Week 7
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14 COMPETENCY #12 Demonstrates Leadership in Public Health Nursing With Communities, Systems, Individuals, and Families
n Patricia M. Schoon with Bonnie Brueshoff, Erin Karsten, and Marjorie A. Schaffer
José is with the Elders at Home Program for his public health nursing clinical. He is assigned to Mr. and Mrs. Santos, a couple in their 70s struggling to manage their healthcare needs and stay in their home in an older inner-city neighborhood. Mrs. Santos provides primary assistance for her husband, who has advanced chronic obstructive pulmonary disease (COPD). After a recent hospitalization, Mr. Santos received home care services from a home care nurse, respiratory therapist, occupational therapist, and home health aide. These services were reimbursed by Medicare because Mr. Santos met the criteria of potential for rehabilitation and progress toward independent living. All went well. Then a 60-day health assessment resulted in a determination that Mr. Santos was no longer eligible for home care services. He was referred to the county public health Elders at Home Program but has been resisting a home visit. José wonders, “I am just a student nurse. What can I do?” He sighs, “Well, it looks like my preceptor has handed me a challenge I can’t avoid. Isn’t there a chapter we are supposed to read on leadership in public health nursing?”
JOSÉ’S NOTEBOOK COMPETENCY #12 Demonstrates Leadership in Public Health Nursing with Communities, Systems, Individuals, and Families
A. Seeks learning opportunities when working with peers, organizations, and communities
B. Demonstrates ability to be flexible, adapt to change, and tolerate ambiguity while working in an unstructured environment
C. Seeks from and provides consultation and support to peers and community partners
D. Responds to population health needs in collaboration with systems and communities
E. Contributes to team efforts to improve the quality of care provided to client populations
F. Prioritizes and organizes workload, time, materials, and resources to maximize benefits to clients and stakeholders
G. Participates in the political process to advocate for changes in health and social policies that affect population health, workforce health, and public health services delivery
Source: Henry Street Consortium, 2017 (continues)
C o p y r i g h t 2 0 1 8 . S i g m a .
A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .
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280 PART II n Entry-Level Population-Based Public Health Nursing Competencies
and community teams; and in diverse community systems, such as government, healthcare organizations, schools, home-care agencies, prisons, faith-based communities, and homeless shelters. PHNs employ many strategies includ- ing persuasion, influencing, role-modeling, networking, and collective social action. Interventions often used are collaboration, community organizing, coalition-building, social marketing, surveillance, and policy development and enforcement. PHNs who work in governmental agencies are responsible for carrying out the core functions and essential services of public health (see Chapter 7). Leadership skills are essential to the success of these services.
Public health nurses practice at that intersection where societal attitudes, government policies, and people’s lives meet. Such privilege creates a moral imperative not only to attend to the health needs of the public but also, like Nightingale, to work to change the societal conditions contributing to poor health (Falk-Rafael, 2005, p. 219).
PHNs are expected to have a passionate commitment to advocate for the health of the clients they serve and the health of their community.
The Leadership Journey Nurses are presented with leadership challenges through- out their careers. Leadership challenges are events or situa- tions that require nurses to use critical thinking and ethical problem-solving to arrive at equitable and effective solu- tions. These situations propel nurses along their leadership
Leadership in Public Health Nursing Practice Leadership is often taught as a separate course in the nurs- ing curriculum. So, you may be asking, why is leadership content included in this book? Why is there a separate lead- ership competency? Isn’t leadership the same no matter where it is practiced?
Leadership theories are certainly applicable to all forms of nursing practice. However, there are two aspects of pub- lic health nursing practice that are unique. Public health nurses (PHNs) are often alone in community settings and required to take immediate actions independently. Some- times PHNs are the only healthcare provider available in a community setting. PHNs must be comfortable making decisions and taking actions independently and know how to access consultation and support by phone and Internet. They need to be risk takers, able to advocate for their clients in situations where they may be alone and in situations that may not always be comfortable. It is important for PHNs to be comfortable in community settings where there is min- imal structure and maximum uncertainty. PHNs must be comfortable providing mentorship and being mentored. Leadership skills are essential.
PHNs spend their daily lives in the community and deal with social determinants of health and the impact of these determinants on health outcomes with individuals, fam- ilies, populations, and communities. They know that they often must go outside the healthcare system to promote and protect their clients’ health. Effective use of leadership skills is crucial to the success of their efforts. PHNs carry out leadership at the individual/family, community, and sys- tems levels; in the home; in interprofessional public health
USEFUL DEFINITIONS
Advocacy-Based Leadership: Advocacy-based leaders are motivated by the needs of others to take actions to improve others’ health and well-being.
Authentic Leadership: Authentic leaders are reflective practitioners whose actions are consistent with their values, ethical standards, and convictions (Murphy, 2012; Wong, Spence Laschinger, & Cummings, 2010).
Leadership: Leadership is the process and art of influencing, motivating, and leading others to achieve shared goals.
Leadership Journey: The leadership journey is a lifelong process of self-discovery, self-efficacy, and goal-directed actions.
Shared Leadership: Shared leadership refers to the concept of being an effective team member (Avolio, Walumbwa, & Weber, 2009).
JOSÉ’S NOTEBOOK (continued)
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281CHAPTER 14 n Competency #12
to be a leader. Staff nurses usually work within healthcare teams and share the workload. Knowing how to work effec- tively within the healthcare team and with groups within the community is referred to as shared leadership. These three forms of leadership are consistently practiced in pub- lic health nursing.
Authentic Leadership Choosing to lead is a conscious choice to take action. The authentic leader moves from concerns about self to con- cerns about the other. Leadership is a journey from the “I” to the “We” (George & Sims, 2007). Leadership conscious- ness starts with an awareness and understanding of one’s own values, beliefs, and convictions. Self-awareness or con- sciousness leads nurses to develop their own personal and professional leadership competencies. This consciousness then leads them to an awareness of the needs of others, thus creating a moral challenge and a call to action. When nurses respond to this call for action, they develop authentic per- sonal and professional leadership styles and competencies. Figure 14.1 demonstrates how you move along your leader- ship journey throughout your nursing career as you respond to transitional moments in your nursing practice.
journey. The leadership journey is a lifelong process of self-discovery, self-efficacy, and goal-directed actions. Nurs- ing students and professional nurses are on a lifelong jour- ney as they develop their leadership potential, explore their authentic leadership styles, and identify their personal and professional reasons and motivations for taking leadership actions. Students and nurses entering public health have their own unique leadership journey.
Nursing leadership begins with the nurse-patient rela- tionship in clinical practice. You started your leadership journey as a nursing student the moment you identified an unmet patient need and advocated for your patient by working to influence other members of the care team to take actions to meet your patient’s needs. In other words, you began to lead when you identified an unmet client need and took the lead in advocating for your client with oth- ers. In doing so, you demonstrated advocacy-based nursing leadership. The actions you took were based on your beliefs and values and reflected your own personal and profes- sional way of being, the beginning of authentic leadership practice. When you move beyond the nurse-client relation- ship and advocate within the healthcare system or commu- nity for changes in attitudes, beliefs, knowledge, actions, and resources that will help meet your client’s needs, you are practicing leadership. You do not have to be in a for- mal position of authority, such as a supervisor or manager,
FIGURE 14.1 The Leadership Journey—Ongoing Leadership Challenges Source: Based on concepts from George & Sims, 2007
Focus on “I”
Development of personal and professional self-efficacy
Ability to take actions to meet own personal and professional needs
Transition Phase from “I” to “We”
Consciousness of needs of others
Take actions to meet needs of others (advocacy)
Develop emerging leadership approaches, strategies, and competencies (authentic leadership)
Focus on “We”
Conscious of and comfortable with own leadership style, approaches, and competencies
Take leadership actions and sometimes leadership role within groups, organizations, and community to meet needs of others
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282 PART II n Entry-Level Population-Based Public Health Nursing Competencies
encouragement that was given to me, I gained confidence and was motivated to advance my knowledge and skills. For example, I received the support to apply to serve on the MDH Maternal and Child Health (MCH) State Advi- sory Task Force. I was appointed to be a member of this task force, which gave me leadership experience in dealing with statewide policy and programs and expanded my profes- sional network. I was given support to pursue the Robert Wood Johnson (RWJ) Executive Nurse Fellowship program that I completed.
What inspires you and keeps you fresh in your leadership vision and strategies? Both my practice experiences and professional development activities have kept me inspired including (1) experiencing the impact that public health has in helping us all be healthy, because the focus of public health is on prevention; (2) being able to be innovative in trying new approaches and using evidence-based practice; (3) reading leadership literature and articles; (4) networking with my colleagues; (5) mentor- ing new PHN staff; and (6) working to influence policies and decision-making on all levels—local, state, and national.
What are your three most important “lessons learned” about leadership in your public health nursing practice?
n To lead, you have to be willing to take risks and know it is OK to fail and learn from your mistakes—to learn how to “fail forward.”
n Networking and lifelong learning are key. You can do more with others than by being solo. Join professional organizations and stretch yourself. Get involved. Never stop. Learning self-awareness is very important and will help you immensely! Ask for honest feedback from others so you can build on your strengths.
n Become politically savvy. Learn about policies and pro- cesses that affect public health. The ability to influence policy has a far-reaching influence on nursing!
–Bonnie Brueshoff, DNP, RN, PHN, Public Health Director and Robert Wood Johnson Executive Nurse Fellow (2006–2009), Dakota County Public Health
Leading Through Relationships PHNs work with their clients, team members, interprofes- sional colleagues, and various members of the community in striving to meet their goals of improving population health. Public health nursing leadership requires influenc- ing others to achieve public health goals (Morrison, Jones, & Fuller, 1997). You are starting your public health nursing leadership journey at the individual/family level of practice, which is where entry-level PHNs often begin to develop their skills and understanding of their role. Table 14.1 out- lines leadership styles that are often used in public health nursing practice and provides examples of how students may develop skill in using these styles.
You have already developed some beginning leadership skills and practices in your previous nursing clinicals. These skills and practices are consistent with the situational chal- lenges you have faced and your authentic sense of self. You may further develop your leadership style and skills as you progress through your public health clinical. This chapter provides guidance to help you consider the public health nursing leadership styles and skills that fit your authentic self. Which transitional moments in your leadership jour- ney do you think you might encounter during your public health nursing clinical experiences?
The Leadership Journey: Reflections of a Public Health Nurse Leader As you progress along your leadership journey, you may want to reflect on the situations, personal decisions, and role models or supporters who helped you develop your authentic leadership style and skills. In the following interview, a PHN leader describes her leadership journey and what she learned along the way (Brueshoff, personal communication, 2013):
Tell a story about how your early experiences in public health nursing and the leadership challenges you confronted helped you along your leadership journey. My first job as a nurse was working in a PHN position in northern Minnesota. I had a generalized caseload of young families and elderly clients. One of my specific roles in the department was to provide follow-up for the Sudden Infant Death Syndrome (SIDS) cases in the county. As a novice PHN, I found my knowledge base about SIDS to be inad- equate, which led me to request additional training avail- able at the state level. Through the training, I made valuable connections with the Minnesota SIDS Center and accessed expertise from SIDS Center staff that provided me with resources for families and much-needed emotional support. Needless to say, I became better prepared to provide the support and assistance that benefited SIDS families during subsequent home visits. This experience early on in my career reinforced the importance of ongoing education and reaching out to access resources and expertise from other professionals. Later in my career, my experience working with SIDS families helped me mentor other PHNs who were working with SIDS cases and was a factor in my leadership journey as I was hired in a position as an apnea home mon- itoring coordinator.
Who were your role models and guides along the way? I was extremely fortunate to have the support and guidance from two public health directors who offered me opportu- nities for growth and challenged me to take on leadership roles. I consider both directors to be my role models and mentors. I also looked to the Minnesota Department of Health (MDH) PHN nurse consultants for guidance with my PHN practice and took every opportunity I could to vol- unteer for state work groups and committees. Through the
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283CHAPTER 14 n Competency #12
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Advocacy-Based Leadership Advocacy-based leadership is foundational to public health nursing. Advocating for clients—whether those clients are individuals, families, populations, or communities—is part of the social justice mission of public health nursing. Although all nurses advocate for the unmet needs of their individual clients, PHNs have a responsibility to advocate for the health of the public, to care about what is causing the health disparities in their communities, and to take action to improve the health status of the affected individuals, families, populations, and communities. This means that PHNs need to be aware of emerging health needs and con- nect the patterns of health disparities they observe among their individual clients. Sometimes advocacy-based lead- ership is an unconscious response to an unmet healthcare need. Sometimes it is a conscious choice triggered by an ethical or moral call to action. Evidence Example 14.1 illus- trates advocacy-based leadership taken by a public health nursing student from a school of nursing in the Henry Street Consortium.
Think about the leadership journey you have been on since starting your public health nursing clinical. Are you able to identify when you began to focus more on your cli- ents and the community than yourself? Can you identify a transformative moment when you realized that it was morally necessary for you to advocate for the unmet health needs of a vulnerable population by enlisting the help of others?
José has just completed his first visit to Mr. and Mrs. Santos. Mrs. Santos is experiencing caregiver stress, and Mr. Santos is becoming less and less active. He loves to smoke even though he has a portable oxygen tank in his bedroom. Mr. and Mrs. Santos do not want nurses and social workers coming in and telling them what to do. They are afraid of strangers. José tells them he will make a joint visit with the social worker and introduce them to her. He is going to take the initiative to find the resources Mr. and Mrs. Santos need to live independently in their own home.
Which public health nursing leadership competencies has José demonstrated? Which leadership styles is he using in working with Mr. and Mrs. Santo?
TABLE 14.1 Nursing Leadership Styles in Public Health Nursing
Leadership Style Student Leadership Learning Examples
Advocacy-based leadership: Advocacy-based leaders are moti- vated by the needs of others to take actions to improve their health and well-being. Advocacy-based leadership is based on the ethical principles of social justice. Advocacy-based leaders are risk takers who act with moral purpose and demonstrate moral courage when faced with perceived or actual opposi- tion. (Refer to a discussion of advocacy and moral courage in Chapter 13.)
n Students meet with county commissioners to advocate for additional funding for low-cost or free dental services to Medicaid clients.
n Students work with local grocery stores to form a coalition to provide food items to stock a school-based backpack program where students take home backpacks filled with food on Fridays so that they have food over the weekend.
Authentic leadership: Authentic leaders are reflective practi- tioners whose actions are consistent with their values, ethical standards, and convictions. They are true to themselves and know why they do what they do. Authentic leaders objectively consider all available information and the opinions of others, clearly and openly share their perspectives, are open and honest in their communication, and have an awareness of their own strengths and weaknesses. They are considered trustworthy and reliable (Murphy, 2012; Wong et al., 2010).
n Students visit a community center hosted by a recent immigrant group to learn how to communicate and develop respectful, trusting relationships in a culturally sensitive manner.
n Students have a post-clinical debrief with their PHN precep- tors to reflect on the communication strategies they used in working with developmentally delayed adults in a sheltered living setting.
Shared leadership: Shared leadership refers to the concept of being an effective team member: sharing responsibilities, mutu- ally organizing the team’s work, maintaining team communi- cation, taking the initiative to try a new approach if something is not working, supporting team members, providing positive feedback, and allocating resources equitably (Avolio et al., 2009). When leadership is shared, PHNs have more time and energy to care for their clients.
n Students plan for and staff a hearing and vision screening program at a local elementary school. Each group of students has a lead student who is the primary liaison with the school nurse and takes the lead in organizing a team of fellow stu- dents to provide the screening.
n Students work with a PHN team to reach out to families who are eligible for PHN services but have not accessed them.
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284 PART II n Entry-Level Population-Based Public Health Nursing Competencies
Using Public Health Interventions as Part of the Leadership Journey You might have noticed that José is practicing many of the public health nursing interventions described in Chapter 2 in his role as Mr. and Mrs. Santos’s PHN. Leadership is integrated into many of the activities that PHNs and stu- dent nurses carry out. Table 14.2 has examples of leadership activities utilizing the Public Health Intervention Wheel (Minnesota Department of Health [MDH], 2001). The inter- vention examples are suggested student learning activities.
What Are Leadership Expectations for Entry-Level Public Health Nurses? The expectation of what leadership roles and responsibilities PHNs take on are dependent of the needs of specific orga- nizations and the community. Individual nurses also bring different leadership abilities to their work. Diverse styles of leadership are necessary to accomplish the work of public health nursing. PHNs select leadership strategies and inter- ventions based on what is most effective. Characteristics such as flexibility, a willingness and openness to develop new leadership skills, and the courage to practice them in the public arena are the key to successful PHN leader ship. Consider what a public health nursing director has to say about leadership and PHNs who are just starting out:
EVIDENCE EXAMPLE 14.1 PHN Student Initiative Demonstrates Leadership and Improves Population Health
A student nurse completed her leadership clinical in an inner-city school with a 95% poverty rate among its stu- dents. She developed a dental screening program for third-graders as her leadership project. After screening all the children, she found that almost all of them had dental disease, such as decay, bleeding gums, abscesses, and missing or broken teeth. Almost none of them had received dental care in the last year, and few owned a toothbrush. Each child was given a toothbrush and toothpaste and taught how to brush his or her teeth. The PHN student then attempted to screen all the children in the elementary school, managing to screen about 90%. She prepared a report showing the need for dental care in almost all the children screened, sent home referrals to all the parents, and included information on local dental clinics that pro- vided care for low-income patients. The principal used the report to obtain a grant to put a dental clinic in the school. Within a few years, dental clinics were established in ele- mentary schools located in high-poverty neighborhoods throughout the school district.
—Senior Student Nurse
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José returns to visit with Mr. and Mrs. Santos. Mrs. Santos is crying and wringing her hands. José asks Mrs. Santos whether she would be willing to see a mental health case worker. She refuses. He remembers that the local Latino Catholic church has a pastoral ministry home visiting pro- gram. He wonders whether Mrs. Santos would allow the pastoral minister to visit her. Mrs. Santos agrees to let José contact the church. José is pleased that he is developing his advocacy-based leadership skills. He is really stretching himself to try to find ways to help Mr. and Mrs. Santos and be an effective advocate.
Margaret, José’s public health nursing preceptor, says to him, “I hope you like a challenge, because this couple has lots of them. You are going to have to think outside the box to keep Mr. and Mrs. Santos in their own home. You really are going to have to use all your communication, advocacy, and leadership skills to work successfully with this family.”
José wonders and then reflects, “Do I have any leadership skills? I thought those came later, after 5 to 10 years of prac- tice. Hmm. Well, maybe I was practicing advocacy-based leadership.”
Margaret agrees, “Yes, you certainly took the lead in advocating for Mr. and Mrs. Santos.”
THEORY APPLICATION Caring Leadership Model
The McDowell-Williams Caring Leadership Model com- bines Watson’s Human Caring Theory (2008) and Kouzes and Posner leadership theory (2007). This model was developed for and implemented in an acute care setting. However, it is applicable to any clinical setting. The model is based on six core values (Williams, McDowell, & Kautz, 2011, p. 33):
n Always lead with kindness, compassion, and equality.
n Generate hope and faith through co-creation.
n Actively innovate with insight, reflection, and wisdom.
n Purposely create protected space founded upon mutual respect and caring.
n Embody an environment of caring-helping-trusting for self and others.
The acronym AGAPE is defined historically as brotherly love and charity, which fits with the social justice and equity precepts of public health nursing.
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285CHAPTER 14 n Competency #12
Based on the PHN population-based practice focus in public health, a new PHN needs to demonstrate clinical leadership for the work with individuals and families as well as at the community level. This lead- ership role might be as a participant or a lead posi- tion on various committees such as an interagency collaborative, an early childhood intervention, or a school health team. The PHN must also be a leader in engaging community members in efforts to improve health and address health inequities. The PHN needs to utilize communication and collaboration skills to lead groups, coalitions, and committees to achieve the goals of improving the health of the population.
–Bonnie Brueshoff, DNP, RN, PHN, Public Health Director and Robert Wood Johnson Executive Nurse Fellow (2006–2009), Dakota County Public Health, 2017
TABLE 14.2 Taking the Lead in Using Public Health Interventions
PHN Intervention Example
Advocacy n Observing/participating in a town meeting designed to address or change a determinant of health n Advocating for parenting classes at a conference center in an apartment complex (community level)
Policy development n Working with schools/work sites to change vending and fundraiser policies to include healthy food choices (systems level)
Policy enforcement n Responding to concerns/complaints about smoking in restricted areas based on the Freedom to Breathe Act (community level)
Surveillance n Attending or participating in immunization registry meetings (systems level) n Locating unlicensed daycare providers and providing teaching on home safety (individual level)
Coalition building n Recruiting and inviting family daycare providers to join the childhood-obesity prevention committee (community level)
Community organizing n Participating in/helping plan youth programs, such as smoking or alcohol-use prevention ( community level)
n Helping/coordinating a bioterrorism tabletop exercise (systems level)
Disease and health event investigation
n Following up on reports of pertussis cases; communicating with the state health department, clinics, and area schools about the outbreak and doing case investigation (individual and systems levels)
n Meeting with clinics and hospitals regarding prenatal hepatitis B program (systems level) n Working with veterinarians, meat packers, and hunting associations on chronic wasting disease
(systems level)
Case management n Participating in a Student Attendance Review Board (SARB) meeting within a school (systems level)
Collaboration n Participating in meetings to observe the collaborative process, decision-making, and problem- solving in groups (e.g., children’s mental health, early childhood family education) (systems level)
Consultation n Working with child daycare centers, adult daycare centers, and battered women’s shelters to establish standards and criteria for prevention of infectious disease (systems level)
Social marketing n Designing messages and materials on “how to make a healthy home” that PHNs can use on home visits to help families deal with asthma (systems level)
Sources: Dakota County Public Health, 2004; Henry Street Consortium, 2004; MDH, 2001
What Are Essential Leadership Skills for Becoming a Public Health Nursing Leader? PHNs are often confronted with the need to use their lead- ership skills in advocating for their clients. As someone new to public health nursing, you might find thinking about the skills needed for leadership in this field daunting. Remem- ber that all good nursing leaders start at the beginning by becoming competent in their practice specialties; as they develop confidence as expert practitioners, they build a rep- ertoire of leadership skills.
Nursing leadership can be formal or informal. PHNs demonstrate leadership at all levels of nursing practice from novice to expert and as staff nurses, clinical experts,
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286 PART II n Entry-Level Population-Based Public Health Nursing Competencies
nursing specialists, supervisors, managers, educators, or administrators. Leadership is a process, not a role. Much of the research on leadership in the literature looks at the leadership roles of managers; however, all nurses can utilize leadership styles and strategies. Leadership is an expected competency for PHNs, regardless of their position (Ameri- can Nurses Association [ANA], 2013; Quad Council of Pub- lic Health Nursing Organizations, 2011).
New PHNs need to be able to carry out entry-level lead- ership competencies. Initially, their leadership opportuni- ties are tied to their daily clinical practice with individuals
and families. However, depending on the size and nature of the agency, they might soon become involved in leadership activities at the community and systems levels of practice. Some public health agencies include leadership develop- ment in their annual performance appraisals (Kalb et al., 2006). You might be expected to demonstrate the leader- ship skills you have developed after you have been in public health nursing for a year or so. The Henry Street Consor- tium has generated a set of leadership skills that beginning PHNs need to develop and strengthen to practice effective PHN leadership (see Table 14.3).
TABLE 14.3 Essential Leadership Skills for Public Health Nurses
Skill Strategies and Considerations Your Leadership Action
Seeks learning opportunities
n Determine goals for professional development. n Strive to see the “big picture” by attending to
community and systems processes.
Match your interests and goals to learning opportunities.
Works independently; is autonomous in practice
n PHNs make many independent decisions based on established programs or protocols.
n PHNs make decisions based on their own expertise within the framework of ethical and professional standards or practices.
Attend a PHN team meeting to observe how PHNs share experiences. Seek suggestions about evidence-based practice and tools to use for com- plex family situations.
Willing to work in an unstructured environment; tolerates ambiguity
n PHNs practice in settings where people live, learn, and work—the priorities in these set- tings are often not health or healthcare.
n Sometimes the goals of others are not clear or consistent with the goals of PHNs.
n PHNs learn to be in ambiguous situations while working to determine individual, family, and community goals.
n PHNs suggest health-oriented goals but ultimately work within the structure of each setting to accomplish goals that are mutually determined or sometimes rejected.
Talk with your preceptors about the challenges they have confronted.
Seeks consultation and support
n It is essential to seek consultation and support in a practice area where role models are often not physically present.
n PHNs use technology to access resources and expertise when additional information is needed.
By reflecting on your experiences with expert practitioners, you can validate your thinking and actions and learn about more effective approaches to your work.
Takes initiative; is a self-starter
n PHNs are responsible for organizing their own schedules.
n Many activities in public health nursing involve long-term planning, especially when building partnerships and coalitions that focus on community and systems changes.
As you are learning the skills needed for public health nursing practice, you can be proactive in identifying ways to prepare for clinical experi- ences. Do you need to do background reading? Do you need to identify specific objectives to guide your preparation? Which questions do you need to ask?
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287CHAPTER 14 n Competency #12
The day-to-day work of the public health or community health agency needs to be accomplished. This means two things: carrying out the organization’s mission and goals, and carrying out the organization’s priority work. For staff nurses, that means managing their caseload of clients on a daily basis, setting priorities based on the changing needs of their clients, and being willing to take on tasks that need to be done. As you work with preceptors and expert nurses in the community, notice their leadership approaches and styles that meet the health needs of their clients as well as the needs of the organization.
Skill Strategies and Considerations Your Leadership Action
Adapts to change n The settings where people live, work, and learn undergo constant changes.
n Adapting to change is a constant in public health nursing practice.
As someone new to public health nursing, you need to change your frame of thinking to a public health model in contrast to the medical model (see Chapter 7).
Is willing and able to respond to population needs
n Healthy People 2020 priorities are based on the most recently identified health goals for the United States (U.S. Department of Health and Human Services [U.S. DHHS], n.d.).
n PHNs and local health departments must adapt to these changes if they are to be relevant in the interventions selected to improve popu- lation health.
Review the health data and health disparities data for your community. Ask your preceptor how the public health or community agency is responding to those needs. Identify a priority that you would like to work on as a student or volunteer in your community.
Demonstrates flexibility n Flexibility is required in situations where fami- lies or coworkers oppose change.
n Sometimes being flexible means being patient and waiting while encouraging others to make a change.
Compare your plan for the day and reflect on what actually occurred. Analyze how you were flexible in adapting to changes in your plan.
Contributes to team efforts
n PHNs need to cultivate skills that make them effective team leaders and team players.
n Listening, being open, valuing the contribu- tions of others, and identifying a common vision and goals are important when bringing others together to improve public health.
Many public health learning experiences include collaborating with your peers on a health promotion project for the community. Use this experience to work on your team-building skills. Take time to learn more about team members and different styles of working together.
Prioritizes and organizes workload, time, materi- als, and resources
n Public health nursing can be overwhelming because so many areas exist in which nurses could spend time and energy for improving population health.
n PHNs use technology (e.g., cellphones, digital calendars) to organize their workloads and manage their time.
Learning time-management skills at the begin- ning of your public health nursing experience can serve you well. Make a plan for what you need to do, gather the information you need, work on prioritization, and seek needed resources. You can always modify your plan as you evaluate how well it is working. You can also share your plan with your preceptor or mentor, who can help you reflect on your organization and preparation for your learning experiences.
Activity Review the activities, strategies, and actions in Table 14.3.
n What skills do you consider your strengths? Choose two strengths and decide what strategies you might use to help you succeed in your public health nursing clinical.
n Consider which nursing skills and strategies you might use to help achieve the mission and work of the public health/ community health agency in which you are working.
n What skills do you think you could strengthen during your clinical? Choose one skill to strengthen. What strategies might you use to help you do this?
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288 PART II n Entry-Level Population-Based Public Health Nursing Competencies
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level of public health practice. The aims of this work are to ensure a high level of care, to create supportive practice environments for nurses, and to build strong partnerships that achieve community health outcomes (Giddens, 2013). Staff nurses use their leadership skills as part of the team to achieve the work of the organization.
Organizational Culture and Leadership The leadership and culture of the organization in which the PHN works determine the support available for effective PHN practice. The culture of support for achieving pub- lic health nursing practice goals must permeate the entire organization, as demonstrated in Figure 14.2. Nurses at all levels within the organization must take responsibility for carrying out the work of public health nursing practice. Fig- ure 14.2 illustrates who needs to provide leadership to shape and maintain a supportive organizational culture at all lev- els within a public health nursing agency. Evidence Exam- ple 14.2 identifies the organizational attributes that support public health nursing leadership and practice.
José makes a joint visit to Mr. and Mrs. Santos with the social worker. Margaret, his PHN preceptor, tells him that the directors of Public Health Nursing and Human Resources have made a renewed commitment for public health nursing and social work staff to work together in the Elders at Home Program. Joint visiting is encouraged. In preparation for that shared visit, José reviews the job description of the social worker and considers how his role as a public health nursing student is both similar to and different from the role of the social worker. He phones the social worker in advance of the visit to discuss how they might work together. During the visit, José and the social worker spend time evaluating the home environment of Mr. and Mrs. Santos and talking with the couple about their goals to live in place. Mr. and Mrs. Santos are committed to living in this home that they have worked so hard to pur- chase and maintain. It is obvious that home maintenance is poor. Stacks of old papers litter the house, they lack working smoke detectors, and they have minimal food stored in the cupboards or refrigerator. The kitchen sink is not draining properly, and the washer and dryer are not working. The social worker offers to help the couple apply for assistance for home repairs and for Meals on Wheels. José is glad he can share the care needs with the social worker. He believes they will be more effective in helping Mr. and Mrs. Santos by working as a team. After the visit, he asks his preceptor for feedback about the leadership skills he demonstrated as a member of the care team.
Challenges of Working in the Community Working in the community is challenging because of the diversity, uncertainty, and constant change you experience in an environment that is not within your control. As one student said, “The patients aren’t lined up nicely in their beds all in a row down the hall.” In home settings, children are running around, animals abound, and the sounds of the television and people coming and going are often dis- concerting. Older or disabled adults might like their slip- pery throw rugs on the floor and might want to have their favorite snacks available even though they are not on their prescribed diets. You might find homes without heat in the winter and homes without refrigerators in the summer. Some people live alone, and others live with myriad rela- tives and friends. You never know what to expect when you knock on the door. But you need to be ready for both the expected and the unexpected. The following student exam- ple demonstrates several leadership skills:
During a home visit, a student was in the process of changing a catheter for a paraplegic man when the man’s cat jumped on the bed. What was the student to do? Her sterile field was about to be compromised. She was wearing her only pair of sterile gloves, and her equipment was laid out on the bed. She thought for a moment. Then, very calmly, she asked the man whether he would hold his cat while she changed his catheter.
Activity n What leadership skills did this student nurse demonstrate?
n If you were the student in this situation, what might you do?
n What leadership skills would you use in this situation?
As you develop the ability to practice nursing in the community, whether in a home, school, clinic, faith-based organization, or other type of community agency, you are developing your leadership skill set.
Achieving the Work of the Organization—Systems Level of Practice The primary work of a public health organization is to improve the health status of the population. PHNs in for- mal leadership roles (e.g., team leaders, supervisors, manag- ers, administrators) are responsible for achieving the work of the organization. Much of this work is done at a systems
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289CHAPTER 14 n Competency #12
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Students can take the initiative to create their own lead- ership opportunities and share leadership with their peers. Evidence Example 14.3 on the next page demonstrates that when students worked together to plan and organize their nursing care, their shared leadership actions enhanced their ability to provide patient-centered care.
José makes another joint visit with the social worker. They talk with Mr. and Mrs. Santos about their healthcare needs. Mr. Santos is on oxygen therapy. Mrs. Santos states that she knows her husband should stop smoking and that she turns off his oxygen when he does smoke. Mr. Santos can- not care for his personal needs. Mrs. Santos says that she is uncomfortable assisting him with hygiene and that he has not had a good bath or shower for several weeks. Mrs. Santos is becoming stressed and showing signs of depres- sion. No one has contacted Mr. and Mrs. Santos about home maintenance. José decides he needs to prioritize their health needs. The social worker starts the application pro- cess for a home health aide to assist Mrs. Santos with Mr. Santos’s personal needs. José is going to follow up on the home-maintenance referral and work with Mr. Santos on a safe smoking program. He will focus on Mrs. Santos’s stress and possible depression on the next visit. José is excited to share with his fellow students what he has learned about his own leadership abilities and how he has been able to work with Mr. and Mrs. Santos and the social worker to help the Santoses stay independent in their own home.
EVIDENCE EXAMPLE 14.2 Organizational Attributes That Support Public Health Nursing Practice
A Canadian study (Meagher-Stewart et al., 2010; Under- wood et al., 2009) identified effective leadership as an organizational attribute that supports public health nursing practice. The study analyzed survey data from more than 13,000 community nurses across Canada and data from 23 focus groups of PHNs and policymakers. The organizational factors that were identified as requisite for effective public health nursing practice included government policy that supports public health, supportive organizational culture, and good management practices. Visionary and empower- ing leadership that permeated the organization facilitated the PHNs’ ability to practice their full scope of competen- cies. These organizational attributes and leadership quali- ties empowered and motivated staff to be effective in their roles. Researchers concluded that it was essential for lead- ership to respect, trust, and value public health for PHNs to be effective.
FIGURE 14.2 Organizational Culture of Support for Public Health Nursing Practice
Administrative- Level
Leadership
Program- and Management-
Level Leadership
Staff-, Team-, Supervisory-Level
Leadership
Entry-Level PHN
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290 PART II n Entry-Level Population-Based Public Health Nursing Competencies
Workload and Resource Management To move the organization toward its vision, a PHN leader must effectively manage workloads and resources. Public health organizations rely on formal leaders to manage bud- gets, supplies, and performance. In a business sense, public health organizations require a variety of management activ- ities to operate effectively (Baker & Baker, 2014). Because the business of a public health organization is service to its pop- ulation, public health nursing leaders must make thought- ful, responsible decisions as they plan and direct various aspects of the organization’s work. Figure 14.3 illustrates how the day-to-day work of formal PHN leaders impacts quality and ensures efficiency.
Although their duties differ from those of a formal leader, informal PHN leaders are just as vital to an organization’s success. Staff and entry-level PHNs can use their leadership skills to effectively manage their workload and achieve the goals of the team. PHN leaders set the standard and role model for their peers of what it looks like to take initiative and to be proactive. They understand how their daily work impacts the mission of the organization and the overall health of the community that they serve. PHN leaders are skilled at time management, problem solving, communica- tion, and relationship building. They regularly share their ideas and volunteer for collaborative projects outside of their regular job duties. These leaders bring a positive energy to the team, which contributes to a high level of morale.
Each of us has a spark of life inside us and our high- est endeavor ought to be to set off that spark in one another.
–Florence Nightingale
EVIDENCE EXAMPLE 14.3 Shared Leadership Enhances Nursing Care in a Homeless Center
An example of how nursing students effectively practiced leadership occurred during a clinical at a homeless shelter. Public health nursing students conducted a monthly foot-care clinic from September through May. During a 3-hour clinic, six to eight students provided foot care to 20 to 45 clients. The instructor and homeless shelter staff oriented the students to the shelter and the foot-care clinic. Then the instructor turned the clinic over to the students to manage. The students deter- mined how to arrange the clinic space, how to allocate the foot-care supplies, and who would carry out the different clinic roles (recruitment and registration of the clients; assigning the clients to students for their foot care; keeping each workspace stocked with supplies; providing hospitality; documenting cli- ent assessments and services provided; and following up with
clients after they received care to make sure all their priority health needs were met). The instructor noticed that when she turned over the management of the clinic to the students, they were much more engaged and took more responsibility for the clinic and their clients. Every group of students organized its clinic a little differently. Each month, the shared responsibility, freedom to be creative and practice autonomously, and mutual contributions to team efforts led to a successful clinic. Because of their ability to prioritize what needed to be done and orga- nize their workload effectively, students managed to take the time to provide a therapeutic encounter with each client who visited the clinic. As one man said, after he spent an hour with one of the students who listened patiently to his story, “This has been the best day of my life.”
Measuring Outcomes of Population-Based Practice The core public health function of assurance requires those working in governmental public health to evaluate the out- comes of programs and interventions (see Chapter 7). PHN leaders rely on meaningful data to demonstrate the posi- tive outcomes of their interventions for individuals/fami- lies and communities. The Omaha System is a valuable tool
FIGURE 14.3 Workload and Resource Management Responsibilities
Monitor workflow and develop new
efficiencies
Develop budget recommendations
Provide clinical and administrative
supervision
Analyze program-related
reports
Monitor input and output data
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291CHAPTER 14 n Competency #12
for public health nursing practice to capture the correla- tion between PHN interventions and client outcomes (see Chapter 3). The Omaha System helps to create meaningful concepts for public health practice. Public health nurs- ing leaders use knowledge-behavior-status (KBS) ratings to evaluate client and program outcomes. This is evidence that the PHN leader can use to leverage population health data (U.S. DHHS, 2016). By evaluating which interventions and targets caused the most effective changes for certain
EVIDENCE EXAMPLE 14.4 Health Literacy Outcomes
A study of health literacy outcomes (Monsen et al., 2012) used Omaha System data to examine knowledge scores across problems over time. Monsen’s team collected pre- intervention and post-intervention KBS (knowledge- behavior-status) scores by traditional racial categories. Their findings showed significant inequities across race categories in pre-intervention knowledge ratings. How- ever, the post-intervention KBS ratings improved for all race categories and, in fact, their ratings began to parallel one another. Racial disparities decreased post-intervention, and all races saw a marked increase in their KBS outcomes. The targeted intervention worked to increase KBS outcomes and promoted health equity.
EVIDENCE EXAMPLE 14.5 Dakota County Family Health Practice Advisory Committee
The Family Health Practice Advisory Committee is a quality assurance committee for the family health unit at the Dakota County Public Health Department. The committee is composed of PHNs with varying levels of experience and is facilitated by the unit coordinator. The main responsibility of the committee is to ensure the implementation of evidence-based practice in family home visiting. The committee utilizes the nursing pro- cess and a continuous quality improvement approach for proj- ects, literature reviews, case consultation, chart audits, and continuing education for PHNs. PHNs on this committee act as evidence champions when changes to practice are imple- mented. This advisory committee ensures that the unit is in compliance with targeted state and federal benchmarks for family home visiting programs. The work of this committee has resulted in improved quality in PHN interventions. One project this committee worked on was the implemen- tation of a Sexually Transmitted Infection (STI) assessment for the Family Home Visiting program. For this project, the identified problem was that the PHNs did not currently have a
standardized STI assessment form, although they were work- ing with a population known to be at-risk for STIs. The commit- tee used evidence from the Minnesota Department of Health and the Centers for Disease Control and Prevention to develop and implement a standardized assessment and teaching kit. The assessment included basic screening questions to ask cli- ents as a part of the nursing assessment, and the kit included information on low-cost testing clinics, a laminated sexual health exposure chart, educational pamphlets, and STI testing recommendations. The committee held an in-person training for all staff prior to implementation, which included presenta- tions by a local epidemiologist and a nurse practitioner. Each PHN received an assessment kit at the training. The initial eval- uation of this project showed that 90% of the clients who were screened using the new assessment form had at least one risk factor, indicating that they were at-risk and required follow-up testing for STIs. The Family Home Visiting program continues to use the assessment and evaluate the data.
Source: Karsten, 2017
problems, PHN leaders can decide how to adjust practice to meet the anticipated outcomes. Use of the data also supports leveraging funding and policy support.
Reports that demonstrate the effectiveness of public health nursing interventions provide a rationale for contin- ued or increased funding for public health nursing services.
Strategies for Improving Quality in PHN Interventions Ongoing evaluation and improvement of services provided by public health and other community agencies is carried out as part of the core public health function of assurance. Public health nursing staff and managers use the qual- ity improvement process to meet this challenge. Qual- ity improvement is defined as “the use of a deliberate and defined improvement process and the continuous ongoing effort to achieve measurable improvement in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality that improve the health of the community” (MDH, 2017a, para. 1).
Along with continuous program assessment and staff supervision, public health nursing leaders use this process to improve quality in PHN interventions. Evidence Exam- ple 14.5 describes how a local public health nursing agency utilizes the quality improvement processes.
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292 PART II n Entry-Level Population-Based Public Health Nursing Competencies
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(see Chapter 8) to achieve the goals of public health (Com- mittee on Assuring the Health of the Public, 2003; Institute of Medicine, 1988). Creative, cost-saving solutions to popu- lation health concerns can result from interprofessional col- laboration (Giddens, 2013). This collaboration is especially important in public health nursing practice. PHNs work regularly with their clients, team members, interprofes- sional colleagues, and various members of the community. This collaborative practice is a form of shared leadership.
Collaboration also occurs between the PHN and the client at the individual/family level of practice. This form of collaboration is part of case management, in which the PHN works to optimize the self-care capacities of the client and empower the client to make positive, healthy decisions (MDH, 2001). The PHN must be flexible and comfortable working in the unstructured environment of the client’s home to share leadership and collaborate with the client in making decisions.
José makes another visit to Mr. and Mrs. Santos. He notices that Mr. Santos is still smoking in the same room as his oxy- gen tank. José is concerned about the safety issues and the possible neglect of a vulnerable adult. He wants to honor the couple’s independence and wishes but understands that his professional responsibility requires him to report the potential for harm to this vulnerable adult. José con- sults with Margaret, his preceptor. She says she will make a joint visit with José the next day to determine whether there is anything else they can do. During the visit the next day, José observes Margaret’s approach to Mr. Santos. Mar- garet and Mr. and Mrs. Santos set up a smoking schedule for Mr. Santos that allows him to smoke while on the front porch. Mr. Santos will use his oxygen before and after each smoking session but not during it. José is impressed with Margaret’s skill in working with Mr. Santos. He is going to use her technique during his next visit.
Collaboration at the systems and community levels of practice occurs through strategic partnerships between two or more parties that use a structured approach to pur- sue agreed-upon goals. As PHNs work with the commu- nity both as client and partner, they share data collection, problem solving, planning, and evaluation in carrying out community assessment, setting priorities, and developing programs (see Chapters 3 and 8). The ability to develop and work in strategic partnerships has become more important in public health nursing practice. A growing expectation of public health practice and PHN leadership is the ability to influence others to achieve the public health goal of health equity (see Chapter 13). A 2016 Public Health 3.0 initiative speaks to this expectation (U.S. DHHS, 2016).
Maximizing Benefits to Clients and Stakeholders Public health organizations are the guardians of avail- able community health resources. Both fiscal and human resources are finite. It is important to manage resources in a way that benefits the public as a whole while not disad- vantaging those who are most in need of assistance. Pub- lic health organizations rely on nursing leaders to develop and implement creative approaches that maximize benefits to clients and stakeholders and ensure health equity for all (U.S. DHHS, 2016). Recipients, or customers, of PHN inter- ventions include direct clients, as well as stakeholders in the community. Public health organizations are continually challenged to respond to the question, what do our custom- ers need from us? Population health models suggest that investments in prevention efforts are highly likely to have a substantial impact on improving a community’s health. Increased spending on traditional medical services does not appear to have the same level of impact on overall popula- tion health. Rather, interventions that have a broad reach across populations have the potential to improve quality of life for community residents (National Home Visiting Resource Center [NHVRC], 2017).
Shared Leadership Through Collaboration Today’s healthcare system requires nurses to work with oth- ers to meet the goal of improving population health. The defi- nition of public health, what nurses do together as a society to ensure the conditions in which everyone can be healthy, reinforces the importance of PHNs working collaboratively
EVIDENCE EXAMPLE 14.6 Family Home Visiting Return on Investment
Public health programs such as home visiting have yielded a strong return on investment over the years. Numerous studies have shown that the cost-effectiveness of home visiting yields $3.75 on average for every dollar invested (NHVRC, 2017). Outcomes of home visiting programs include a reduction in the number of childhood emergency room visits, early identification of developmental and social-emotional delays in children, higher employment rates and tax revenues, and reduced dependence on wel- fare programs. These improvements in child health and well-being and parental self-sufficiency demonstrate how public health services maximize benefits not only to indi- viduals, but to entire communities.
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293CHAPTER 14 n Competency #12
EVIDENCE EXAMPLE 14.7 Public Health 3.0
Public Health 3.0 (PH 3.0) refers to “a new era of enhanced and broadened public health practice that goes beyond tradi- tional public department functions and programs” (U.S. DHHS, 2016, p. 11). Led by the U.S. Department of Health and Human Services, PH 3.0 emphasizes collaboration across public and private sectors in an effort to advance health equity. This initia- tive requires businesses, lawmakers, community leaders, and federal policymakers to incorporate health into all areas within their span of control. Collaboration with community partners and the involvement of multiple sectors is essential to the vision of PH 3.0, which is aimed at improving the social deter- minants of health. Strong public health leadership is necessary
to develop and maintain cross-sector relationships because this interprofessional collaboration is the foundation for policy approaches that have the potential to affect large populations (U.S. DHHS, 2016). Throughout 2016, a series of regional lis- tening sessions brought community leaders from the private and public sectors together to learn more about opportunities to improve and modernize public health. In October 2016, the Office of the Assistant Secretary for Health (OASH) issued a white paper titled Public Health 3.0: A Call to Action to Create a 21st Century Public Health Infrastructure. This white paper pro- vides recommendations for advancing Public Health 3.0 (see Table 14.4).
TABLE 14.4 Five Critical Leadership Dimensions in Enhanced Scope of Public Health Practice
Dimension Scope
Strong leadership and workforce
n Think outside of the box to leverage data in communications within and outside the traditional health sector
n Partner with educational institutions to build a strong public health workforce pipeline n Create opportunities for growth within the organization to maintain strong public health
professionals already working in the field
Strategic partnerships n Cultivate relationships and identify collective goals n Develop sustainable partnerships
Flexible and sustainable funding
n Advocate for flexible funding models that allow leaders to respond more rapidly to emerging community needs
n Capture and document cost-savings attributable to public health efforts n Engage funders in shared goals and values
Timely and locally relevant data, metrics, and analytics
n Explore new types of data, including healthcare utilization trends, that paint a more complete picture of the community’s strengths and challenges
n Address data gaps and challenges by advocating for timely, sub-county, de-identified data that will quickly move evidence into action
Foundational infrastructure n Develop a clear mission and values statement that guides the organization’s strategic plan n Document processes for decision-making n Build interdisciplinary teams within the organization n Focus on equity and cultural competence
Source: Based on U.S. DHHS, 2016
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294 PART II n Entry-Level Population-Based Public Health Nursing Competencies
of populations (Falk-Rafael, 2005). PHNs need to move from behind the scenes to put forward strategies that can make a difference for the health of populations. This means increasing their knowledge and skills to transform the envi- ronments where they live, learn, work, and play into settings that foster good health through public health interventions and public policy (French, 2009).
Taking the initiative to improve health by reducing risk factors that contribute to chronic disease demonstrates nursing leadership. Evidence Example 14.8 in the school environment outlines leadership interventions that PHNs can use to create good health by decreasing obesity rates and reducing tobacco use and exposure, both major contribut- ing factors to chronic diseases and rising healthcare costs (MDH, 2017b).
PHNs can bring about change through initiating pub- lic discussion and building awareness of proven strategies to promote healthy eating and physical activity. Actions include putting chronic disease prevention on the agenda of professional organizations and using the media to increase awareness. PHNs can use the data from their monitoring activities to inform other professionals, organizations, and the public about how the lack of access to healthy food and physical activity contributes to health disparities and ineq- uities. Partnership skills for collective action (see Chapter 8) are essential in bringing about change through advocacy action.
Although PHNs can identify and study the impact of health determinants, they cannot solve such problems as poverty, housing, unemployment, and unsafe environ- ments. PHNs can, however, call attention to these problems and get them on the policy agenda and into the public dis- course. PHNs can also study the causes and results of these health determinants and examine the effectiveness of social and collective responses to these problems. They can help mobilize public will and coordinate actions of the public and private healthcare, education, and business sectors. Leading successful change in communities involves many different strategies (Hill, 2008; Nissen, Merrigan, & Kraft, 2005). Examples of such strategies are outlined in Table 14.5.
healthypeople.gov
Healthy People
Immunization rates across the life span are highlighted in Healthy People 2020 Topics and Objectives (https://www.healthypeople. gov/2020/topics-objectives). Click the National Snapshots tab under the topic “Immunization and Infectious Diseases” to find the proportion of children in your state who have been immu- nized for measles, mumps, rubella, hepatitis B, and pneumonia. Which vaccination rate is of most concern to you? Click the Interventions & Resources tab to find evidence-based informa- tion and recommendations for best practices for immunizations. Which intervention would you like to see implemented in your community to increase immunization rates? Which leadership strategies might you use to convince elected officials to fund this intervention to increase the immunization rate in your community?
Leadership at the Community Level of Practice As leaders, PHNs aim to be change agents to reduce the social conditions that contribute to poor health (health dis- parities and inequity). Power to influence key stakeholders and decision-makers is gained through developing alliances (coalition building) with individuals and groups who have influential power. The PHN’s ability to engage with com- munities and develop effective partnerships to address the priorities in the community is critical. Nurses have a long history of advocacy and coalition-building to improve the health of populations. Florence Nightingale made alliances with politicians, journalists, philosophers, scientists, and influential thinkers and writers who contributed to her understanding of the public health issues of her time, but also helped her bring about change for improving the health
EVIDENCE EXAMPLE 14.8 Statewide Health Improvement Partnership (SHIP) in Action Working to Create Good Health
The SHIP program uses evidence-based strategies based on the latest science, compiled by the Minnesota Depart- ment of Health (MDH) in collaboration with local public health (MDH, 2017b). Local public health staff, including PHNs, are involved in working with communities to choose strategies that address local needs. The community-led improvements have resulted in healthy eating, physical activity, and reduced commercial tobacco use. One suc- cessful component of SHIP in Dakota County, Minnesota, has been working with schools to create healthier food environments (Dakota County Public Health, 2017). This partnership, called Smart Choices, has engaged schools with the highest rates of students receiving free and reduced-price lunch (a measure of poverty). Currently, 32 schools across 6 districts are involved in Smart Choices. Public health provided startup funds to schools to support projects that are sustainable and impact school policies or practices. Changes to systems or policies are important to reach all children regardless of race, income, or other fac- tors. Partner school districts have made multiple success- ful changes to their food environments. For example, during a visit to a school, public health staff observed that most students in the lunch room had water bottles. A senior at the school commented that they could remember when the food and drink options weren’t nearly as healthy, and they were glad that incoming freshman would never know a time when the water wasn’t the norm. Other successes include establishing district-wide farm-to-school infra- structure, including salad bars, water-only vending options, and district-wide treat-free classroom birthday celebration policies (MDH, 2017b).
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295CHAPTER 14 n Competency #12
The leadership skill of being willing and able to respond to population needs is extremely important. PHNs often refer to this as having a passion for public health. Taking the initiative to advocate for and to participate in the process of social change to improve the health status of vulnerable populations requires a passionate commitment to the health of the public. Evidence Example 14.9 illustrates the complex mix of leadership skills required to improve the health sta- tus of vulnerable populations.
PHNs can bring about social change through initiating public discussion on the effects of poverty and the contribu- tion of policy decisions to reduce poverty. Actions include
TABLE 14.5 Leadership Strategies for Successful Community Change
n Define the roles and responsibilities for stakeholders involved in leading the change.
n Seek input from all who will experience the change. n Be present “at the table.” As Hill says, “Interpersonal and
political skills and personal presence are essential during periods of change” (Hill, 2008, p. 460).
n Look for traditional as well as nontraditional partners, including funding sources.
n Consider the big picture. n Collaborate with others to create a positive vision of the
future, and choose strategies to work toward that vision. n Remember that leadership is about relationships every day. n Engage in self-examination and self-correction. n Consistently integrate evidence-based approaches. n Be hopeful but realistic when planning change.
Sources: Hill, 2008; Nissen et al., 2005
Public-Private Partnership in the Health Sector
GOAL 11 At the global level, private public partnerships (PPP) have been encouraged to achieve specific national healthcare goals in countries where there is a mismatch between demand for and supply of healthcare services. The Chiranjeevi Yojana Scheme in Gujarat, India, was initiated in 2005 when the government realized it did not have the resources to provide necessary emergency and routine obstetri- cal care to its population due to lack of medical providers and emergency hospital care. Its goals were to: reduce the maternal mortality ratio from 389/100,000 to 100/100,000 live births, reduce total fertility rate from 3.0 to 2.1, and reduce the infant mortality rate from 53/1,000 to 30/1,000 live births by 2010. The assumption for the PPP is that the private sector has experience and resources to provide quality
and cost-effective services. The government operationalized this scheme to provide obstetrical care to nontaxpaying families, families below the poverty line, and tribal families. The District Health Service enrolled trust hospitals and private gynecologists and obstetricians to provide maternity services. The Maternal Mortality Rate in 2010 was 200/100,000 live births, so although that goal was not achieved, significant progress was made. Problems identified were lack of enrolled physicians providing care, high cost of care provided by private providers and hospitals, poor quality of care with some providers, and tendency to refer complex cases to the public hospitals. Several PPP models currently in use are working to balance existing resources, skills, and expertise and to reduce disparities between rich and poor by expanding access.
Source: Thadani, 2014
EVIDENCE EXAMPLE 14.9 Bringing About Social Change to Reduce Child Poverty
Cohen and Reutter (2007) reviewed literature from Canada, the United States, and the United Kingdom as well as the professional standards and competencies for nursing prac- tice in Canada. Based on their review, the authors recom- mend using Blackburn’s (1992) framework for working with families living in poverty. Blackburn conceptualizes three broad roles, which can be carried out at all levels of practice:
n Monitoring: Collecting and analyzing information to determine the impact of poverty on families
n Alleviating and preventing: Helping families avoid, reduce, and counteract the impact of poverty
n Bringing about social change: Working with organiza- tions and the government to create policies that reduce or eliminate poverty.
putting poverty on the agenda of professional organizations and using the media to increase awareness. Working with the community as your client, just as working with individ- uals and families, requires a mutual egalitarian approach as you share data collection, problem solving, planning, and evaluation with community members. See Chapter 8 for examples of PHNs collaborating with communities, and note in Chapter 3 how they work with community members in carrying out a community assessment. Taking leadership in working toward social change involves skills in shared leadership strategies.
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296 PART II n Entry-Level Population-Based Public Health Nursing Competencies
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José has almost completed his public health nursing clini- cal. He is feeling like he has taken on leadership in working with Mr. and Mrs. Santos. He has a meeting with Marga- ret, his PHN preceptor, to review his leadership journey throughout the clinical experience. Margaret tells him that in her evaluation of his leadership competencies, he has shown initiative in taking on challenges and responsibilities and has become more flexible in accepting Mr. and Mrs. Santos’s independence in deciding on their own healthcare and lifestyle. She tells him that he has demonstrated col- laborative leadership in working with her and the social worker. Margaret asks José if he wants to go to a community meeting where a group of PHNs, social workers, faith com- munity leaders, and members of the business community are considering forming a coalition to influence legislators to fund more living-in-place programs for older adults. She would like him to support Mr. and Mrs. Santos in telling their story at the meeting. Margaret believes that storytell- ing will help the different members of the group find the common ground needed to form the coalition. José agrees. He is ready to work on strengthening his advocacy-based leadership.
Coalition Formation as Community and Civic Engagement PHNs work in community and interprofessional coali- tions to build capacity to meet the health and social needs of diverse community groups. These coalitions are part of community engagement. When public health nursing lead- ers work in coalitions to influence elected and appointed officials and key community decision-makers, they are par- ticipating in civic engagement or the political process. See Chapter 13 for a discussion of civic engagement. Evidence Example 14.10 demonstrates the long-term commitment of a public health department and collaborative leadership to work with partners at a state-wide level to influence policy development, a core function of public health.
Ethical Considerations In addition to considering the impact of decisions on the health of individuals, families, communities, and systems, public health nursing leaders must consider how decisions affect PHNs and other public health staff. Nursing leaders can apply ethical perspectives to guide decisions that affect their teamwork and leadership activities (see Table 14.6).
Collaborative Leadership at the Community Level of Practice Public health nurses are skilled at adapting to change and responding with flexibility and creativity when working with groups in the community. PHNs work collaboratively as leaders in two different ways (Work Group for Commu- nity Health and Development, University of Kansas, 2016): n Collaborative leadership: Leadership of a collaborative
effort, such as a coalition or inter-agency task force, in which the leader guides and coordinates the group to solve a problem, create something new, or lead an initiative
n Leading collaboratively: Leadership as a collaborative effort within a community organization in which leadership shifts to take advantage of different talents or abilities, or leadership is permanently shared by the entire group or members of the group
Finding Common Ground One of the most difficult challenges public health profes- sionals experience is to build consensus in a community with groups who have diverse histories, values, and beliefs. A barrier to consensus-building or finding common ground is dissensus, which is demonstrated by community con- troversy, disagreement, and conflict. However, enduring change seldom occurs without the consensus of disparate groups. So PHNs take on the challenge by working within communities to form coalitions to achieve a common pur- pose. The process of consensus-building takes both com- mitment and persistence, as illustrated in Figure 14.4.
FIGURE 14.4 Consensus-Building to Achieve a Common Goal
Find Common Ground
Form a Coalition
Act as One to Achieve Common Goal
Meet the Opposition
Know the Opposition
Select an Issue
Take a Position
Study the Issue
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297CHAPTER 14 n Competency #12
EVIDENCE EXAMPLE 14.10 Tobacco Prevention Program
Haley Thorson, the PHN Tobacco Prevention Coordinator, recounted the activities of the Grand Forks Public Health Department in Grand Forks, North Dakota, as a statewide leader in tobacco prevention since the early 1990s. The public health nurses have led the tobacco prevention efforts in Grand Forks for nearly three decades. The nurses working in the Tobacco Prevention Program have focused pri- marily on evidence-based policy changes recommended by the Centers for Disease Control (CDC, 2014) to shift the social and cultural norms related to tobacco use. When this norm changes, it is realized in reductions of tobacco use rates among youth and adults within the community. Specifically, in 2010, the tobacco prevention nursing staff led a local coalition who collaborated with key partners in the community to strengthen the local smoke-free law, removing exemptions that left sev- eral pockets of the workforce unprotected from exposure to secondhand smoke. In the months prior, the nurses utilized relationship-building skills to cultivate both a champion on the city council and a well-known champion within the medical community. With past tobacco-related policy initiatives taking controversial tones, the nurses decided that a community-wide assessment of attitudes, awareness, and perceptions sur- rounding the policy change would be important.
A collaboration with the University of North Dakota’s research department led to the conduction of the Grand Forks Secondhand Smoke Study (Social Science Research Institute-University of North Dakota, 2010), which validated the community support for a secondhand smoke policy. The nurses’ connectedness and respect in the community led to relationships with unconventional partners such as the Con- vention and Visitor’s Bureau and the Chamber of Commerce. These connections were instrumental in sharing messages to calm unsubstantiated financial fears related to the policy change within the business community. These newfound part- nerships in combination with focused, on-point health mes- saging led to the successful passage of the proposed changes to the local smoke-free law. In an effort to evaluate the effec- tiveness of the new law, the public health nurses collabo- rated on several key pieces of research, including an indoor air quality study (Travers & Vogl, 2011), a community impact study (Social Science Research Institute- University of North Dakota, 2012), and a study on the economic impact of the pol- icy change (Goenner, 2013). These data were instrumental in building the evidence base to assist additional communities across the state in passing similar policies and eventually a comprehensive statewide law in 2012.
Source: Thorson, 2017
TABLE 14.6 Ethical Action in Public Health Nursing Leadership
Ethical Perspective Application
Rule ethics (principles) n Make leadership decisions that promote good and prevent harm to families, communities, organiza- tions, and public health workers.
n Consider which leadership actions promote social justice in the community and among public health staff members.
n Use advocacy-based leadership to improve population health at the individual/family and community levels of practice.
Virtue ethics (character)
n Be conscious of the needs of others, moving from the “I” to the “we” perspective. n Use your authentic leadership styles based on your beliefs, values, ethical standards, and convictions. n Be a leader who establishes caring relationships as a foundation for leadership actions. n Be a leader who values both the success of the organization and the well-being of public health staff
members. n Value the contributions of all team members.
Feminist ethics (reducing oppression)
n Identify the moral and ethical leadership challenges related to population health and health disparities.
n Be inclusive in the decision-making process within the community. Include all population groups that will receive services.
n Use a team approach versus a hierarchical approach to prioritizing public health strategies. n Use a shared leadership approach to be an effective team member within the interprofessional public
health team and within the community. n Use an advocacy-based leadership approach to empower communities to take charge of and manage
their own healthcare needs.
Table based on work by Racher, 2007 and Volbrecht, 2002
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298 PART II n Entry-Level Population-Based Public Health Nursing Competencies
organize, and complete assigned workloads; seek con- sultation and support; take initiative and be self-starters; be flexible and adapt to change; and respond to popula- tion needs.
n PHNs use many of the interventions from the Public Health Intervention Wheel (see Chapter 2) to carry out leadership activities.
n PHNs are able to be effective leaders when they are sup- ported by a shared leadership culture that permeates all levels of the organization.
n PHNs are expected to advocate for improvement in population health and to reduce health disparities by working collaboratively with interprofessional and community groups.
KEY POINTS
n Providing leadership at all three levels of public health nursing practice—individual/family, community, and system—is a professional expectation of nurses who work in public health.
n Students and professional nurses are on leadership journeys that will continue throughout their nursing careers. Leadership approaches that are particularly relevant to public health nursing practice include advocacy-based leadership, authentic leadership, and shared leadership.
n Students and new graduates demonstrate entry-level leadership skills in public health by their ability to seek learning opportunities; work independently and autonomously; work in unstructured environments and tolerate ambiguity; contribute to team efforts; prioritize,
REFLECTIVE PRACTICE
Think about the imperative that PHNs are expected to pro- vide leadership to improve the health status of individuals, families, and communities. Think about how you might respond to an unexpected situation that might prompt you to take the lead in resolving a healthcare concern in the community. How might you respond to the leadership chal- lenge in the following scenario?
During a staff meeting, several PHNs in a health department shared their concerns about new moms dealing with postpartum depression and the lack of a postpartum depression support group in the county. Working with their supervisor, the PHNs discovered that a hospital bordering the county did have an active postpartum support group/program. Through several meetings and discussion of the needs that could be met and roles that each could provide, a partnership was established. The hospital agreed to provide staff with the expertise to facilitate the support group at no cost,
and the PHNs were able to make space and childcare available at no cost, as well as do outreach and adver- tise this new program. Through these PHNs’ leader- ship, the postpartum support group was established and continues to be successful in reaching many new moms who benefit from the encouragement and sup- port provided during the group meetings.
Consider the following questions: n What was the leadership challenge in this situation? n Which ethical principles might be used to resolve this
leadership challenge? n How did the PHNs demonstrate advocacy-based and
authentic leadership? n Which leadership skills did the PHNs demonstrate? n Which levels of practice did PHNs use in planning and
implementing nursing interventions?
APPLICATION OF EVIDENCE
1. Which examples of public health nursing leadership have you observed at the individual, community, and systems levels when working with PHNs during your clinical experience?
2. Identify three leadership skills you have read about in this chapter that you have observed during your public health clinical.
3. Give an example of how a PHN has used advocacy- based leadership to improve the health of an individual/family or community during your public health nursing clinical.
4. Give an example of a PHN who has used authentic leadership to carry out the mission and the work of the public health agency.
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299CHAPTER 14 n Competency #12
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