online Journal of Issues in Nursing, 22(1), 3. doi: 10.3912/OJIN.Vol22No01Man02
Environmental Protection Agency. (n.d.a). EPA strategic plan. Retrieved from https://www.epa.gov/planandbudget/strategicplan
Environmental Protection Agency. (n.d.b). Our mission and what we do. Retrieved from https://www.epa.gov/aboutepa/our-mission-and-what-we-do
Environmental Protection Agency. (n.d.c). Research on nanomaterials. Retrieved from https://www.epa.gov/chemical-research/research-nanomaterials
Environmental Protection Agency. (2016). Climate change indicators in the United States. Retrieved from https://www.epa.gov/climate-indicators
EveryCRSReport. (2017). The ACA Prevention and Public Health Fund: In brief. Retrieved from https://www.everycrsreport.com/reports/R44796.html#fn5
Gyles, C. (2016). One medicine, one health, one world. Canadian Veterinary Journal, 57(4), 345-346. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4790223
Healthcare Triage. (2014). The healthcare system of the United States. Retrieved from https://www.youtube.com/watch?v=yN-MkRcOJjY
HealthyPeople.gov. (n.d.a). Development of the national health promotion and disease prevention objectives for 2030. Retrieved from https://www.healthypeople.gov/2020/About-Healthy-People/Development-Healthy-People-2 030
HealthyPeople.gov. (n.d.b). Environmental health. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/environmental-health
Hernández, D. (2016). Understanding “energy insecurity” and why it matters to health. Social Science & Medicine, 167, 1-10. doi: 10.1016/j.socscimed.2016.08.029
Institute of Medicine. (1988). The future of public health. Washington, DC: The National Academies Press.
Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: The National Academies Press.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: The National Academies Press.
Institute of Medicine. (2003). The future of the public's health in the 21st century. Washington, DC: The National Academies Press.
Institute of Medicine. (2011a). For the public’s health: The role of measurement in action and accountability. Washington, DC: The National Academies Press.
Institute of Medicine. (2011b). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.
Jackman-Murphy, K. P. (2015). Environmental health 101: Incorporating environmental health into the nursing curriculum. Teaching and Learning in Nursing, 10(4), 192-195. doi: 10.1016/j.teln.2015.05.005
Kahn, S. (2011). Healthcare system overview. Retrieved from https://www.youtube.com/watch?v=LMHxxvbzFqc
Ki-moon, B. (2011, September 21). Address to the 66th General Assembly: “We the peoples.” Retrieved from https://www.un.org/sg/en/content/sg/speeches/2011-09-21/address-66th-general-assembly- we-peoples
Medicaid.gov. (n.d.a). Monthly Medicaid and CHIP application, eligibility determination, and enrollment reports & data: Preliminary December 2017 report. Retrieved from https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data /monthly-reports/index.html
Medicaid.gov. (n.d.b). Program history. Retrieved from https://www.medicaid.gov/about-us/program-history/index.html
Micha, R., Peñalvo, J. L., Cudhea, F., Imamura, F., Rehm, C. D., & Mozaffarian, D. (2017). Association between dietary factors and mortality from heart disease, stroke, and type 2 diabetes in the United States. JAMA, 317(9), 912-924. doi: 10.1001/jama.2017.0947
National Association of Free and Charitable Clinics. (n.d.). About us. Retrieved from http://www.nafcclinics.org/content/about-us
National Academies of Sciences, Engineering, and Medicine. (2017a). Combating antimicrobial resistance: A One Health approach to a global threat: Proceedings of a workshop. Washington, DC: The National Academies Press.
National Academy of Sciences, Engineering, and Medicine. (2017b). Protecting health and well-being of communities in a changing climate: Proceedings of a workshop—in brief. Retrieved from https://www.nap.edu/catalog/24797/protecting-the-health-and-well-being-of-communities-in- a-changing-climate
Occupational Safety & Health Administration. (n.d.a). About OSHA. Retrieved from https://www.osha.gov/about.html
Occupational Safety & Health Administration. (n.d.b). Hazards communication standard: Safety data sheets. Retrieved from https://www.osha.gov/Publications/OSHA3514.html
Occupational Safety & Health Administration. (n.d.c). Healthcare wide hazards. Retrieved from https://www.osha.gov/SLTC/etools/hospital/hazards/hazards.html
Olen, H. (2017). Even the insured often can’t afford their medical bills. Retrieved from https://www.theatlantic.com/business/archive/2017/06/medical-bills/530679
One Health Initiative. (n.d.a). About the One Health initiative. Retrieved from http://www.onehealthinitiative.com/about.php
One Health Initiative. (n.d.b). One Health initiative will unite human and veterinary medicine. Retrieved from http://www.onehealthinitiative.com/index.php
Paquin, S. O. M. (2011). Social justice advocacy in nursing: What is it? How do we get there? Creative Nursing, 17(2), 63-67.
Prüss-Üstün, A., Corvalán, C., Bos, R., & Neira, M. (2016). Preventing disease through healthy environments: A global assessment of the burden of disease from environmental risks. Geneva, Switzerland: World Health Organization. Retrieved from http://www.who.int/quantifying_ehimpacts/publications/preventing-disease/en
Reinhard, S. (2018, February 7). Seeding a culture of health by spreading innovative ideas. Retrieved from https://www.aarp.org/ppi/?intcmp=AE-SEARCH-AARPSUGG-ppi
Robert Wood Johnson Foundation. (n.d.a). Culture of health initiative. Retrieved from https://www.rwjf.org/en/how-we-work/building-a-culture-of-health.html
Robert Wood Johnson Foundation. (n.d.b). Future of nursing: Campaign for action. Retrieved from
https://www.rwjf.org/en/how-we-work/grants-explorer/featured-programs/future-of-nursing--c ampaign-for-action.html
Robinson, M. D. (2016). Universal healthcare coverage around the globe: Time to bring it to the United States? Journal of Health Care Finance, 43(3), 1-10. Retrieved from http://healthfinancejournal.com/index.php/johcf/article/view/53
Schneider, E. C., Sarnak, D. O., Squires, D., Shah, A., & Doty, M. M. (2017). Mirror, mirror 2017: International comparison reflects flaws and opportunities for better U.S. health care. Commonwealth Fund. Retrieved from http://resource.nlm.nih.gov/101712671
Schneider, E. C., & Squires, D. (2017). From last to first—Could the U.S. health care system become the best in the world? New England Journal of Medicine, 377(10), 901-904. doi: 10.1056/NEJMp1708704
Seibert, D. J., Speroni, K. G., Oh, K. M., DeVoe, M. C., & Jacobsen, K. H. (2014). Preventing transmission of MRSA: A qualitative study of health care workers’ attitudes and suggestions. American Journal of Infection Control, 42(4), 405-411. doi: 10.1016/j.ajic.2013.10.008
Shrestha, K., Acharya, K. P., & Shrestha S. (2018). One Health: The interface between veterinary and human health. International Journal of One Health, 4, 8-14. doi: 10.14202/IJOH.2018.8-14
SurgeonGeneral.gov. (n.d.). National prevention strategy. Retrieved from https://www.surgeongeneral.gov/priorities/prevention/strategy/index.html
The Commonwealth Fund. (2017, July 14). New 11-country study: U.S. health care system has widest gap between people with higher and lower incomes. Retrieved from http://www.commonwealthfund.org/publications/press-releases/2017/jul/mirror-mirror-press- release
The Jane Goodall Institute New Zealand. (n.d.). Choose the impact of your choices. Retrieved from http://www.janegoodall.org.nz/jgi-nz-campaigns/sustainable-selves-tacare-nz/
Thurman, W., & Pfitzinger-Lippe, M. (2017). Returning to the profession's roots: Social justice in nursing education for the 21st century. Advances in Nursing Science, 40(2), 184-193. doi: 10.1097/ANS.0000000000000140
Tricare. (n.d.). Eligibility. Retrieved from https://tricare.mil/Plans/Eligibility United Nations Economic Commission for Europe. (2013). Globally harmonized system of
classification and labeling of chemicals (GHS) (5th ed.). New York, NY: United Nations Publications. Retrieved from http://www.unece.org/trans/danger/publi/ghs/ghs_rev05/05files_e.html
United Nations. (n.d.). Sustainable development goals: 17 goals to transform our world. Retrieved from https://www.un.org/sustainabledevelopment/sustainable-development-goals/
U.S. Bureau of Labor Statistics. (2017, November 9). Employer reported workplace injuries and illnesses–2016. Retrieved from https://www.bls.gov/news.release/pdf/osh.pdf
Van Helden, P. D., Van Helden, L. S., & Hoal, E. G. (2013). One world, one health: Humans, animals and the environment are inextricably linked—A fact that needs to be remembered and exploited in our modern approach to health. EMBO reports, 14(6), 497-501. doi: 10.1038/embor.2013.61
Volunteers of America. (n.d.). Senior living and care. Retrieved from https://www.voa.org/senior-living-and-care
Walter, R. R. (2017). Emancipatory nursing praxis: A theory of social justice in nursing. Advances in Nursing Science, 40(3), 225-243. doi: 10.1097/ANS.0000000000000157
Webb, J. K. (2017). Why nurses need to be involved. Nurse Leader, 15, 323-324. doi: 10.1016/j.mnl.2017.07.006
World Health Organization. (2016a). An estimated 12.6 million deaths each year are attributable to unhealthy environments. Retrieved from. http://www.who.int/mediacentre/news/releases/2016/deaths-attributable-to-unhealthy-enviro nments/en
World Health Organization. (2016b). WHO releases country estimates on air pollution exposure and health impact. Retrieved from http://www.who.int/mediacentre/news/releases/2016/air-pollution-estimates/en
World Health Organization. (2017a). Antibiotic resistance. Retrieved from http://www.who.int/mediacentre/factsheets/antibiotic-resistance/en
World Health Organization. (2017b). Preventing noncommunicable diseases (NCDs) by reducing environmental risk factors. Retrieved from http://www.who.int/quantifying_ehimpacts/publications/preventing-ncds/en
World Health Organization. (2017c). Tracking universal health coverage: 2017 global monitoring report. Retrieved from http://www.who.int/healthinfo/universal_health_coverage/report/2017/en
World Health Organization. (2017d). Vector-borne diseases. Retrieved from http://www.who.int/mediacentre/factsheets/fs387/en
World Health Organization. (2018a). Environmental health. Retrieved from http://www.searo.who.int/topics/environmental_health/en
World Health Organization. (2018b). Health and sustainable development: BreatheLife. Retrieved from http://www.who.int/sustainable-development/news-events/breath-life/en
World Health Organization. (2018c). High levels of antibiotic resistance found worldwide, new data shows. Retrieved from http://www.who.int/mediacentre/news/releases/2018/antibiotic-resistance-found/en
World Health Organization. (2018d). Neglected zoonotic diseases. Retrieved from http://www.who.int/neglected_diseases/diseases/zoonoses/en
World Health Organization. (2018e). Secretary-General, at launch of international decade for action, supports new approaches for better managing fresh water scarcity. Retrieved from https://www.un.org/press/en/2018/sgsm18951.doc.htm
World Health Organization. (2018f). Sustainable development goals. Retrieved from http://www.who.int/sdg/en
World Health Organization. (2018g). What is universal coverage? Retrieved from http://www.who.int/health_financing/universal_coverage_definition/en
World Health Organization & United Nations Children’s Fund. (2017). Progress on drinking water, sanitation, and hygiene: 2017 update and SDG baselines. Geneva, Switzerland: Authors.
CHAPTER 5 Disaster Management By Angel Falkner Essential Questions
● What responsibilities does the community/public health nurse have in disaster nursing? ● What is the chain of command and communication process when a disaster occurs? ● What is the nursing process in disaster management? ● What are the different types of disasters? ● Identify the common physical, psychological, and social effects on disaster victims and
workers.
Introduction Over the past decade, the incidence of natural and man-made disasters has increased substantially, warranting the attention of federal and health care agencies. Public health nurses (PHNs) play a vital role in the disaster management process. PHNs are involved in the prevention, preparation, intervention, and aftermath-management processes involved in handling disasters; this is called disaster nursing. PHNs are also actively involved in educating and preparing members of the community for disasters. In all cases, PHNs must demonstrate cultural competence when caring for victims of disaster.
What is a Disaster?
● According to the International Federation of Red Cross and Red Crescent Societies (IFRC) a disaster is “a sudden, calamitous event that seriously disrupts the functioning of a community or society and causes human, material, and economic or environmental losses that exceed the community’s or society’s ability to cope using its own resources,” (International Federation of Red Cross and Red Crescent Societies, n.d.). There are two major types of disasters,
man-made and natural. Man-made disasters include terrorism, transportation accidents, food and water contamination, and building collapse (see Figure 5.1). Natural disasters include forces of nature such as hurricanes, blizzards, mudslides, earthquakes, tsunamis, epidemics, and fires (see Figure 5.2). In either type of disaster, there is a primary agent and a secondary agent that cause damage. The agent is the cause of injury or insult during a disaster. During Hurricane Irma in 2017, the primary agent that caused damage was the flood waters from the storm. The secondary agents were the viruses and bacteria that cultivate in stagnant water and have the propensity to spread disease. When the outcomes of the event supersede the community’s ability to manage the effects on their own, involvement of federal agencies to provide assistance on multiple levels is warranted. Figure 5.1
Types of Natural Disasters
Figure 5.2
Types of Man-Made Disasters
Several terms define the severity of casualties associated with disasters. Multiple casualty incident occurs when the casualty toll is isolated to fewer than 100 people. A mass casualty incident involves larger numbers, typically more than 100 people, and has an apparent effect on local emergency medical services and resources. Mass casualties can occur in any type of disaster. Many factors will impact the individuals directly affected by the event during a disaster. Individuals who typically require the care of another are often at the greatest degree of risk. These vulnerable population groups include young children, the geriatric community, persons with severe mental or physical handicaps, and those physically dependent upon medical equipment either in acute or long-term care facilities. Individuals who fall into the vulnerable population category may not be able to evacuate during a disaster event and may require high-priority assistance because of advanced medical needs.
Dimensions of a Disaster
● Disasters are made up of multiple dimensions. A disaster’s predictability is based upon the ability to foresee the impending event, such as with weather forecasting systems that have the ability to deliver a hurricane or tornado warnings. Man-made disasters, such as a terrorist attacks or vehicle accidents, are more difficult to predict as they can occur without warning and are often dependent on the behaviors and perceptions of specific individuals or groups. Geographic areas can help to determine the frequency of disasters. For instance, those living in the Midwest area of the United States known as “Tornado Alley” have a greater risk of experiencing a natural disaster from a tornado. People living in the state of Florida have a higher incidence of experiencing a hurricane because of their proximity to the coastline. Controllability refers to the ability to plan ahead for the possibility of an event in the future. Though the event itself cannot be controlled or even predicted, people can prepare and plan for it. An example of this would be having an emergency kit in the house at all times in the event of a disaster such as a fire, tornado, or hurricane. These kits should include basic household items such as canned foods and bottled water. Such planning is described as mitigation. The Federal Emergency Management Agency (FEMA) describes mitigation as the effort to reduce loss of life and property by lessening the impact of disasters (Federal Emergency Management Agency [FEMA], 2018).
Time is yet another uncontrollable factor. For instance, in the event of a hurricane, the developments in weather forecasting have made it possible for warnings to be issued days in advance, allowing time for people to evacuate and prepare for the upcoming event. Other events such as tornadoes, flash floods, or man-made events such as terrorist attacks, offer little to no warning.
Scope and intensity refer to the scale of damage upon the community and the casualties that occur as a result of the event. Scope is more specific to the depletion of typical resources within the effected community, while intensity evaluates the effect on the community’s health and loss of life. The greater the scope and intensity, the larger the disaster and the more resources and support are required.
Disaster Phases
● Phases during a disaster include preimpact, impact, and postimpact. See Table 5.1 for information on the disaster phases and the nursing process (Millet, 2013; Jakeway, LaRosa, Cary, & Schoenfisch, 2008; Association of Public Health Nurses, 2013).
Preimpact During the preimpact phase, preparation or mitigation occurs. This phase is optimal for planning and preparing for a disaster as individuals and as a community. Individuals may plan and prepare by gathering items for an emergency kit for the home or discussing where to meet family members in the event of an emergency. On a community level, planning and preparing may involve government agencies and health care facilities assessing inventories for resources and equipment necessary in the event of a disaster. This phase also provides emergency management services as well as health care facilities time to orchestrate drills and review policy and procedures that need to be followed in a disaster. When an impending disaster is predicted, PHNs may be called upon to set up shelters or emergency aid centers preemptively. Nurse managers and team leaders in health care facilities may help coordinate practice drills or meetings with staff for discussion of how to navigate the influx of patients expected during and after the event.
Impact The impact phase occurs during the actual disaster event, which may last for minutes, days, or even weeks depending on the type of disaster. The priority for this phase is survival. The extent of predicted damage must be assessed in order to disseminate the appropriate resources. This assessment includes determining the appropriate number of health care workers and emergency first responders necessary to provide care to victims. The impact phase is also when search and rescue efforts are coordinated and executed. The PHN in this phase is a provider of physical and psychological care who helps to triage victims according to their injuries.
Postimpact The postimpact phase occurs once imminent danger has ceased. During this period, rescue and emergency medical care becomes the primary focus. Once victims are treated and transported to safety, the process of recovery can begin. This disaster phase can last months or years and, depending on the scope and intensity of the disaster, may even have lifelong effects. The postimpact phase includes debriefing and reevaluation of disaster and emergency preparedness and prevention strategies to improve outcomes should another disaster occur.
Table 5.1
Disaster Phases and the Nursing Process
Disaster Phase
Prevention (Mitigation) Preparedness Response Recovery
Definition ● Planning for disasters or emergencies to reduce vulnerability/damag e/injury should an event occur.
● Develop capacity to respond swiftly, efficientl y, and effectivel y to disasters and emergen cies.
● Provide support to populatio ns affected by disasters and emergen cies.
● Restore support systems to functional levels.
Assessment ● Assess population groups for awareness of potential disasters.
● Assess special needs of populatio n groups in the event of a disaster.
● Conduct assessm ent of threats or hazards that pose the greatest risk to the
● Use public health incident triages and teams to assess the impact of and health needs arising from the disaster.
● Participat e in the incident response assessm ent of postdisas ter communi ty needs for health care and health resources .
populatio n.
Planning ● Develop emergency awareness programs to increase awareness of potential emergency or disaster events.
● Develop plans to address access to and needs of populatio ns in the event of a disaster.
● Plan for the needs of small or large populatio ns to shelter in place, evacuate, and mass casualty surges.
● Develop plans in collabora tion with incident triages and teams to determin e care and care logistics needed to serve the populatio ns and reduce stress and burnout among responde rs.
● Collabora te with communi ty stakehold ers and partnershi ps to plan long-term recovery priorities, resources , and care logistics.
Implementati on
● Conduct community education programs to increase awareness with a variety of media approaches.
● Conduct exercises and training drills to care for various size populatio ns.
● Include training scenario s involving persons with special needs and family separatio ns.
● Follow incident emergen cy response plans to deploy personne l to locations with affected populatio ns such as emergen cy shelters.
● Conduct ongoing assessm ent of needs.
● Participat e in restoratio n of health care services.
Evaluation ● Evaluate community education activities for effectiveness.
● Evaluate exercises and training drills for gaps and remainin g educatio n and training needs.
● Participat e in incident emergen cy response evaluatio ns, including gap analysis and planning for future events.
● Participat e in evaluatio n of the long-term conseque nces of the populatio ns who experienc ed or responde d to the disaster.
Self-Protection In times of crisis, caregivers and health providers become first responders, providing aid to those in need; however, it is essential for providers to care for themselves first before rendering aid. FEMA reiterates the steps of initiating an emergency response in their Community Emergency Response Team (CERT) training, stating, a CERT member’s first job is to stay safe (PerformTech, Inc., 2011). One of the primary ways providers can ensure their own safety on the scene of a disaster is with the use of personal protective equipment (PPE). Nurses use PPE in practice on a regular basis, but there are some differences in PPE at the bedside in nursing versus during disaster relief efforts.
Figure 5.3
PPE
Prior to assessing a scene, the first thing anyone responding to a disaster must do is to determine the level of safety risk. A firm awareness of one’s surroundings does not stop during rescue efforts. Disaster scenes often change quickly, and responders must remain vigilant. During the Ebola epidemic, a series of transmissions among health care providers revealed gaps in infection prevention and control (IPC) procedures (Hageman et al., 2016). To address this gap, the CDC worked with facilities in the United States to provide new and improved IPC training in order to prevent further transmission of the Ebola epidemic (Hageman, et al., 2016).
Health care providers and volunteers responding to a disaster where the spread of infectious disease is a concern should be cautious, particularly when caring for victims, and use the appropriate protocol when handling patients and bodily fluids. Though nurses are familiar with universal precautions enforced in clinical settings, they must also follow protocols in the field to ensure their safety and the safety of colleagues, other volunteers, and effected persons.
Disaster Management Services There are multiple federal and local agencies involved in disaster management that contribute to safety and survival of citizens in the event of a disaster. Disaster response begins at a local level and then, if necessary, proceeds to a state and federal level. The PHN should be familiar with such systems and how they function.
National Disaster Medical System (NDMS) The National Disaster Medical System is a division of the U.S. Department of Health and Human Services (HHS) and is composed of health professionals who are allocated to respond in the event of a disaster. These well-trained professionals are hired as intermittent federal employees and have an expected on-call deployment of a minimum of 2 weeks per year. They undergo a rigorous applicant screening process that ensures physical and psychological ability to fulfill expected duties. Once hired to be a part of this program, there are various teams that the health care professionals can be assigned to depending on background and expertise. These include Disaster Medical Assistance Teams (DMAT), Trauma and Critical Care Teams (TCCT), Victim Information Center Teams (VIC), Disaster Mortuary Operational Response Teams (DMORT), or and the National Veterinary Response Team (NVRT) (Public Health Emergency, 2018). Each of these respective teams are deployed to the sites of various natural and man-made disasters. Nurses typically serve on the DMAT or TCCT teams where their specialized skills can be best utilized. Nurses who are part of these teams have responsibilities similar to those within the area for which they are trained. For instance, a trauma critical care nurse would provide this type of nursing care to victims at the scene.
Federal Emergency Management Agency (FEMA) Established in 1979 by President Jimmy Carter, FEMA is a division of the Department of Homeland Security (DHS) and is the coordinating agency for allocation of assistance in the event of disasters in the United States. “FEMA’s mission is to support citizens and first responders to ensure that as a nation we work together to build, sustain and improve our capability to prepare for, protect against, respond to, recover from and mitigate all hazards” (FEMA, 2017).
FEMA works with state and local governments to provide assistance, preparation, and training associated with disaster management. Since its inception, the department has been reformed several times to optimize its ability to provide necessary resources during disasters, with the most recent reformation occurring in 2006 following Hurricane Katrina. FEMA is responsible for formulating the National Response Framework (NRF), which is a guide that helps the nation understand how to respond to disasters and emergencies. FEMA outlines four primary phases regarding disaster management: mitigation, preparedness, response, and recovery (see Table 5.2) (FEMA, 2016).
It is important to note that in order for FEMA to provide aid during the recovery phase of disaster management, the disaster must be declared a major disaster by the acting President of the United States. This is a process that begins with the local governor of the affected area applying to FEMA to declare the affected region a major disaster area. Once this occurs, the allocation of resources, such as grant funding, is provided by FEMA.
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●
Table 5.2
Elements of Disaster Management
Disaster/Emergency Management Phases
Definition/Characteristics Role/Responsibilities of the Nurse and/or the PHN
Mitigation ● Any activity that prevents or reduces the impact of unavoidable emergencies
● Acquiring insurance such as flood or fire protection
● Takes place before and after events
● Provide education to public regarding planning and reaction in the event of emergencies
● Coordination of preparation drills, such as mass casualty drills
Preparedness ● Plans and preparation for life-saving efforts, including rescue and response
● Evacuation plans, such as creating a disaster kit
● Education of the public ● Helping the public and
families create disaster kits and plans of action in the event of an emergency
● Helping coordinate and institute plans of action in facilities (e.g.,
Note. Adapted from Infection Prevention Orientation Manual: Section 15: Emergency Preparedness, by K. Bryan & B. Wardle, 2014. Copyright 2014 by the Wyoming Department of Health.
National Response Framework (NRF) The NRF was developed by FEMA as a guide for preparedness in the event of a disaster or crisis situation. The framework recognizes the need for involvement beyond the federal government and incorporates the assistance of local, tribal, and state government agencies as well as assistance from the private sector and nonprofit organizations. Five key principles guide the framework (FEMA, 2016).
1. Engaged Partnership: All sectors of the community are involved and do not solely rely on governmental agencies. This involvement includes the private sector as well, including volunteer organizations such as the American Red Cross and Christian Disaster Response.
2. Tiered Response: Assistance begins at the local level where the event occurs and then branches outward as assistance is needed.
3. Scalable, Flexible, and Adaptable Operational Capabilities: The amount of allocated resources must expand to meet the needs the disaster has created.
4. Unity of Effort and Unified Command: The allocation of assigned roles during disaster management must be understood, meaning that each agency involved maintains its own respective authority, responsibility, and accountability.
5. Readiness to Act: Organizations’ members and volunteers must be adequately prepared prior to disaster events and understand the risk associated with responding to the needs
hospitals, care homes, schools)
Response ● Safety is the priority ● Activation of
preparation plans made during mitigation and preparedness phases
● Seeking shelter
● Helping citizens find appropriate shelter
● Personal accountability for self and one’s own family
Recovery ● Medical assistance ● Rescue and recovery of
victims ● Physical and
psychological healing ● Begin to rebuild ● Mitigation continues
● Provide medical attention to victims
● Help provide emotional support
● Begin planning for mitigation phase
of victims. It is important to follow regulated processes and procedures to operate effectively.
Figure 5.4
National Response Framework
Note. Adapted from National Response Framework (3rd ed.), by the Federal Emergency Management Agency, 2016.
National Incident Management Systems (NIMS) National Incident Management Systems (NIMS) is a division of FEMA and DHS that helps provide prevention training and coordination between public and private entities in managing disaster incidents across the nation. They utilize the Incident Command System (ICS), which provides protocols and structure that helps coordinate various parts of disaster management, such as operations, planning, logistics, and finances (see Figure 5.5). The system has various leadership roles, such as the incident commander who helps oversee the various areas that need to be managed in an organized manner during disasters. While in use, the ICS works from an Emergency Operations Center (EOC) that can vary depending on the type of disaster.
Figure 5.5
Incident Command System
Note. Adapted from “Incident Management,” by Ready.gov.
Emergency Operations Center (EOC) The Emergency Operations Center (EOC) serves as a command center where government agencies can manage the disaster response. According to FEMA, “EOC core functions include coordination; communications; resource allocation and tracking; and information collection, analysis, and dissemination,” (FEMA, n.d., para. 28). The EOC may be any type of building or structure, from a warehouse to a gymnasium, that provides ample space and is safe from the effects of the disaster. This is where coordination efforts occur, but it is also where emergency medical aid may be provided to the first survivors of the event.
Emergency Medical Services Traditionally, Emergency Medical Services (EMS) is thought of as the phone call to 9-1-1 in times of danger. From a young age, children are taught the importance of learning how to dial 9-1-1 in the event of a crisis in order to receive help from first responder medical personnel and law enforcement as quickly as possible. The Federal Interagency Committee on EMS (FICEMS) was established by Congress in order to streamline coordination between local EMS chapters and the federal government to improve the delivery of EMS to citizens across the country in times of crisis (Federal Interagency Committee on EMS, n.d.). In addition, the U.S. Department of Defense (DOD) provides specialized training to EMS workers in preparation for deployment to hostile or combat areas around the world. EMS also works with FICEMS to coordinate and institute casualty drills and provide preparedness education to the public. Courses such as pediatric and mass casualty triage training are available for free on their website. Nurses may be involved in the coordination and the execution of such training and drills throughout the community.
American Red Cross The American Red Cross (ARC) is an organization that provides aid during disasters and is composed of nearly 90% specially trained volunteers. Founded by renowned nurse, Clara Barton, ARC’s mission is to provide assistance to those in dire need of emergency services related to any disaster occurrence. ARC works in conjunction with FEMA and other federal emergency response agencies and Community Emergency Response Teams (CERTs) to coordinate relief efforts for victims of disasters across the country. ARC assists with providing medical care, emergency supplies, and education and preparedness strategies as well as setting up and running emergency shelters among communities across the United States (American Red Cross, n.d.). Nurses can apply to volunteer for the ARC and will go through required volunteer training. After training, nurses will be utilized depending upon the need within the community and the volunteers’ availability.
Faith-Based Disaster Response Organizations There are a plethora of faith-based, nonprofit organizations that provide support during disaster relief throughout the United States. Each organization provides resources such as food, water, and basic necessities as well as volunteer relief workers who assist in many capacities and work in conjunction with government agencies to assist victims of disasters when they occur. In addition, many of these organizations provide training and assistance in the planning process to help improve efforts when the next disaster hits. These faith-based organizations provide support and assistance following their religious doctrines that speak largely of compassion, caring, and helping the less fortunate. Some commonly known faith-based disaster organizations include Catholic Charities USA, United Methodist Committee on Relief (UMCOR), and Lutheran Disaster Response. During recent events, such as Hurricane Irma in Florida, the United Methodist Committee on Relief provided a tremendous amount of support to relief efforts, including clean up following the hurricane and helping citizens with organization of aid and insurance to help them begin to rebuild their lives. Another organization, The Convoy of Hope, deployed several trailer trucks stocked with food and water prior to the impact of the hurricane to help prepare for the impending needs of the community (Rehwald, 2017).
Community Emergency Response Teams (CERTs) Community Emergency Response Teams (CERTs) are composed of community volunteers who work to prepare their communities against threats. Though they are not first responders to disaster events, they are well trained to assist first responders (Ready.gov, n.d.a). CERT volunteer teams are valued members of the community who provide aid to victims quickly and assist first responders in the management of disaster scenes. Nurses may volunteer for CERT teams, but they would be completing the duties as described in their CERT training for volunteers rather than providing nursing care to victims.
Some of the things CERT volunteers are trained to do include:
● Prepare for the hazards that threaten their communities. ● Apply size-up and safety principles.
● Locate and turn off utilities. ● Extinguish small fires. ● Identify hazardous materials situations. ● Triage and treat victims. ● Set up a medical treatment area. ● Conduct search and rescue operations in lightly and moderately damaged structures. ● Understand the psychological impact of a disaster on themselves and others. ● Organize CERT members and spontaneous volunteers for an effective and safe
response. ● Apply response skills in a disaster simulation.
Hospital Disaster Plans
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●
● Hospitals play a critical role in responding to and preparing for disasters. Hospitals have policies and procedures in place in the event of a disaster that may vary slightly from facility to facility, but they cover the basics of disaster management and response. The Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), American Nurses Association (ANA), and FEMA provide advice on the components that should be incorporated into a hospital disaster plan. The Joint Commission requires every hospital to have a disaster plan in place. These plans should include management of internal and external disasters and are to be practiced several times a year. Nurse leaders will be involved in the planning, coordination, and incorporation of such drills to prepare employees. Internal disasters might
include the rapid spread of an infectious disease process within the patient population inside the hospital. An external disaster would include any natural or man-made disaster that occurs within the nearby communities.
Nurses’ Duty to Respond
● Nurses are licensed providers who have an obligation to respond in emergency situations. When disaster strikes, nurses are faced with numerous challenges, including the care of multiple stakeholders. According to the Provision 2 of the ANA Code of Ethics, the nurse retains a primary commitment to the patient at all times (American Nurses Association, 2015). However, this does not to negate Provision 5, which emphasizes self-care as equally important. Nurses have a moral obligation to uphold their fundamental duty to care, but this does not mean jeopardizing their own safety or the safety of others in times of crisis.
Social Justice
●
●
● The Agency for Healthcare Research and Quality (AHRQ) and the Institutes of Medicine (IOM) have developed a framework that includes six aims for the health care system. These aims indicate that patient care should be safe, effective, patient-centered, timely, efficient, and equitable. When discussing health equity, it is essential to underline the importance of providing disaster victims with equitable care despite social determinants of health (SDOH). In areas that are impoverished or have a high number of immigrants or diverse cultures, special attention and care must be considered when providing support to victims following a disaster. This issue was highlighted in the aftermath of Hurricane Katrina in the Gulf Coast area. Many communities affected by the hurricane’s impact were impoverished, and it became evident very quickly that planning and response for these types of communities was not adequate. Victims did not receive the financial support, supplies, or medical attention they needed in a timely manner, extending their recovery time and leading to poor outcomes. The devastation that occurred in these areas gave rise to the development of more particular and critical response methods that addressed special issues such as poverty and culture (Lichtveld, 2018). This might include ensuring appropriate translation services are provided in order to communicate needs to communities that do not speak English.
Evacuation
● In the event of an impending disaster, the best-case scenario would allow a few days to coordinate evacuation efforts. In events when early warnings are not possible, evacuation efforts may prove to be more chaotic. Properly planning ahead helps to ensure safe and prompt escape from the area of threat. Planning involves identifying the types of disasters that could occur in the surrounding area, identifying where to go when evacuation is necessary, preparing a safe places for pets, and being familiar with escape routes and alternate routes out of the area. Families should also determine a location where they should meet if they become separated for any reason. Keeping a bag containing household essentials, including
nonperishable food, bottled water, flashlights, batteries, and a first-aid kit, is another necessary item to have in the home at all times. Before returning home, always check with local authorities to make sure it is safe to do so. Nurses should be careful when reporting for duty in response to a disaster; they should ensure their families’ safety first and that the route and available transportation to the hospital is safe before embarking on the journey.
Rescue and Recovery Once the imminent threat of the disaster’s effects are over, the rescue and recovery process begins. This process is commonly referred to as search and rescue (SAR). The rescue process begins at the local level, with first responders from the local fire and police departments as well as emergency management personnel being on the scene. The largest SAR system was established under FEMA and includes 28 urban rescue task forces that are deployed in the event of disasters around the nation. The local emergency manager may request assistance from the state and, if necessary, FEMA will deploy its three closest SAR task forces to intervene. The scene is assessed for safety before the search and rescue crew is sent in, and heavy equipment is used to clear away large pieces of debris that may be trapping survivors. Emergency health care workers are on scene to provide stabilizing medical treatment once survivors are extricated. During the process, hazardous material specialists are also on scene to evaluate for possible contamination that could pose a threat to the rescue team (FEMA, 2017).
Principles of Disaster Management Disaster Preparedness
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● The concepts of primary, secondary, and tertiary prevention have been described in detail throughout the baccalaureate-nursing program. These concepts can also be applied to disaster preparation as well. Prevention is a key component in the NRF for disaster management that warrants further discussion and elaboration. Though true prevention of disasters is not possible, prevention in disaster preparation is described in terms of management versus total aversion of disaster occurrence.
Preventable Versus Nonpreventable Disasters cause destruction in part because of their unpredictable nature, which warrants proper preparation versus true prevention. Prevention measures, such as mitigation efforts, are the best ways that the impact of disaster can be lessened. The major difference between mitigation and preparedness is that mitigation looks at long-term solutions that help to reduce risk instead of merely reacting to consequences of disaster events once they have occurred (FEMA, 2018). Though impossible to stop disasters altogether, it is possible to educate, plan, and collaborate efforts to prepare communities to withstand, survive, and recover from events that are not in anyone’s control.
Primary Primary prevention in disaster management involves planning prior to the occurrence or onset of a disaster event. The PHN assists in educating the community and families about having plans in place in the event of a disaster and being aware of the local resources families may need during a disaster. This is particularly important for families with small children and those in care of persons who are severely disabled or in need of continual medical care and treatment.
Ready.gov is a government website that provides a wide range of information regarding preparation for common emergencies and disaster events. The website is a resource the PHN can recommend to people for assistance in creating a plan that includes evacuation, safety skills, and financial concerns (Ready.gov, n.d.c). Another tool this website provides is a list of supplies recommended for preparing an emergency supply kit (see Figure 5.6). Preparedness is essential, yet is often overlooked as a necessity in American society. A recent national survey conducted by Columbia University determined that two-thirds of American households do not have adequate plans for disasters (Petkova et al., 2016).
Figure 5.6
Emergency Supply List
Note. Adapted from “Emergency Supply List,” by the Federal Emergency Management Agency, 2014.
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Mitigation
Mitigation refers to the specific measures taken prior to the onset of a disaster event
that help to decrease or eliminate the disaster’s associated risks. Though the levee
system in Louisiana failed during Hurricane Katrina in 2005, their original construction
and institution is an example of mitigation. The levees were meant to help diminish the
floodwaters associated with massive storms such as Katrina, thereby decreasing the
damage. According to FEMA the following are also examples of mitigation:
● Complying with or exceeding National Flood Insurance Program floodplain management regulations
● Enforcing stringent building codes, flood-proofing requirements, seismic design standards, and wind-bracing requirements for new construction or repairing existing buildings
● Adopting zoning ordinances that steer development away from areas subject to flooding, storm surge, or coastal erosion
● Retrofitting public buildings to withstand ground shaking or hurricane-strength winds
● Acquiring damaged homes or businesses in flood-prone areas, relocating the structures, and returning the property to open space, wetlands, or recreational uses
● Building community shelters and tornado-safe rooms to help protect people in their homes, public buildings, and schools in hurricane- and tornado-prone areas (FEMA, 2018).
Secondary Secondary prevention may occur when the onset of the disaster has occurred or within hours of its impact; this is when response occurs during a disaster. Response in disaster management indicates the period of time for emergency assistance with the goal of maintaining and saving lives, improving health, surviving the disaster event, and supporting victims (National Disaster Recovery Framework, 2016). The priority is safety and survival during the response phase and occurs when it is necessary to evacuate or, if more appropriate, find and take shelter. Families and individuals can prepare for this phase by having a designated safe area or location in which they plan to take refuge. PHNs educate families on possible evacuation and alternative routes as well as locating places of refuge when evacuation is not an option.
Tertiary Tertiary prevention occurs after the offending event has ceased and the focus is on recovery. The tertiary and recovery phases may last weeks, months, or even years and involves property damage recuperation, physical rehabilitation of those injured, mental illness evaluation and treatment, planning for future disasters, and financial recuperation. While the focus is on recovering from the event, thought should be given to how well the first two prevention phases went and what can be done to improve them. PHNs can help to evaluate the process and devise and implement changes in the prevention plan that may help to avoid devastating results in the next disaster event.
Community Reaction
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● The effects of a disaster can be longstanding and life changing for individuals and communities. Effects can be on many levels, from the psychological to spiritual. All varying needs must be taken into consideration when caring for those affected following a disaster event.
Psychological Impact Following disasters, individuals within the affected community may have varying emotional reactions. It is normal to see a degree of panic within the community when the disaster is occurring. Panic is the sudden onset of excited feelings brought on by the fear of impending danger; this is what causes people to run franticly from buildings or the scene of a disaster in search of refuge.
Shock is defined as a period of disbelief that may render a person incapable of typical thought processes or role function; this usually sets in once the imminent danger of the disaster has ended. This is a very typical reaction following a disastrous event and, while usually temporary, may have a profound impact on a person’s sense of normalcy and control. If the initial shock of the event does not dissipate, the emotional strain may lead to long-term mental disorders such as depression or post-traumatic stress disorder (PTSD).
There are a wide range of psychological effects following a disaster. Some level of distress is considered typical; however longstanding depression, anxiety, and PTSD may affect individuals for years following the disaster event itself (Martin, 2015). The psychological effects can last years and have a devastating effect on the daily lifestyle, personal relationships, and return of typical daily functions in individuals struggling with such diagnoses. There are also correlations between exposure to a disaster and increased incidence of drug and alcohol abuse as a means of coping with the stress of the experience (Maclean, Popovici, & French, 2016).
Nurses within the community must take this into account when caring for survivors of such events, remembering to consider that the event may have occurred many years ago and still have an impact on the patient. Nurses should refer patients to case management, chaplain
services, and social work as well as coordinate counseling services or other appropriate resources for mental health when indicated. The Disaster Distress Hotline, a free telephone hotline offered by the Substance Abuse and Mental Health Services Administration (SAMHSA), is available for people seeking help following a disaster event (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012). People can call or text 365 days a year, 24 hours a day to receive free emotional support related to being involved in a disaster; these services are provided in English, Spanish and accommodations are made for the hearing impaired (SAMHSA, 2012).
Under normal, controlled circumstances, the business of caring for the sick is emotionally draining; therefore, doing so in the midst of total chaos adds additional strain and may have an impact on health care professionals that warrants attention. Nurses should stay aware of their own emotional health during these times and reach out for support when needed. Nurses may fall victim to the psychological affects following a disaster and should be supported by their managers, peers, and other health care professionals to provide them with the care they may need.
Spiritual and Cultural Considerations As previously discussed, disasters take a significant toll on mental health, causing short and long-term distress. During these times, the need for spiritual care may become dire. Regardless of religious affiliation, chaplains play an important role in supporting the communities’ emotional needs during and after a devastating event (Graham, 2014). Nurses working with the victims can advocate for the spiritual needs of patients by locating the chaplain whenever possible and facilitating the incorporation of spiritual practices that do not interfere with patient safety or the course of treatment to provide comfort. Reaching beyond spiritual guidance, chaplains are trained to provide psychological support. Chaplains are valuable members of society, providing counsel and comfort to the shocked, grieving, and emotionally devastated victims in disasters.
Cultural needs must also be considered when preparing for disasters and caring for survivors. Different cultures may respond to a traumatic event differently, whether it be with prayer, crying, or stoic affect. The PHN should be aware of cultural differences and approach each patient with sensitivity and respect, allowing them to grieve, react, and respond the way that is appropriate for them, as long as they are not causing self-harm or harming others. In areas where populations are extremely vulnerable, such as areas of high poverty, their ability to cope and recover financially as well as psychosocially following a disaster may be severely impaired (Knox & Haupt, 2015). These individuals will require more support from local and federal agencies to move forward with the recovery process. PHNs are valuable advocates helping to allocate resources for those with limited capacity to do so on their own. In preparing a community for disaster, the community’s culture should be examined, and appropriate adjustments should be made to account for cultural differences. This may mean PHNs must adjust how they educate community members about disaster preparations or utilizing translation services if needed.
Physical Impacts
Beyond the short-term injuries that may be sustained during a disaster event, some survivors may experience life-long effects on their health. These effects stem from a number of things, including severe injuries or exposure to carcinogenic, toxic, or radioactive substances during or after the event.
Fertility One major longstanding physical impact seen in disaster survivors is a decrease in fertility. This is due to a variety of reasons associated with the disaster, including exposure to toxic agents, psychological trauma, and general exposure to the traumatic event (Zotti, Williams, Robertson, Horney & Hsia, 2013). Along with decreased rates of fertility, studies have shown an impact on pregnancy loss, birth defects, low-birth weights, and preterm births (Zotti et al., 2013). Studies point to the stress of the disaster event having profound negative effects on women in their child-bearing years. These negative effects may inhibit women from conceiving or carrying to term, which may cause an increase in emotional strain on the woman and her partner. While there are promising infertility treatments that can be offered to a struggling couple, their mental health and coping must be of concern as well. Nurses must consider offering services that will address the issue of fertility and childbearing as well as mental well-being.
Toxic Exposure Regardless of the type of disaster, there is always risk of exposure to toxic substances or carcinogens that have the potential to impact health throughout one’s lifetime. A prime example of this type of exposure that is still being researched and studied is the exposure to various toxic inhalants during the September 11, 2001 terrorist attack on the World Trade Center in New York City. During this terrorist attack, high concentrations of dense dust particles were inhaled and swallowed by survivors and first responders in the surrounding area, causing a host of respiratory and digestive issues that continue to cause these individuals health problems, such as gastroesophageal reflux (GERD) and lung cancer (Lippman, Cohen & Chen, 2015).
Nurses must understand that the health effects following a disaster can have lifelong impacts that cause a multitude of issues long after the disaster occurrence. The skill of history taking is essential in these instances. The patient may not mention being a survivor of a disaster, especially if it was many years ago, and they see no reason to bring it up. Discovering that a patient is a survivor of a disaster event and was exposed to toxic agents may indicate a need for different diagnostic procedures, which highlights the importance of detailed and thorough health history taking. In addition, the patient may be suffering from other effects of surviving a disaster as well, such as PTSD or other mental health issues, and may require appropriate referral and support from other members of the health care team, such as social work and case management.
Population Health Considerations Post Disaster There are a great number of considerations to be made during the recovery phase to help the affected community fully recover. Beyond the physical injuries and loss of lives, there is damage to buildings and property, loss of housing, lack of running water and electricity, overwhelmed emergency services and local hospitals, and inadequate financial resources to provide the
necessary items for relief and recuperation. Each of these issues warrants time, resources, collaborative planning, and efforts in order to restore balance to a community that has suffered immeasurable losses. PHNs are instrumental to this process by evaluating patients in the community, assessing their needs, and providing necessary education for health promotion measures and/or preparation for the next disaster that may occur.
Economic Impact The economic impact on communities after a disaster can vary depending on various elements of the disaster itself and the severity of its impact. According to FEMA, in the 1990s more than $25 billion was allocated to provide disaster assistance in the United States, and money sent to assist after disasters worldwide skyrocketed to over $608 billion (FEMA, 2009). While the costs and lives lost are seemingly unavoidable, proper preparation and improvement of preparation processes are essential to decreasing cost as well as saving lives. PHNs can contribute to this by being involved in the mitigation and preparation processes in disaster management, as well as the evaluation postdisaster to help improve preparation plans before the next disaster strikes. Table 5.3 provides information on the five costliest hurricanes on record to strike the United States (Office for Coastal Management, n.d.).
Table 5.3
Economic Impact
Nurse’s Role in Disaster Management
Name Year Cost
Katrina 2005 $161 billion
Harvey 2017 $125 billion
Maria 2017 $90 billion
Sandy 2012 $71 billion
Irma 2017 $50 billion
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● PHNs play an integral role in the community as trusted and esteemed caregivers. PHNs not only have a responsibility to their patients, but also to their community as a whole. Whether natural or man-made, disasters are inevitable, and nurses must be prepared to respond. Nurses have a long and proud history of caring for the sick and injured in tumultuous times, most notably in the days of Florence Nightingale during the Crimean War. These roots remain a driving force that inspires nurses to dutifully and skillfully care for patients. PHNs take this care a step further by helping to plan for the sustainability of their communities, especially during times of disaster. According to the Association for Public Health Nurses (APHN), the role of public health nurses in disaster management includes “population based practice like rapid needs assessments of communities impacted by the incident, population based triage, mass dispensing of preventive or curative therapies, community education, and providing care or managing shelters for displaced populations” (Association of Public Health Nurses, 2013, p. 4). The basic steps of the traditional nursing process—assessment, planning, implementation, and evaluation— is the same process utilized for nursing during disaster management with some modification necessary to address public health (see Table 5.4). Table 5.4
Nursing Process in Disaster Management
Nursing Process Step Description
Note. Adapted from The Role of the Public Health Nurse, by the Association of Public Health Nurses, 2014.
Disaster Management in Years to Come
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Assessment ● PHNs are responsible for assessment of the local population for risks and needs during times of disaster
● PHN may also conduct a hazard vulnerability assessment, which involves identifying threats and hazards in the area that pose the greatest amount of risk.
Planning ● PHNs formulate plans of care that address functional needs of the population during a disaster.
● PHNs then work with key stakeholders within the community to address these needs, which might include sheltering, evacuation planning, and mass casualty capabilities.
Implementation ● PHNs participate in training for community health care providers, including forming and conducting casualty drills and education regarding protocol during a disaster
Evaluation ● PHNs evaluate training, drills, and education ● PHNs evaluate operational plans and protocols to make
improvements in the future
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● With political shifts, climate changes, and increasing populations worldwide, both natural and man-made disasters have and will continue to change. The threat of impending disasters will continue to warrant appropriate action and planning. PHNs need to remain aware of these changes to prepare themselves and their communities adequately.
Mass Shootings Over the past few decades, there has been an increase in mass shootings in the United States. Such events often result in multiple casualties, many more injuries, and often a lifetime of devastation for the victims and victims’ loved ones (Terrades, 2017). Because of this, it is essential that PHNs and all health care professionals take steps to prepare for such an event in their local communities. This involves education regarding response and survival during an active shooter event in every setting, from schools to churches to businesses. This also involves preparing acute care facilities, emergency management plans and processes, and drills to practice proper response efforts in advance. Educating parents and caregivers regarding gun safety and the importance of keeping guns unloaded and in a locked safe at all times should be reiterated and stressed at every opportunity. Mandatory survival training and education is often being implemented in many workplaces that help employees to understand how to respond in case of an active shooter event in their place of business (U.S. Department of Homeland Security [DHS] 2017). The DHS offers several training handouts and videos that are free for use in educating the public regarding surviving active shooter situations (see Figure 5.7).
Figure 5.7
Active Shooter Response
Note. Adapted from “Active Shooter Pocket Card,” by the U.S. Department of Homeland Security.
Terrorism After the events of September 11, the thought process regarding mitigation and preparedness for terrorist events shifted. In 2002, President George W. Bush enacted the Homeland Security Act with the goal of reducing the nation’s vulnerability to terrorism, protecting the United States from future attacks, and minimizing the damage in the event of terrorist and disaster attacks (FEMA, 2008). Mitigation strategies, such as enhanced security procedures, were elevated and continue to be the gold standard in the effort to prevent terrorist attacks. The DHS also started a campaign called “See Something, Say Something” that emphasizes public awareness and involvement in reporting suspicious activity of any kind in order to assist in prevention measures (DHS, n.d.). PHNs can be actively involved in educating members of the community about safety and reporting suspicious activity to help keep their community safe.
Bioterrorism In recent years, the threat of impending terrorist attacks has warranted the attention of health care professionals in collaboration with federal agencies to help prevent and respond to an act of bioterrorism. The act of bioterrorism, or chemical terrorism, is defined as the use of biological or chemical agents as a weapon to cause injury, death, and disruption (Centers for Disease Control and Prevention [CDC], 2017). In response to the impending threat of anthrax attacks, the CDC (1999) published the National Bioterrorism Preparedness and Response Initiative, which is a guide for prevention and response to bioterrorism attacks. The CDC’s five
primary focus areas are preparedness, detection, diagnosis, response, and communication (CDC, 2016).
Health care facilities have their own protocols to follow when dealing with bioterrorism threats. The protocol is largely directed by recommendations from the CDC. Nurse leaders are an important part of the process of understanding the protocol and knowing how to properly educate their staff regarding procedures in the event of a bioterrorist attack. The protocol details procedures such as isolation precautions, handling of patient specimens, decontamination following exposure, patient placement, and postmortem care of infected patients. In addition, it provides an overview of a handful of bioterrorism agents, their expected clinical features, and recommendations for treatment and care for agents such as botulism, anthrax, and plague (CDC, 2018).
Within hospital settings, the Occupational Safety and Health Administration (OSHA) has published guidelines to assist hospitals with response to an attack of this nature. These guidelines discuss preplanning, care of the victims, and avoidance of cross contamination (Occupational Safety & Health Administration, 1997). Health care personnel must be familiarized and educated on bioterrorism agents and how to protect themselves and the victims of the event. Because nurses have a great deal of contact with patients, providing them with the education necessary to work in these conditions is crucial. PHNs can be advocates for such education in order to protect their own health, the health of their colleagues, and the health of their patients. Nurses working at the bedside or in leadership roles can help to establish and implement education plans that would inform nurses of proper protocol in a bioterrorism event.
Nuclear Threats and Response In light of political tension around the globe, it behooves any well-organized government to be well prepared for any disaster, including one as devastating as a nuclear detonation. FEMA and the CDC have plans in place to respond in the event that nuclear war were to become aa reality. PHNs serve as educators of the community, helping to institute plans for survival and safety in the event of a nuclear detonation. The website Ready.gov also provides numerous tips and advice regarding surviving a nuclear blast and necessary steps to survive after detonation.
Three of the primary factors reiterated in survival of a nuclear blast are distance, shielding, and time. Individuals should be instructed to put as much distance and protection between themselves and the fallout particles as possible, this means immediately heading indoors and staying there. The thicker the walls of the structure or the deeper underground the individuals can go, the safer they are from the nuclear fallout materials. Time is the final factor; following a nuclear detonation, the first few weeks pose the greatest amount of risk. People are advised to stay indoors for a minimum of two weeks, as the nuclear materials can cause the greatest degree of damage in this time period (Ready.gov, n.d.b). PHNs can be valuable in providing education regarding these important survival guidelines to the communities they serve.
Reflective Summary
Preparation for a disaster is something all nurses must be involved with no matter what area of expertise they choose. With proper preparation and intervention, the impact and consequences following a disaster can be reduced greatly. Nurses are often called to respond in the event of disaster events and must prepare themselves and their families for such an occurrence. PHNs are valued and important responders, often acting as coordinators of care in the prevention and management of disaster occurrences.
Key Terms Bioterrorism: The use of biological or chemical agents as a weapon to cause injury, death, and disruption.
Community Emergency Response Team (CERT): Team of volunteers within a community trained on disaster management skills, such as fire safety and search and rescue.
Controllability: The ability to plan ahead for the possibility of an event in the future.
Disaster Nursing: Nursing that specifically involves disaster planning, prevention, and response.
Emergency Preparedness: A continuous cycle of planning, organizing, training, equipping, practicing, evaluating, and taking corrective action in an effort to ensure effective coordination during incident response.
Evacuation: Temporary and rapid removal of people from an area or building that has an impending threat of disaster whether man-made or natural.
Federal Emergency Management Agency (FEMA): U.S. federal agency that coordinates the response to disasters.
Frequency: Probability of occurrence of a potentially damaging phenomenon within a given time period and geographic area.
Impact: Phase of disaster planning that occurs during the actual event; may last for minutes, days, or even weeks depending on the type of disaster; focus is on survival.
Intensity: Specific to the effect of the disaster on the community’s health outcomes and loss of life.
Man-Made Disaster: Occurs as a result of human involvement, such as terrorism, transportation accidents, food and water contamination, and building collapse.
Mass Casualty Incident: Involves larger numbers, typically more than 100 people, and has an apparent impact on local emergency medical services and resources.
Mitigation: Measures that eliminate or reduce the impacts and risks of hazards through preventative measures taken before disaster occurs.
Multiple Casualty Incident: Occurs when the casualty toll is isolated to fewer than 100 people.
Natural Disaster: Caused by forces of nature such as hurricanes, blizzards, mudslides, earthquakes, tsunamis, epidemics, and fires.
Postimpact: Phase of disaster planning that occurs once imminent danger has ceased; during this period, rescue and emergency medical care becomes the primary focus.
Post-Traumatic Stress Disorder: Disorder that develops in some people who have experienced a shocking, scary, or dangerous event.
Predictability: Based upon the ability to foresee the impending event, such as with weather forecasting systems that may have the ability to deliver a hurricane or tornado warning.
Preimpact: Phase of disaster planning that is optimal for planning and preparing for a disaster.
Primary Agent: Offending cause that creates primary damage, such as a tornado or bomb.
Recovery: Period of time that may last weeks, months, or even years and involves property damage recuperation, physical rehabilitation of those injured, mental illness follow up, extended care, planning for future disasters, and financial recuperation.
Response: Indicates the period of time for emergency assistance with the goal of maintaining and saving lives, improving health, surviving the disaster event, and supporting victims.
Scope: Specific to the depletion of typical resources within the effected community.
Secondary Agent: Offending cause that is created as a result of the primary agent, such as the bacteria that grows in stagnant water following a flood.
References American Nurses Association. (2015). Code of ethics with interpretive statements. Silver
Springs, MD: Author. Retrieved from http://nursingworld.org/DocumentVault/Ethics-1/Code-of-Ethics-for-Nurses.html
American Red Cross. (n.d.). Mission and values. Retrieved from http://www.redcross.org/about-us/who-we-are/mission-and-values
Association of Public Health Nurses. (2013). The role of the public health nurse in disaster preparedness, response, and recovery: A position paper. Retrieved from http://www.achne.org/files/public/APHN_RoleOfPHNinDisasterPRR_FINALJan14.pdf
Centers for Disease Control and Prevention. (1999). National bioterrorism preparedness and response initiative. Atlanta, GA: Author.
Centers for Disease Control and Prevention. (2016). Anthrax: Bioterrorism. Retrieved from https://www.cdc.gov/anthrax/bioterrorism/index.html
Centers for Disease Control and Prevention. (2017). Emergency preparedness and response: Preparation and planning for bioterrorism emergencies. Retrieved from https://emergency.cdc.gov/bioterrorism/prep.asp
Centers for Disease Control and Prevention. (2018). Emergency preparedness and response: Bioterrorism agents/diseases. Retrieved from https://emergency.cdc.gov/agent/agentlist.asp
Federal Emergency Management Agency. (2008). FEMA strategic plan: Fiscal years 2008-2013. Washington, DC: Author. Retrieved from https://www.fema.gov/pdf/about/fy08_fema_sp.pdf
Federal Emergency Management Agency. (2009). Federal assistance in Hurricane Ike disaster tops $2.5 billion. Retrieved from https://www.fema.gov/news-release/2009/08/20/federal-assistance-hurricane-ike-disaster-to ps-25-billion
Federal Emergency Management Agency. (2016). National response framework (3rd ed.). Washington, DC: U.S. Department of Homeland Security.
Federal Emergency Management Agency. (2017). FEMA’s mission statement. Retrieved from https://www.fema.gov/media-library/assets/videos/80684
Federal Emergency Management Agency. (2018). What is mitigation? Retrieved from https://www.fema.gov/what-mitigation
Federal Emergency Management Agency. (n.d.). Lesson summary. Retrieved from https://emilms.fema.gov/IS800B/lesson4/L4_Print.htm
Federal Interagency Committee on EMS. (n.d.). FICEMS. Retrieved from https://www.ems.gov/ficems.html
Graham, L. K. (2014). Political dimensions of pastoral care in community disaster responses. Pastoral Psychology, 63(4), 471-488.
Hageman, J. C., Hazim, C., Wilson, K., Malpiedi, P., Gupta, N., Bennett, S., … Park, B. J. (2016). Infection prevention and control for Ebola in health care settings – West Africa and United States. Morbidity and Mortality Weekly Report Supplement, 65(3), 50-56. doi: 10.15585/mmwr.su6503a8
International Federation of Red Cross and Red Crescent Societies. (n.d.). What is a disaster? Retrieved from http://www.ifrc.org/en/what-we-do/disaster-management/about-disasters/what-is-a-disaster/
Jakeway, C. C., LaRosa, G., Cary, A., & Schoenfisch, S. (2008). The role of public health nurses in emergency preparedness and response: A position paper of the association of state and territorial directors of nursing. Public Health Nursing, 25(4), 353-361.
Knox, C.C., & Haupt, B. (2015) Incorporating cultural competency skills in emergency management education. Disaster Prevention and Management: An International Journal; 24(5), 619-634. doi: 10.1108/DPM-04-2015-0089
Lichtveld, M. (2018). Disasters through the lens of disparities: Elevate community resilience as an essential public health service. American Journal of Public Health, 108, 28-30. doi:10.2105/AJPH.2017.304193
Lippmann, M., Cohen, M. D., & Chen, L. (2015). Health effects of World Trade Center (WTC) dust: An unprecedented disaster with inadequate risk management. Critical Reviews in Toxicology, 45(6), 492-530. doi: 10.3109/10408444.2015.1044601
Maclean, J. C., Popovici, I., & French, M. T. (2016). Are natural disasters in early childhood associated with mental health and substance use disorders as an adult? Social Science & Medicine, 151, 78-91. doi:10.1016/j.socscimed.2016.01.006
Martin, U. (2015). Health after disaster: A perspective of psychological/health reactions to disaster. Cogent Psychology, 2(1). doi: 10.1080/23311908.2015.1053741
Millet, C. (2013). The public health nurse’s role in disaster preparedness. Retrieved from https://www.maphn.org/Resources/Documents/CMilletpostver073113.pdf
National Disaster Recovery Framework. (2016). Retrieved from https://www.fema.gov/media-library-data/1466014998123-4bec8550930f774269e0c5968b1 20ba2/National_Disaster_Recovery_Framework2nd.pdf
Occupational Safety & Health Administration. (1997). Hospitals and community emergency response – What you need to know. Washington, DC: U.S. Department of Labor. Retrieved from https://www.osha.gov/Publications/OSHA3152/osha3152.html
Office for Coastal Management. (n.d.). Fast facts: Hurricane costs. Retrieved from https://coast.noaa.gov/states/fast-facts/hurricane-costs.html
PerformTech Inc. (2011). Community Emergency Response Team: Basic training instructor guide. Washington, DC: Federal Emergency Management Agency. Retrieved from https://www.fema.gov/media-library-data/1448914296662-6907d9939a58ca269944137d1d 232c6a/cert_basic_training_instructor_guide_compiled_508_102815.pdf
Petkova,E. P., Schlegelmilch, J., Sury, J., Chandler, T. E., Herrera, C. D., Shwetha Bhaskar, S., . . . Redlener, I. E. (2016). Children in disasters: Do Americans feel prepared? A National Survey. Columbia University Academic Commons. doi.:10.7916/D85M65J9
Public Health Emergency. (2018). NDMS teams. Retrieved from http://www.phe.gov/Preparedness/responders/ndms/ndms-teams/Pages/default.aspx
Ready.gov. (n.d.a). Community emergency response team. Retrieved from https://www.ready.gov/community-emergency-response-team
Ready.gov. (n.d.b). Nuclear explosion. Retrieved from https://www.ready.gov/nuclear-explosion Ready.gov. (n.d.c). Home. Retrieved from https://www.ready.gov Rehwald, J. (2017). “To the max:” Simultaneous disasters stretch Springfield-based Convoy of
Hope. Retrieved from https://www.news-leader.com/story/news/2017/09/07/max-simultaneous-disasters-stretch-s pringfield-based-convoy-hope/633260001
Substance Abuse and Mental Health Services Administration. (2012). Disaster Distress Helpline brochure. Retrieved from https://store.samhsa.gov/product/Disaster-Distress-Helpline-Brochure/PEP12-DDHBRO
Terrades, V. (2017). Mass shootings and offenders' motives: A comparison of the United States and foreign nations. ILSA Journal of International & Comparative Law, 23(3), 399-423.
U.S. Department of Homeland Security. (2017). Active shooter preparedness. Retrieved from https://www.dhs.gov/active-shooter-preparedness\
U.S. Department of Homeland Security. (n.d.). If you see something, say something. Retrieved from https://www.dhs.gov/see-something-say-something
Zotti, M. E., Williams, A. M., Robertson, M., Horney, J., & Hsia, J. (2013). Post-disaster reproductive health outcomes. Maternal and Child Health Journal, 17(5), 783-796. doi:10.1007/s10995-012-1068-x
