Week 7
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CHAPTER
6COMPETENCY #4 Practices Within the Auspices of the Nurse Practice Act
n Marjorie A. Schaffer with Jill Timm
Jennifer, a public health nurse (PHN), has worked for the Weaver County Health Department for 10 years. Jennifer’s first nursing position, after completing her bachelor of science in nursing (BSN) and passing nursing boards, was on a medical-surgical unit in a large metropolitan hospital. Since her public health experience in nursing school, she has been anxious to find a PHN position. She now works at a small local health department in the town of Aurora, the county seat of Weaver County.
Aurora is surrounded by an agricultural community. Corn, soybeans, and sugar beets are the major crops. Cattle are also raised in this area. The town of Aurora has a population of 15,000. German immi- grants settled Aurora in the 1850s. Today, Aurora is a multicultural community. The racial makeup is 91% Caucasian, 2% African-American, 2% Hispanic or Latino, 1% Native American, 1% Asian, 1% Pacific Islander, and 1% other. The median income is $33,000.
Weaver County has a significant population of migrant workers from Mexico who provide a large portion of the workforce for many farms in the area and also provide the labor for a poultry-processing company located on the northern edge of the county. This processing company opened 10 years ago. The town has needed to learn to adapt to a new cultural group.
Sarah, a public health nursing student, has been assigned to work with Jennifer to complete her public health nursing field experience. She is excited to start this experience. Sarah is completing her undergrad- uate BSN degree at a university about 45 miles from Weaver County. She is familiar with Weaver County only through media reports regarding the difficult racial issues in the county over the past years. Sarah grew up in an urban area, where a variety of cultures and races were represented. She is Korean and was adopted into an American family as an infant. Sarah is eager to learn not only about the role of the PHN but also how the community environment affects the work of the Weaver County Public Health Depart- ment and its PHNs.
As Sarah has been reflecting on her public health nursing class, she remembers the three core functions of public health—assessment, policy development, and assurance. Along with this underlying framework, Sarah knows the importance of the Cornerstones of Public Health Nursing. She is particularly interested in learning about how independent nursing practice is carried out and how PHNs use the Public Health Intervention Wheel in Weaver County. Sarah will spend 5 weeks with Jennifer, learning as much as possi- ble about public health nursing.
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128 PART II n Entry-Level Population-Based Public Health Nursing Competencies
SARAH’S NOTEBOOK COMPETENCY #4 Practices Within the Auspices of the Nurse Practice Act
A. Understands the scope of nursing practice (independent nursing functions and delegated medical functions)
B. Establishes appropriate professional boundaries
C. Maintains confidentiality
D. Demonstrates ethical, legal, and professional accountability
E. Delegates and supervises other personnel
F. Understands the role of a public health nurse as described under public health nursing registration
G. Considers how to practice public health nursing in a variety of public and private healthcare settings
Source: Henry Street Consortium, 2017
USEFUL DEFINITIONS
Accountability: “To be answerable to oneself and others for one’s own choices, decisions and actions as measured against a standard” (American Nurses Association [ANA], 2015, p. 41).
Assignment: “Designating nursing activities or tasks to be performed by another nurse or unlicensed assistive person” (Minnesota Nurses Association, 2013, p. 10).
Confidentiality: Nondisclosure of health information that is considered to be private.
Delegation: “Transferring to a competent individual the authority to perform a selected nursing task in a selected situation” (Minnesota Nurses Association, 2013, p. 10).
Independent Practice: Professional decision-making guided by professional standards of the profession; scope of practice that includes independent functions might also be defined legally.
Nurse Practice Act: State statute that describes the practice of nursing; describes scope of professional nursing practice.
Professional Boundaries: “The spaces between the nurse’s power and the patient’s vulnerability. The power of the nurse comes from the nurse’s professional position and access to sensitive personal information” (National Council of State Boards of Nursing, 2014).
Public Health Nursing Registration: Requirements for practicing public health nursing, which are not universal across all states.
Reflective Supervision: A supervisor-supervisee relationship that pays attention to the influence of relation- ships on other relationships, the parallel process, and empowers the supervisee to discover solutions/concepts through consciously using strategies that include active listening and waiting. The goal of reflective super- vision is to support staff who then support families and create a more effective working relationship (Zero to Three, 2017).
Supervision: Guidance by an RN “consisting of the activities included in monitoring as well as establishing the initial direction, delegating, setting expectations, directing activities and courses of action, critical watching, overseeing, evaluating, and changing a course of action” (Minnesota Nurses Association, 2013, p. 10).
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129CHAPTER 6 n Competency #4
settings differs from the experience of nurses in hospitals and other structured settings, in which medical orders are required for many nursing tasks. On some occasions in public health settings, a physician’s order is needed for reimbursement from insurance, Medicare, or Medicaid for public health nursing services. Standing orders for vaccina- tions or condition- specific protocols also require physician oversight and review.
Understanding Public Health Nursing Roles Ethically, Legally, and Professionally This chapter discusses the Nurse Practice Act and how state legislation guides independent practice in public health nursing. Every state has its own Nurse Practice Act that lays out legal specifications for definitions, titles, licensing, and other parameters for the practice of nursing. Because much of public health nursing involves independent decision-making on the part of nurses and in collabora- tion with others, PHNs need to be aware of how the Nurse Practice Act for their state guides their professional role and defines professional accountability. Nurse Practice Acts also address the scope of practice for advanced practice regis- tered nurses.
Each state has a board of nursing that develops guide- lines through rules and regulations that go through a public review before they are enacted. The board of nursing also sets standards for prelicensure nursing education and clini- cal learning experiences, reviews complaints of misconduct, and follows up with any needed disciplinary action. Amber Zupancic-Albin, a nurse and lawyer, describes each state’s Nurse Practice Act as “your nursing rulebook,” which speci- fies rules for ethical and professional conduct for nurses. She represents nurses who are being investigated by the nursing board for a violation of the act. Zupancic-Albin identified five categories of common violations: failure to promote patient safety, dishonesty, controlled substances, improper supervision or delegation, and poor documentation and communication (Zupancic-Albin, 2017).
Although Nurse Practice Acts vary somewhat among states, they all include the following components (Russell, 2012, p. 37): n Definitions n Authority, power, and composition of the board of
nursing n Educational program standards n Types of titles and licenses n Protection of titles n Requirements for licensure n Grounds for disciplinary action, other violations, and
possible remedies States may revise their Nurse Practice Act based on new
roles and expertise in the nursing profession. For example, Evidence Example 6.2 addresses the addition of holistic, complementary, and integrative therapies into the scope of practice.
When PHNs practice independently, they make deci- sions based on their own expert knowledge and skills, professional standards, and the best evidence that guides nursing practice. Independent practice in public health
TABLE 6.1 Nurse Practice Act Themes
Theme Percentage of
Occurrence
Care in the context of nursing 98%
Nursing process 88%
Supervision or delegation of nursing 82%
Executing the medical regimen 73%
Health maintenance and prevention 65%
Teaching nursing 65%
Source: Jarrin, 2010, p. 170
EVIDENCE EXAMPLE 6.1 Core Elements of U.S. Nurse Practice Acts
Jarrin (2010) conducted an analysis of the core elements of Nurse Practice Acts in the United States for all 50 states and the District of Columbia. The researcher used quali- tative analysis software to identify the major themes and frequency of occurrence in the Nurse Practice Acts (see Table 6.1).
EVIDENCE EXAMPLE 6.2 American Holistic Nurses Association Nurse Practice Act Summary
The American Holistic Nurses Association is conducting a yearly analysis of Nurse Practice Acts about language changes that address holistic, complementary, or integra- tive therapies in the RN scope of practice. Four states (Illi- nois, Nevada, Oregon, and Texas) recognize holistic nursing as a specialty. Seventeen states include references and/or identify separate position statements on holistic or com- plementary health approaches (American Holistic Nurses Association, 2016).
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130 PART II n Entry-Level Population-Based Public Health Nursing Competencies
What Is the Scope of Public Health Nursing Practice? Chapter 1 explains that the scope of practice includes the boundaries of safe and ethical practice. The Public Health Intervention Wheel (see Chapter 2) describes what PHNs do and further explains activities that fall within the scope of public health nursing practice. In public health nursing, PHNs often collaborate with staff from different disciplines. It is important to clarify job descriptions and professional roles so that representatives from each discipline make the best use of their specific expertise as they work together on reaching a common goal.
TABLE 6.2 Task Analysis of PHN Interventions
Task/Intervention Frequency
Emergency preparedness 100%
Health teaching to individuals and families
100%
Receive and make referrals 100%
Immunization clinics 93%
Health promotion/prevention programs in the community
88%
Case management 88%
Facilitate vulnerable individuals’ access to services
87%
Work with groups related to public health issues
87%
Home visits 83%
Health teaching to groups 82%
Work with vulnerable children and/or adults
81%
Investigate disease and other health threats
78%
Health screening 78%
Educational classes, meetings, workshops for providers
73%
Advocate for increased healthcare availability and access
70%
Community organizing activities 60%
Lead groups related to public health issues
47%
Source: Schaffer et al., 2015
In addition to PHNs, examples of other occupations in the public health workforce are clerical staff, health educa- tors, nutritionists, epidemiologists, emergency preparedness staff, environmental health workers, information special- ists, and public health physicians (Beck & Boulton, 2015). The Institute of Medicine (IOM) released a progress report on its 2010 seminal report on The Future of Nursing: Leading Change, Advancing Health that delineated the competencies and skills needed by nurses in order to be fully instrumental in influencing delivery of care in a rapidly changing health- care environment. For PHNs, the development of skills and competencies in interprofessional collaboration and lead- ership is necessary for working with others to accomplish health system redesign that aims to provide quality, accessi- ble, and affordable care (IOM, 2015).
A study on the work of PHNs (Schaffer, Keller, & Reck- inger, 2015) demonstrated the breadth and consistency of public health nursing practice. Sixty PHNs, representing 28 states, completed two online surveys about their pro- fessional activities. Many of the activities implemented by the PHNs were consistent with the interventions from the Public Health Intervention Wheel and represent the scope of public health nursing practice. See Table 6.2 to find out which interventions PHNs in the study used most often.
In this same study, the PHNs were asked which activities they thought had the greatest impact on the health of the community. The activities they perceived to have the greatest impact were: “(1) childhood immunizations, (2) communi- cable disease (including tuberculosis and sexually transmit- ted infections), surveillance, education, and investigation, (3) maternal and child health-focused activities (early inter- vention and school readiness activities, prenatal and parent- ing education, case management of high-risk families, and growth and development follow-up), and (4) linking peo- ple to resources” (Schaffer et al., 2015, p. 716). When asked about how the lack of public health nursing services would affect the health of the community, they identified the fol- lowing potential negative effects: (1) an increase in disease and health problems, (2) worse health related to no focus on prevention, 3) loss of services for vulnerable populations, (4) a negative impact on the public health system, and (5) nega- tive effects for local health departments.
Study participants observed that PHNs are viewed as trustworthy, approachable, and holistic, which contrib- utes to the public’s confidence in recommendations made by PHNs. A PHN captured the important contribution of PHNs to the health of communities:
While all aspects of public health are important, it is the nurse who pulls all the little pieces together. It is the nurse who looks at the big picture to ensure services are being received (p. 118).
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131CHAPTER 6 n Competency #4
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EVIDENCE EXAMPLE 6.3 Independent Practice
A national sample of school nurses completed an electronic survey on their use of the public health interventions as defined in the Public Health Intervention Wheel. Screening, referral and follow-up, case management, and health teaching were the most frequently performed interventions. School nurses reported that they spent 65% of their time on individual-level interventions, 22% on community-level interventions, and 14% on systems-level interventions. Participants reported con- ducting activities consistent with the Public Health Interven- tion Wheel, although 67% of the participants were not familiar with the Wheel. The Public Health Intervention Wheel can be used by school nurses to guide their practice and explain to the school community what school nurses do. Understanding Wheel interventions at the three levels of practice will assist school nurses in improving the health status of a greater num- ber of students at the population level (Schaffer, Anderson, & Rising, 2016).
In Hennepin County, Minnesota, the Perinatal Hepatitis B PHN serves a growing population of refugees and immigrants. The program provides case management, contact investiga- tion of household members, monitoring of immunizations and titers (test for presence of antibodies) for exposed infants, and education to address cultural myths about Hepatitis B for pregnant women who are antigen-positive. The PHN collabo- rates with the medical provider, social worker, mental health worker, and family members at clinic visits and, through case management, makes any needed referrals. Program effective- ness is measured by improved outcomes in vaccine and serol- ogy completion for infants (from 92% to 100%), increases in the number of women referred to liver specialists for follow-up, and increases in the number of referrals of sexual partners and household members for follow-up (Przybilla, Johnson, & Hooker, 2009).
Sarah’s first day of her public health nursing clinical expe- rience with Jennifer begins right away on Monday morn- ing. Sarah meets Jennifer at the Public Health Office at 7:30 a.m. She met Jennifer briefly a week earlier, but this is the first time that Sarah will have the opportunity to observe nursing through the eyes of a PHN.
Sarah rides with Jennifer. Jennifer has three home visits scheduled for the morning, followed by two home visits in the afternoon. Jennifer briefly describes the three morning home visits, which are to families whom she knows from previous visits: (1) a 93-year-old woman with congestive heart failure who lives alone, (2) a toddler with an elevated lead level whose parents had emigrated from Mexico last year, and (3) a 17-year-old with a 3-month-old girl. After the morning visits, Jennifer plans to return to the office for a short time to make any follow-up phone calls and review plans for the afternoon home visits.
See Table 6.3 on the next page for Jennifer’s schedule.
Expanded Description of Activities Asthma Coalition: One of the school nurses in Aurora noticed that more and more children with asthma were com- ing to her office every year. She mentioned this concern to a
local physician, who had also noticed an increase in pediat- ric patients needing asthma-related care. The school nurse contacted the public health department to find out whether it was aware of an increase in asthma rates in the county or state. The timing of that call was good—the public health nursing director had just learned of funds that were avail- able for starting a coalition related to asthma in children. The state and county statistics were showing an increase in asthma cases over the past five years. Based on these conver- sations, a coalition was formed. Currently one of the PHNs is the chairperson of this coalition, which meets monthly to identify ways to increase public and provider awareness of methods to manage asthma. This coalition includes school nurses, nurse practitioners, physicians, PHNs, coaches, and parents of children with asthma.
Diversity Coalition: This is a group of community part- ners (educators, healthcare providers, local business own- ers) who are interested in supporting the various groups represented in Aurora. The overall goal of this group is to make Aurora a welcoming community for everyone. One of the elementary school teachers in town initiated this group, as he was observing segmentation of racial groups that led to tension not only in the elementary school but also in the community at large.
Foot Care Clinic: Twice a month, the PHNs hold a clinic to provide foot care for senior citizens at the commu- nity senior center. The PHNs worked with a podiatrist in the community and the public health medical director to develop a foot-clinic protocol and referral system. Because
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132 PART II n Entry-Level Population-Based Public Health Nursing Competencies
TABLE 6.3 Jennifer’s Schedule
Time Monday Tuesday Wednesday Thursday Friday
8am–9am Home visit: Hanson Staff meeting Prep for immuniza- tion clinic
Women, Infants, and Children Clinic
Intake, referrals, and nursing documentation
9am–10am Home visit: Garcia Diversity Coalition meeting
Immunization clinic Women, Infants, and Children Clinic
Weekly reflective supervision
10am–11am Home visit: Loften Diversity Coalition: Collect county data for grant application
Immunization clinic Women, Infants, and Children Clinic
Intake, referrals, and nursing documentation
11am–12pm Office: Follow up on calls, new referrals, nursing documentation
Intake, referrals, and nursing documentation
Meet with program manager to deter- mine funding for Asthma Coalition
Women, Infants, and Children Clinic
Intake, referrals, and nursing documentation
12pm–1pm Lunch Lunch Lunch Lunch Lunch
1pm–2pm New Referral Home visit: Ahmed
Prep for foot clinic at community center
Office: Follow up on phone calls and referrals, prep for afternoon home visits
Prep for immunization clinic
2pm–3pm New Referral Home visit: Johnson Foot care clinic Home visit: Wallis
Immunization clinic
3pm–4pm Nursing documentation
Nursing documentation
Foot care clinic Home visit: Froeland
Immunization clinic
an identified need existed in the community to provide basic skin and nail care and assessment for elderly citizens, this has been a very popular clinic. Two PHNs staff the clinic.
Immunization Clinic: Each week, the public health office holds an immunization clinic where people can receive low- cost vaccinations for children or adults in their families. The clinic is held at the local health department, which is centrally located. It is a walk-in clinic, so no appointments are required. Each PHN takes a turn staffing the clinic. One PHN oversees the clinic by ordering vaccines, following current protocols for administration, and informing the PHNs of updated information.
Phone Triage and Intake: The PHNs all take turns pro- viding intake services. During this time, the PHN works on documentation or projects at his or her desk and answers calls that come to the agency that require a PHN to assess and provide feedback. Examples of the types of calls include referrals for home visiting services, questions about where to get a car seat inspection, parents asking where to get vac- cinations, or daycare providers worried about head lice.
Reflective Supervision: Each week PHNs in the agency meet with their supervisor for reflective supervision. This time is set aside for the nurse and supervisor to thoughtfully consider the families receiving home visiting services. The time allows the PHN to consider ethical or other challenges in providing services, and it allows the nurse to consider his or her own thoughts and reactions to each family.
WIC Clinic: Women, Infants, and Children (WIC) is a federally funded food program administered by states and counties that provides screening, nutrition counseling, and health referrals for pregnant and breastfeeding women and their children from birth to 5 years of age. In Aurora, PHNs and nutritionists from the Health and Human Ser- vices department staff this clinic twice a month at the pub- lic health nursing office. Jennifer’s role is to provide height, weight, and hemoglobin checks for the children and preg- nant women in the program.
Sarah’s assignment for the day was to observe Jennifer’s communication and actions. Sarah planned to take notes about her observations and communication between the PHN and her clients. See Sarah’s notes.
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133CHAPTER 6 n Competency #4
SARAH’S NOTEBOOK
Activity Sarah’s Observations
Visit 1: Lily Hanson, a 93-year-old woman with congestive heart failure. Lives alone.
Arrived at a four-plex apartment building. The yard and building were maintained well, with big shade trees, grass, and flower beds surrounding the building. Lily’s apartment was on the first floor (no steps). Jennifer knocked on the door and opened it slightly; Lily called to Jennifer to come in. Lily was sitting at the dining room table and using her portable oxygen, neatly dressed, with her pill bottles lined up. The apartment was well kept, with many photos on the walls.
A fan was running quietly in the corner of the living room. Jennifer completed a heart and lung assessment and asked Lily about her activity level. Lily reported that even in the hot, humid weather, if she stayed indoors with the fans running, she felt comfortable. Jennifer filled Lily’s pillbox for the week. Jennifer also asked Lily about alternate plans if her apartment became too hot for her to tolerate. Lily reported that she did have a window air conditioner, but it broke, and she did not have enough money to buy a new one. Jennifer suggested that Lily call the County Senior Support Network (SSN). The SSN has funds for elders in need of basic housing supplies. In this heat wave, Jennifer has learned that the SSN will provide air conditioners.
Jennifer talked to Lily so naturally. Jennifer explained that she had known Lily for three years. The first year she came to visit, Lily was not friendly at all. She thought Jennifer was visiting to get information that would cause her to go to a long-term care facility. After that first year and many short conversations, Lily accepted that Jennifer was trying to help her maintain her independence so that she could continue to live in her apartment. Jennifer hypothesized that her persistence and nonjudgmental attitude helped Lily realize she was there to support her.
Visit 2: Toddler with an elevated lead level whose parents emigrated from Mexico last year
Drove to an older part of town with many single-family homes. Much of the paint had worn off or was peeling. In most of the yards, the grass was worn away, and there were many children’s toys. Jennifer rang the doorbell, knocked, and called in the front window, but there was no response. There was no response to a phone call either. Jennifer explained that sometimes families might not be home even though an appointment had been made for the visit. Persons living in poverty experience more crises, and with fewer resources they might live from day to day, with less emphasis on future planning. I thought about how persons living with poverty might more often choose to meet survival needs and how these choices are consistent with Maslow’s Hierarchy of Needs theory.
Visit 3: First-time 17-year-old mom, Jewel, who has a 3-month-old girl
Stopped at an old apartment building that had broken glass on the front steps. Entry security system was working. Jewel lives on the third floor. No elevator. Smelled musty. Jewel had the door open for us and responded cheerfully to Jennifer. It was 90 degrees out at 10 a.m. Jewel had the shades pulled to keep the sun out, but there were no air conditioners or fans in the efficiency apartment. Jennifer focused this visit on baby Kayla’s development. She used the Ages and Stages Questionnaire that has questions specific to development expected for the age of the child. I noticed Jennifer also gave some suggestions to Jewel about what she could expect to happen in Kayla’s development over the next few months. Jennifer gave information to Jewel about an organization that would help her get a fan and discussed how to prevent dehydration with the hot weather. During the visit, Jennifer coached Jewel in making a phone call to the apartment manager to report the glass on the front steps.
(continues)
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134 PART II n Entry-Level Population-Based Public Health Nursing Competencies
SARAH’S NOTEBOOK (continued)
Activity Sarah’s Observations
Office (and lunch) Jennifer checked for messages and had one from the Garcia family—they will not be home today. Completed some charting. Checked for new referrals. Made calls to these families.
New Referral: Active case of tuberculosis (TB)
Met Mr. Adams at his house. Mr. Adams was diagnosed with pulmonary TB (tuberculosis) about 4 months ago. He likely acquired TB working overseas in a disaster relief effort. He recently moved to Aurora to be near his aging parents. Jennifer will be providing Direct Observed Therapy (DOT) for Mr. Adams. In DOT, Jennifer will observe Mr. Adams to make sure he takes his medication cor- rectly. When TB medication is taken inconsistently, the TB bacteria can become resistant to medication.
In comparison to Jennifer’s interaction with Lily earlier today, this was a very formal meeting. Jennifer asked questions to get the intake information. She also inquired about Mr. Adams’s preferences for DOT. After the discussion and a brief health history, Jennifer observed Mr. Adams taking the medication and left.
New Referral: Postpartum visit
We met Amy Chan. She is 2 weeks postpartum. Her baby boy is doing well. However, Amy is anxious and nervous about her son, as her first child died of Sudden Unexpected Infant Death (SUID) three years ago. Jennifer assessed the home environment for infant sleep practices, reviewed guidelines for safe infant sleep, and provided positive feedback regarding Amy’s care for her son. Jennifer used the Edinburgh Postnatal Depression Scale (EPDS) to screen Amy for post- partum depression. Short messages and positive feedback seemed to help Amy. Jennifer suggested a support group for Amy.
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Sarah speaks with Jennifer after the first day of her clinical experience. Jennifer explains that her planning for home visits needed to be flexible. Sometimes her plan needed to change because a client might have an unexpected health problem or family crisis. Sarah comments, “I don’t know how I will ever become independent in my decision-making about what to do.”
Jennifer suggests, “Let’s review the day. Then we can analyze what we did today and which independent pub- lic health nursing interventions were accomplished. Also, I will have you look at my schedule for the rest of the week. You can begin to think about which interventions you would consider to be independent practice and how you might collaborate with others. We can discuss the skills and knowledge a PHN needs for these interventions.”
Activity Review Jennifer’s schedule for the week (Table 6.3) and answer the following questions:
n Which public health interventions from the Public Health Intervention Wheel did Jennifer use?
n Which interventions were independent, and which were delegated functions?
n What skills and knowledge enabled Jennifer to practice independently?
n How did Jennifer collaborate with other individuals, groups, professionals, or organizations?
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135CHAPTER 6 n Competency #4
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healthypeople.gov
Healthy People
On the Healthy People 2020 website, go to “Topics & Objectives” and under “M” click “Maternal, Infant, and Child Health.” Read about factors that affect pregnancy and childbirth. Go back to the Topics & Objectives page and under “S” click “Social Determinants of Health.” Scroll to review examples of social and physical determinants of health. Refer to the 17-year-old mother described in Sarah’s journal. Which determinants of health are important to consider and address for this young mother? Return to the “Maternal, Infant, and Child Health” page and click “Interventions and Resources” at the top of the page. Find one intervention among the suggestions that you could use to address the needs of this young family.
How to Establish Professional Boundaries in Public Health Nursing Understanding professional boundaries is essential for all nurses. PHNs practice in environments that are sometimes more challenging for maintaining professional boundaries, such as in homes, schools, and other community settings that have different norms of behavior in contrast to the hos- pital setting. In the hospital setting, professional and client roles are more clearly defined. In community and home set- tings, relationships and the norms of interaction need to be differentiated from more casual social relationships. Some- times students and PHNs find it difficult to keep from mov- ing into a social friendship with the client as the relationship progresses over time. PHNs must clarify their role and the purpose of the relationship with clients to maintain profes- sional boundaries. PHNs can also use dedicated reflective supervision time with their nursing supervisor to consider challenges around client relationships and boundaries.
On Tuesday, Jennifer has a visit scheduled with a client being seen in the targeted home visit program, Mindy, who is 16 and lives with her mother. Mindy has a 6-month-old baby girl. Mindy’s former boyfriend, the baby’s father, had been physically abusive to Mindy during her pregnancy. Mindy has developmental delays and struggles with school and fitting in. Mindy was referred to public health nursing after her first prenatal clinic visit when she was six months pregnant. Mindy and Jennifer have developed a trusting relationship. Mindy has worked hard to follow through with good parenting practices and has been receptive to Jennifer. Jennifer checked her Facebook account last night and saw that Mindy had made a friend request to her. Jennifer feels torn between the professional, therapeutic, and supportive roles she provides for Mindy.
A Nurse’s Guide to Professional Boundaries, published by the National Council of State Boards of Nursing, provides guidelines for managing boundaries in nursing practice. See Table 6.4 for specific guidelines and their application to managing boundaries in public health nursing practice.
PHNs need to be aware of the potential for boundary vio- lations in their interactions with individuals, families, and communities. Consider the following potential red flags that could lead to crossing boundaries (National Council of State Boards of Nursing, 2014, p. 5): n Discussing intimate or personal issues with a patient n Engaging in behaviors that could reasonably be inter-
preted as flirting n Keeping secrets with a patient or for a patient n Believing that you are the only one who truly under-
stands or can help the patient
Scope of Nursing Practice in New Zealand
GOAL 17 New Zealand’s new health strategy emphasizes prevention and early interventions aimed at ensuring that New Zealanders “live well, stay well, get well.” Jane O’Malley, chief nursing officer, is leading the way toward using the health workforce to the maximum potential (full scope of practice for nurses). To improve health and access to care: 1) the Nursing Council of New Zealand can now deter- mine the education, experience, competence, and supervision requirements to allow RNs to prescribe, and 2) a legislative change replaces the term medical practitioner with health practitioner in relevant laws. This increases the scope of practice for nurse practitioners in New Zealand (International Council of Nurses, 2017).
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136 PART II n Entry-Level Population-Based Public Health Nursing Competencies
TABLE 6.4 Boundaries and the Continuum of Professional Nursing Behavior
Management of Boundaries Examples of Nursing Actions
The nurse’s responsibility is to delineate and maintain boundaries.
Sarah introduces herself as a nursing student working with Weaver County PH, shadowing Jennifer.
The nurse should work within the therapeutic relationship. Jennifer has an open conversation with Mindy about why she cannot accept Facebook requests from clients.
The nurse should examine any boundary crossing, be aware of its potential implications, and avoid repeated crossings.
Sarah considers what it would mean for a nurse to have a non- work relationship on Facebook with a current or former client.
Variables such as the care setting, community influences, patient needs, and nature of therapy affect the delineation of boundaries.
Jennifer encourages Mindy to continue to share her personal experiences when Jennifer comes for visits and shows interest in Mindy’s life as a parent.
The nurse should avoid situations where he or she has a personal, professional, or business relationship with the patient.
Jennifer declines Mindy’s Facebook request and also discusses the agency policy with her supervisor.
Post-termination relationships are complex because the patient may need additional services. It may be difficult to determine when the nurse–patient relationship is completely terminated.
Jennifer works collaboratively with Mindy to ensure she feels competent as a parent. Jennifer helps Mindy understand when and why the home visiting services are no longer needed.
Be careful about personal relationships with patients who might continue to need nursing services.
Upon case closure, Jennifer takes time to celebrate Mindy’s suc- cesses on a home visit and provides encouragement to Mindy to reach out to the agency with future needs. She does not use Facebook to stay in contact with former clients.
Source: National Council of State Boards of Nursing, 2014, p. 3
n Spending more time than is necessary with a particular patient
n Speaking poorly about colleagues or your employment setting with the patient or family
n Showing favoritism n Meeting a patient in settings besides those used to pro-
vide direct patient care or when you are not at work
Confusion about the nurse’s role may occur when clients want to give gifts or offer money. Although PHNs do not wear uniforms, they need to choose professional-appearing attire that is comfortable. Individuals from some cultures might frown on clothing that they consider too revealing and might be reluctant to believe what the PHN is saying is important if the PHN is not professionally dressed. How- ever, PHNs may also dress more casually in some settings, such as homeless shelters or schools, which may help clients feel more comfortable when talking to them. PHNs need to be alert for any situation or conversations that might result in self-disclosure. They need to ask themselves whether what they are doing is what a nurse would typically do. PHNs can use touch as a comfort measure but need to consider the meaning of any physical contact to the nurse and client. Touch and eye contact are not considered accepted practices in some cultures.
On some occasions, physical assessment is required, and although it is a norm for adults and children to remove clothes for physical exams in the hospital and clinic settings, removing clothes is not a norm in a community setting.
If infants and children require a physical examination, the PHN should ask the parent or the child, if old enough, to remove the child’s clothes.
Maintaining professional boundaries does not mean being detached from clients. At the same time, the PHN does not fulfill the role of being a friend to a client. In inter- actions with clients, PHNs need to balance how they develop a trusting relationship with clients while maintaining their own separate professional identity.
EVIDENCE EXAMPLE 6.4 Defining Boundaries in Public Health Nursing
Five PHNs who participated in a qualitative study described the challenge of defining boundaries as they worked with clients. They described situations of being persuaded to do something and then feeling regret that they had not said “no.” The authors of the study suggested that one’s pro- fessional ethical responsibility does not mean doing what others demand. Closer relationships that develop over a long-term time period with clients can lead to a sense of duty, which can result in over-involvement and possi- ble development of a friendship, a potential professional boundary violation. “Each nurse has to make decisions that are not only based on quality standards, but also on their professional intuition and personal involvement” (Clancy & Svensson, 2007, p. 163).
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137CHAPTER 6 n Competency #4
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Activity Discuss the following questions:
n When is it helpful to share something personal about yourself with a client? When is it not helpful?
n What are some red flags indicating that you might not be maintaining professional boundaries with clients?
n Is it a boundary violation to attend a patient’s baby shower? A funeral for a client? Why or why not?
n How do you think Jennifer should handle Mindy’s Facebook request?
How Do Public Health Nurses Establish and Maintain Confidentiality? Confidentiality in public health nursing often goes hand in hand with professional boundaries. Maintaining profes- sional boundaries requires that PHNs keep health informa- tion private. PHNs must consider whom they speak to about clients and the confidentiality of their documentation pro- cesses. The Health Insurance Portability and Accountability Act (HIPAA), which specifies how health information may be communicated, is discussed in Chapter 7. Respecting patient confidentiality is a professional and legal duty. How- ever, PHNs must also balance this duty against the need to disclose information to protect someone from harm, such as in situations of suicidal ideation. When children or vulner- able adults are involved, the duty to protect outweighs the duty to keep health information in confidence. Competing interests can exist, which means disclosure can be justified for the public good, such as child protection (Griffith, 2015).
Jennifer is well known at one of the apartment buildings in Aurora where many elderly adults live. Jennifer has made many visits to residents in this complex over the years. The residents, although not related, have become like family to each other and welcome Jennifer. They have an informal system of checking on each other daily and helping each other with trips to the grocery store or pharmacy. Often as Jennifer exits a client’s apartment after a visit, several residents stop Jennifer to ask how her client is doing. The neighbors are genuinely concerned and want to be help- ful in any way possible. Sarah notes that Jennifer does not offer any specific information, and after the visit she asks Jennifer how she usually responds to questions about the well-being of residents in the complex.
What Does Ethical, Legal, and Professional Accountability Mean in Public Health Nursing? Ethical and professional standards and legal guidelines drive accountability in public health nursing practice. Public Health Nursing: Scope and Standards of Practice (ANA, 2013) specifies areas of accountability for PHNs (see Chapter 1). PHNs have more accountability to populations compared to nurses in other practice settings. The PHN is account- able for improving population health. Legal accountability is discussed in Chapter 7. See Chapter 1 for an explanation of ethical theory and a framework for analyzing ethical prob- lems in public health nursing practice.
Public health ethics is driven by social justice. The aim is to create a flourishing community for all rather than satisfy- ing individual self-interests. A bioethics perspective focuses more on autonomy and individual rights (Easley & Allen, 2007). Ethical challenges in public health nursing can result from the conflict between protecting the community and respecting individual autonomy. For example, individuals might be required to take medication to treat tuberculosis
EVIDENCE EXAMPLE 6.5 Maintaining Boundaries and Confidentiality in Working With Families With Intimate Partner Violence
Evanson (2006) investigated the role of PHNs who con- ducted home visits with families who had experienced intimate partner violence. The PHNs who worked in rural settings had more challenges in keeping confidentiality, helping women find resources, getting their own sup- port, and keeping professional and personal boundaries. Although all the PHNs viewed setting boundaries as an essential part of their work with families who were expe- riencing intimate partner violence, Evanson concluded that the boundaries between personal and professional lives for rural PHNs are less clear than those for nonrural nurses. The rural PHNs had learned to be flexible with boundar- ies because they were highly visible in the community and often knew their clients personally through attending the same church, having children who were friends, or know- ing mutual acquaintances. Personal ties were perceived as a barrier to disclosure of the interpersonal violence. Rural PHNs needed to be vigilant about maintaining confidenti- ality and at times needed to withhold the truth from others within a client’s family or community. Evanson recom- mends that rural agencies provide support opportunities through staff meetings and case conferences to help nurses who work with families experiencing intimate partner vio- lence cope with the emotional labor of their jobs.
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138 PART II n Entry-Level Population-Based Public Health Nursing Competencies
(even when they would prefer to choose otherwise) to pro- tect others’ health. Protecting individual rights to privacy might conflict with the need to share information to bene- fit the public’s health, such as in the case of reporting cases of communicable diseases to the health department so that disease incidence can be monitored (Racher, 2007).
In the study by Clancy and Svensson (2007), PHNs expressed that they thought they had a greater sense of responsibility than hospital nurses, because the PHNs pri- marily worked on their own. They expressed that they felt alone with their worries and their uncertainties about what to do. Ethical decision-making does not occur in a vacuum. Resolutions are better with input from other experts in the field. PHNs need to seek out collegial and organizational support for their decision-making to ensure ethical, legal, and professional accountability.
Activity Consider the attributes of nursing professionalism found in Table 6.5. Which attributes did Ellen Johnsen demonstrate in her quest to achieve a safe and legal medication policy in her school district?
EVIDENCE EXAMPLE 6.6 Ethics of Caring and Social Justice in Public Health Nursing Practice
Falk-Rafael and Betker (2012) interviewed ten expert public health nurses in Canada about how ethics guided their practice. Participants provided descriptions of situa- tions that were consistent with caring, social justice, and social activism in their professional practice. The analysis revealed three themes: the moral imperative, the pursuit of social justice, and barriers to moral agency. Participants identified important values for interactions with clients (respect, autonomy, honesty, fairness, social justice, pro- tection of human dignity) as imperative in their practice. They provided examples of addressing social determinants of health and advocating for health equity in social policy. Examples of barriers to moral agency identified by the PHNs included: 1) financial and administrative constraints, 2) feeling powerless to make changes, and 3) a shift to relying on electronic data for priority-setting that resulted in less involvement of the PHN with the community and a lack of priority-setting based on needs expressed by com- munity members. Falk-Rafael and Betker proclaim that eth- ical practice for PHNs and their professional organizations requires caring through advocacy for social justice as vitally important to both the nursing profession and society (see Chapter 13).
EVIDENCE EXAMPLE 6.7 A School Nurse’s Heroic Journey
Ellen Johnsen worked as a school nurse in Broken Arrow, Oklahoma, in the 1980s. Johnsen brought her concerns about a proposed unsafe and illegal medication administra- tion policy to the school superintendent. A committee was formed to review the policy; however, school nurses were not included on the committee. They were invited to submit input by phone or mail. The committee proposed a revised policy that was consistent with the Oklahoma Nurse Prac- tice Act. All medications, prescribed and over the counter (OTC), required physician orders. However, the superinten- dent rejected the committee’s recommendation and pro- posed a policy draft that required parental permission but not a physician’s order for OTC medications. The nurses were told if they did not agree with this policy, they would be replaced with school aides. Johnsen demonstrated a commitment to professionalism and standards of practice through her continued quest for a safe and legal policy. An analysis of her journey identified the following actions that demonstrate a commitment to professionalism and stan- dards of practice in her leadership and change agent roles: She gathered information about professional standards; sought expert opinion on relevant laws, regulations, and policies; shared her knowledge with colleagues; collabo- rated on policy development; advocated for change in the face of barriers; and accepted the consequences of being a change agent. Although her contract was not renewed, Johnsen continued her quest for a safe and legal medica- tion administration policy (Johnsen & Pohlman, 2017).
TABLE 6.5 Attributes of Nursing Professionalism
n Sense of nursing as a calling
n Self-regulating behaviors
n Presentation of self (image, attire, and expression)
n Personal integrity n Autonomy n Knowledge and
specialization
n Critical thinking n Intellectual and individual
responsibility n Respect for human dignity n Protection of patients and
the vulnerable n Well-developed group
consciousness n Belief and participation in
public service n Belonging to professional
organization
Sources: Akhtar-Danesh et al., 2013; Wynd, 2003
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139CHAPTER 6 n Competency #4
What Should I Know About Delegation and Supervision in Public Health Nursing? PHNs practice within their professional scope and stan- dards of practice as well as within the guidelines of state Nurse Practice Acts, which define the legal parameters of nursing practice. Delegation is based on requirements addressed in each state’s Nurse Practice Act. PHNs may be in the role of accepting delegated activities, such as carry- ing out provider orders for administering immunizations or monitoring respiratory status, and they also may be in the role of delegating specific functions to unlicensed assistive personnel (UAP) or licensed practical nurses (LPNs). UAPs include nurses’ aides, certified nursing assistants, health aides, or other nonlicensed positions (ANA, 2012). Practice environments often include multiple services and interven- tions to promote the health of individuals, communities, and populations. The ability to work interprofessionally and to clearly identify the components of the delegation process is crucial to successful PHN practice. Weydt (2010) states:
RNs are required to understand what patients and families need and then engage the appropriate care givers in the plan of care in order to achieve desired patient outcomes while maximizing the available resources on the patient’s behalf. Delegation is an important skill that influences clinical and financial outcomes (para. 2).
Effective delegation is an essential nursing skill and is guided by three concepts the PHN must understand: responsibility, accountability, and authority (Weydt, 2010). The PHN has the authority to delegate specific tasks to indi- viduals or groups, and these individuals or groups accept the responsibility for the tasks. However, at all times, the PHN retains accountability for the safety and quality of the outcome (Stanhope & Lancaster, 2012). Delegation is most effective when it is based on effective communication and mutual trust (Kaernested & Bragadottir, 2012).
The PHN must determine when and whether delegation is appropriate. The process for determination follows the steps of the nursing process (ANA, 2012). Some tasks should not be delegated because they fall in the realm of profes- sional nursing—for example, counseling; health teaching; and activities that require nursing knowledge, skill, and judgment based on evidence or data (ANA, 2007). Tasks that can be delegated are more often repetitive and support- ive in caregiving (Williams & Cooksey, 2004). It is import- ant to note the emphasis on individuals or communities as partners in the plan of care and the importance of commu- nication at all phases among healthcare consumers, UAPs, and PHNs. To determine whether delegation is appropriate, the American Nurses Association (2012) has identified six care provisions (see Table 6.6).
TABLE 6.6 Care Provisions for Determining Effective Delegation
1. Perform an assessment of the healthcare consumer’s: n Care needs and determine whether any cultural
modifications are required. n Condition to determine whether it is stable and
predictable. n Environment where the care will be provided.
2. Develop a plan of care with the healthcare consumer and his or her family, identifying the delegable task and intended outcome as part of the overall plan of care. Involving and educating healthcare consumers and their families about appropriate expectations of the roles of care providers promotes a safer environment and improved patient outcomes. The plan of care should include: n Baseline status of the healthcare consumer. n Specific unchanging task performance steps. n When and to whom the UAP needs to report if the
baseline status changes. n Documentation of expectations as appropriate.
3. Analyze the following: n Is the task within the delegating registered nurse’s
(RN’s) scope of practice? n Do federal or state laws, rules, or regulations support
the delegation? n Does the employing organization/agency of the delegat-
ing RN and the UAP permit delegation? n Is the delegating RN competent to make the delegation
decision? n Is the UAP competent to perform the delegated task? n Is RN supervision of the UAP available?
4. Monitor implementation of the delegated task as appropri- ate to the overall plan of care.
5. Evaluate the overall condition of the healthcare consumer and the consumer’s response to the delegated task.
6. Evaluate the UAP’s skills and performance of tasks and provide feedback for improvement, if needed.
Source: ANA, 2012
Activity Read the case study on the next page and analyze how a PHN could ensure that the Care Provisions of Delegation are followed when delegating to the family health aide. Then analyze how the Care Provisions of Delegation are represented in this case study.
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140 PART II n Entry-Level Population-Based Public Health Nursing Competencies
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Do I Need to Become Registered to Become a Public Health Nurse? Public Health Nursing: Scope and Standards of Practice iden- tifies the baccalaureate degree in nursing as the credential for public health nursing practice (ANA, 2013). In addition, the Association of Community Health Nurse Educators (ACHNE) assumes the minimum requirement for entry- level public health or community nursing practice is a bac- calaureate nursing degree (ACHNE, 2009). There are several routes to achieving this entry-level education preference. Nurses with associate degrees may choose to enter RN-to- BSN programs, or graduates with a baccalaureate degree or higher in another major may choose an “accelerated” nurs- ing program. Accelerated programs may offer a master’s degree (check individual institutions) for this select group of students. For students interested in advanced studies in the area of public health nursing, the doctor of nursing prac- tice (DNP) or the PhD are degrees that support practice and research in the field.
You can look at your state’s Nurse Practice Act to deter- mine whether a baccalaureate degree is required for the practice of public health nursing in your state. Some states require certification or registration for the title of PHN. The baccalaureate is the preferred entry into practice degree.
Sarah is very excited about public health nursing and asks Jennifer how she could obtain public health nursing certi- fication. Jennifer recommends that Sarah read the Nurse Practice Act in whichever state she practices nursing after she graduates with her baccalaureate degree in nursing. Sarah can also contact the board of nursing in that state to learn more about nursing practice guidelines specific to that area.
Examples of Legal Requirements in Nurse Practice Acts n California, Hawaii, Iowa, Minnesota, New York, North
Carolina, South Carolina, and Wisconsin require a baccalaureate degree for PHN practice.
n In California, Minnesota, New York, and South Caro- lina, licensure acts or rules have language that defines the scope of public health nursing practice and reserves the use of the title “public health nurse” for those profes- sional nurses who meet specific criteria.
n In California, PHN certification requires training in child abuse and neglect, and a PHN certificate is needed to use the title of “public health nurse” (California Board of Registered Nursing, 2006).
CASE STUDY Delegation
I received a referral on a 22-year-old and her 2-month-old baby. At my initial home visit, the baby appeared overweight and over- fed. The young mom had started him on rice cereal in a bottle at 2 weeks. Every time he cried, she gave him a bottle, even though he often struggled and tried to pull away from the nipple. I talked with her about feeding the baby and my concern about his weight, but she responded with, “Once he starts moving around, the weight will come off.” By 4 months of age, the baby was 27 pounds. By now I was very concerned and called both the nurse and the doctor at the clinic, but no action was taken. Next, I arranged a joint home visit with a nutritionist from WIC (Women, Infants, and Children Supplemental Food Program). We counseled the mom to feed the baby only when he was truly hungry. Two weeks later, I returned to do an NCAST* feeding interac- tion and videotaped the mom feeding the baby. We watched the tape together and talked about hunger cues and how the baby did not appear hungry. The young mother listened but continued to feed the baby whenever he fussed or cried. It was as though she had no other way to comfort him other than to feed him. I was also becoming concerned about the baby’s development, as he exhibited several delays in fine motor and language when I tested him. At this point, I started visiting every 2 weeks and placed a family health aide in the home for 2 hours at a time 1 day a week. The aide’s assignment was to role-model appropriate parenting and feeding. I also arranged to get a highchair for feeding the child through a nutrition program grant. Currently, I continue to coordinate services from the clinic, nutritionist, and family health aide. At the present time, the baby’s weight has stabilized, and he has not gained any more weight. *NCAST (Nursing Child Assessment Satellite Training) is an objective and systematic assessment of interactions between parent and child (30 hours of continuing education). It can alert the nurse to areas of concern and the need for teaching. It has been used as legal documentation in court cases of child abuse.
Source: Minnesota Department of Health [MDH], Office of Public Health Practice, 2006
Discuss how these Care Provisions of Delegation do or could take place in this case study:
n Perform an assessment of the healthcare consumer.
n Develop a plan of care with the healthcare consumer and his or her family.
n Analyze delegation factors.
n Monitor implementation of the delegated task as appropriate to the overall plan of care.
n Evaluate the overall condition of the healthcare consumer and the consumer’s response to the delegated task.
n Evaluate the UAP’s skills and performance of tasks and provide feedback for improvement, if needed.
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141CHAPTER 6 n Competency #4
Public Health Nursing Practice in a Variety of Public and Private Healthcare Settings PHNs provide care for individuals, families, and commu- nities in many settings as well as in local and state health departments. This section provides a description of how nurses in home care, school, corrections, and faith commu- nity settings use public health nursing knowledge and skills in their practice.
n Home Care: Home visiting nurses in New York, West Virginia, and Ohio provided a specific intervention to facilitate chronic disease management for elderly clients enrolled in Medicare. The nurses made monthly visits to clients, using behavior change approaches and empowerment strategies to work with clients on managing chronic disease. They used handbooks to encourage physical activity. Public health interventions implemented by the home visiting nurses included case finding, health teaching, counseling, and case manage- ment. Following the intervention, the group receiving the home visits had less difficulty bathing and experi- enced less dependence in walking (Friedman, Li, Liebel, & Powers, 2014).
n Schools: Five nursing students from a local college of nursing partnered with a school district in Dakota County, Minnesota, to carry out an aggregate assess- ment of children with seizure disorders in five elemen- tary schools. They identified health determinants at the individual and systems levels of practice and identified risk factors at the systems level of practice. They found that lunch room, playground, and transportation staff did not know how to respond to a student having a seizure. In response, the students: 1) developed a hand- out and PowerPoint presentation for school teachers and staff with input from the Minnesota Epilepsy Society, and 2) created a laminated business-card-size “Seizure Action Steps” that could be attached to staff name tag lanyards. These Seizure Action Step cards were distributed to all teachers and staff district-wide. The cards have increased staff comfort levels in having access to quick guidelines about actions needed if a child has a seizure. This systems-level health teaching intervention—implemented in partnership with the district Health Services Coordinator, who is a licensed school nurse—was an independent nursing action (con- tributed by Stacie O’Leary, health service coordinator, and Patricia Schoon, assistant professor, Metropolitan State University).
n Correctional Facilities: The Washington County, Minnesota, Sheriff’s Office contracts with the local Department of Public Health & Environment to provide nursing services to inmates in the Washington County jail. The Correctional Health Nursing supervisor in the jail medical unit attends weekly Re-entry Assistance Program (RAP) team meetings that are facilitated by
Community Corrections staff. The goal of the RAP is to provide multidisciplinary support to inmates who are preparing to be released from jail into the community. The collaboration between Corrections, Jail Medical, the Workforce Center, Community Financial Services, and other providers allows inmates to ask questions and get concrete assistance and guidance around barriers to successful re-entry. The Correctional Health Nursing supervisor provides referrals for physical and dental healthcare and assists with facilitating overall medical care needed upon release (contributed by Jill Timm, senior program manager, Washington County Depart- ment of Public Health & Environment).
n Faith Communities: Pappas-Rogich and King (2014) conducted a survey of 247 faith community nurses (FCNs) to identify their use of faith community nursing functions and practice standards and how often they implement Healthy People 2020 leading indicators in their practice. More than 50% of FCNs in the study used the following indicators in their practice weekly or monthly: 1) promote daily physical activity, 2) promote good nutrition and healthier weight, and 3) promote emotional health and well-being. FCNs partnered with many organizations in the community, including hos- pitals, local public health departments (LHDs), senior service agencies, faith-sponsored agencies, and hospices. Also, 30% of FCNs reported participating in partner- ships with health system–sponsored FCN programs.
Ethical Application When working with individuals and families, PHNs often must balance acting in the professional role with building a trusting relationship. In the attempt to find this balance in working with at-risk families, a PHN might encounter tension between different ethical perspectives. If a PHN emphasizes the expert role, the client might feel inadequate or judged.
The client might need a “friend” and want to view the PHN as a friend. However, framing the relationship as a friendship implies expectations of sharing and obligation that might fall outside the professional role. Professional caring does not mean being a friend but carries the respon- sibility of ethical action based on promoting good for the client, contributing to a flourishing community, and strat- egizing to reduce oppression for clients and families who receive public health services.
See Table 6.7 for an application of ethical perspectives to maintaining professional boundaries. Think about the related scenarios in this chapter: 1) the adolescent mother asked Jennifer to be her friend on Facebook; and 2) residents in the apartment building where Jennifer visited several elderly clients asked her how her clients were doing.
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142 PART II n Entry-Level Population-Based Public Health Nursing Competencies
TABLE 6.7 Ethical Action in Maintaining Professional Boundaries
Ethical Perspective Application
Rule ethics (principles) n Use expert public health nursing knowledge to promote good and prevent harm to clients and families.
n Keep health information confidential to protect the client.
Virtue ethics (character) n Be compassionate in recognizing the hardships and health challenges encountered by clients and families.
n Use caring interactions to communicate confidence in the client’s ability to make positive health decisions.
n Focus on building trusting relationships as a basis for mutual goal setting.
Feminist ethics (reducing oppression)
n Connect families to resources that reduce some of the inequities they experience because of poverty.
n Establish a relationship with the client that communicates valuing others as equal individuals.
Activity For either of the two scenarios discussed earlier in the chapter (the Facebook incident and the apartment residents asking about the well-being of clients), analyze the resolution to the ethical problem by answering the following questions:
n Which values related to the situation do you see as import- ant to you as a professional and as a person?
n Who do you think you should be as a PHN (important virtues)?
n Based on your values and who you should be, what would you do in this situation?
n Which ethical perspectives (rule ethics, virtue ethics, and feminist ethics) support your chosen action?
n Protection of patient confidentiality can be more chal- lenging for PHNs to ensure in rural communities, where many residents know the PHNs.
n HIPAA provides legal standards for handling protected health information.
n PHNs can use the six Care Provisions of Delega- tion identified by the ANA to guide their delegation responsibilities.
n Nurses in a variety of settings use expert public health knowledge and skills in interventions with individuals, families, communities, and systems.
KEY POINTS
n Nurse Practice Acts in each state and the scope and standards of public health nursing provide expectations for PHNs’ professional accountability.
n The Public Health Intervention Wheel defines the inde- pendent interventions that PHNs implement in their practice.
n Professional boundaries can be more challenging to maintain in public health nursing, given the community setting and long-term relationships with clients.
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143CHAPTER 6 n Competency #4
REFLECTIVE PRACTICE
Nurses who practice in healthcare organizations, such as hospitals, are constantly reminded about rules and reg- ulations that guide their nursing practice. They are sur- rounded by other nursing staff and supervisors whom they can quickly ask for guidance in any situation that might seem confusing. In many situations, PHNs do not have the security of having other nurses and nursing administrators immediately available to them. School nurses are often the only nursing professionals in the building. PHNs who make home visits might feel isolated and unsure of which response conforms to ethical and legal actions. PHNs must be knowl- edgeable about the scope of professional practice and guide- lines for ethical and legal practice. They need to provide rationales that are based on ethical, legal, and professional guidelines to support their choice of nursing actions.
Read the case study and write your answers to the fol- lowing questions. Then discuss them with your classmates.
1. How does the scope of public health nursing practice (see Chapter 1) guide the responsibilities of the PHN in this case study?
2. What do you think are the most relevant interventions for the PHN to implement from the Public Health Intervention Wheel?
3. What is the PHN’s ethical and legal accountability for the boyfriend’s domestic violence?
4. What concerns do you have about maintaining con- fidentiality and professional boundaries in this case study?
5. Which Cornerstones of Public Health Nursing do you think are consistent with supporting the PHN’s inter- ventions in working with this family?
6. How would you ensure ethical practice on your part in working with this family?
Source: Adapted from a case study developed by the Minnesota Department of Health, n.d.
Your initial referral to the family was for the premature birth of Adan, who had respiratory complications and spent 3 weeks in the hospital before he came home. Mariana is estranged from her mother, reporting, “She kicked me out when she found out I was pregnant.” She appears to have minimal parenting skills but is receptive to your visits and is working on developing parenting skills. She has declined your referral to Early Childhood and Family Education (ECFE) activities. Adan was within normal developmental limits for the first six months of his life but is now starting to exhibit some delays. You suspect that his frequent illnesses are contributing to the developmental delays. He suffers from chronic upper respi- ratory illnesses and otitis media. Mariana smokes a half pack of cigarettes per day and has not been receptive to discussing smoking cessation. Mariana’s lack of a routine lifestyle, increased levels of stress, lack of sleep, and poor nutrition has negatively affected both her and Adan. Mariana revealed she took a pregnancy test last week and is pregnant again. Her smoking is putting both Adan and the unborn child at risk.
CASE STUDY Scope of Public Health Nursing Practice
You are a PHN with approximately 40 high-risk families in your caseload. One of your clients is a 17-year-old adolescent, Mariana, who has an 11-month-old baby boy, Adan, whom she delivered at 34 weeks gestation with a birth weight of 4 pounds 1 ounce. Mariana lives in a trailer court off and on with an unemployed boyfriend who has hit her twice in the past month. She will not report the assaults because he is on probation for selling drugs and would immediately go to prison. She states, “He has promised it will never happen again.” Mariana’s boyfriend not only isolates her from family and friends; he has pressured her to drop out of an alternative school, where she had successfully secured onsite licensed childcare and school bus transportation. She was on track to achieve her high school diploma this year. Mariana is unable to acquire her WIC vouchers for purchase of healthy foods because she has no transportation to the WIC office. In addi- tion, Mariana has missed several healthcare appointments for Adan and herself. Her healthcare provider has requested PHN assistance in helping this family keep medical appointments.
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144 PART II n Entry-Level Population-Based Public Health Nursing Competencies
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APPLICATION OF EVIDENCE
Jennifer, the PHN from Weaver County Health Department, has received a referral from the county’s Child Protection Services. The referral was originally made by an RN who worked at the local hospital and suspected possible child abuse of a 2-year-old named Marcie who had a minor injury that required a visit to the emergency department. The child protection worker did not find any evidence of child abuse or neglect but asked to have a PHN follow up to promote positive parenting practices with the child’s parents.
n Which independent nursing interventions could Jennifer use in working with the child’s parents? How are these interventions consistent with the Nurse Practice Act in your state?
n What should Jennifer remember about maintaining pro- fessional boundaries as she meets with Marcie’s parents?
n During the visit, Jennifer discovers that Marcie attends the same community daycare as one of Jennifer’s children, although the two children are not in the same group. What will Jennifer need to do to maintain confi- dentiality in the small community setting?
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